Postpartum Hemorrhage Study Notes

Definition of PPH • be defined as a blood loss exceeding 500ml after delivery of the infant • PPH: occurs in 24 hour of delivery • the late PPH: occurs after 24 hour of delivery to 6 weeks Major causes • Uterine atony (90%) • lacerations of the genital tract(6%) • retained placenta(3%-4%) • coagulation defects (blood dyscrasia) • (4T: tone, tissue,trauma,thrombin) 1. Uterine atony Local factors • overdistention of the uterine (hydramnios, multiple pregnancy, macrosomia ) • condition that interfere with contraction(leiomyomas) • complications(PIH,anaemia, placenta praevia Systemic factors: • nervous • drugs(magnesium sulfate,sedative) • abnormal labor(prolonged,precipitous) • History of previous PPH • Preeclampsia, abnormal placentation, pathology • Contraction constricting the spiral arteries • preventing the excessive bleeding from the placenta implantation site • the uterine atony give rise to PPH when no contraction occur Prevention and therapeutic of uterine atony • Administration of medicine: • promotes contraction of the uterine corpus • decreases the likelihood of uterine atony • Oxytocin agents • Methegine • prostaglandin • Mechanical stimulation of uterine contraction: • Massage of uterus through the abdomen and bimanual compression • intrauterine packing Surgical methods • If massage and agents are unsuccessful: • Ligation of the uterine arteries • ligation of the hypogastric arteries • selective arterial embolization • hysterectomy taking into account the degree of hemorrhage,the overall status of patient,her future childbearing desires 2. Lacerations of the genital tract Causes: • Instrumented delivery (forceps) • manipulative delivery(breech extraction,precipitous labor, macrosomia) Types: • perineum laceration • vaginal laceration • cervical laceration perineum and vaginal laceration • The first degree tear: involves only skin and a minor part of the perineal body • the second degree tear: involves the perineal body and vagina • the third degree tear: involves the anal sphincter and anal canal management • Vaginal examination soon after delivery repair: • cervical laceration >2cm in length and be actively bleeding • laceration of vaginal and perineum 3. Retained placenta • Separation and explosion of placenta is caused by strong uterine contraction • Placenta tissue remaining in the uterus prevent adequate contraction and predispose to excessive bleeding causes: • adherence of placenta (previous cesarean delivery,prior uterine curettage) • succenturiate placenta • placenta accreta (into the decidua) • placenta increta(into the myometrium) • placenta pericreta(through the myometrium to the peritoneal) Prevention and treatment • The placenta should be examined to see that it is complete or not • part of placenta is missing, removed digitally • not separated, manual removal of placenta is done • hysterectomy is required for placenta increta(percreta,accreta) • uterine contraction drugs 4. Coagulation defects Acquired abnormality in blood clotting: • abruptio placenta, • amniotic fluid embolism • severe preclampsia congenital abnormality in blood clotting: • thrombocytopenia • severe hepatic diseases • leukemia disseminated intravascular coagulopathy(DIC) • if bleeding persists in spite of all other treatment described, DIC should be suspected • the blood passing from the genital tract is not clotting • shock: reduction of effective circulation inadequate perfusion of all tissues oxygen depletion depression of functions Record: • pulse • blood pressure • maternal heart rate • central venous pressure • urine output • Lab tests: • Hb, • BT(bleeding time), CT( clotting time), • platelets count • fibrinogen • prothrombin time and patial thromboplastin time • FDP • women’s group and cross-matching Treatment: • the key is correcting the coagulation defect • resuscitation must be started as soon as possible • infusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusion • blood transfusion is essential • infusion of platelets, fresh frozen plasma, FDP , clotting factors, • Potential complications of PPH: • Postpartum infection • Anemia • Transfusion hepatitis, • Sheehan’s syndrome • Asherman’s syndrome • The best management of PPH is prevention