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Postpartum hemorrhage for undergraduate

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Undergraduate course lectures in Obstetrics&Gynecology ,Faculty of medicine,Zagazig University ,Prepared by DR Manal Behery – PowerPoint PPT presentation

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Title: Postpartum hemorrhage for undergraduate


1
  • Postpartum Hemorrhage

Dr Manal Behery Assistant professor ,Zagazig
University 2013
2
Definition
  • Blood loss gt 500 ml at vaginal delivery
  • gt 1000 ml at Cesarean
  • ACOG 10 drop in hematocrit
  • Need for blood transfusion
  • Severe PPH gt 1000 ml loss at vaginal delivery
  • Any amount of blood loss causes
  • S/O Hypovolemic Hemorrhagic Shock
  • - Tachycardia - Hypotension - Reduced urine
    out put

3
Why it is important?
  • PPH remained one of the top 3 causes of direct
    maternal deaths.
  • Incidence 4 after vaginal delivery
  • 6,5 after CS delivery

4
We have 4 problems
  • Problem 1 almost 50 of deliveries lose gt500 ml
    of blood.
  • Problem 2 estimated blood loss is often less
    than half the actual blood loss.
  • Problem 3 Most of the serious causes of PPH
    have origins prior to the end of the 3rd Stage of
    labor.
  • Problem 4 PPH, as defined, is technically
    misdiagnosed and clinically irrelevant.

5
Measuring Blood Loss A key step to EFFECTIVE
TREATMENT..
  • Underestimation leads to delayed intervention.
  • Visual estimated amounts of blood loss are far
    from accurate by as much as 30-50 especially
    for very large amounts.
  • Old methods for estimating blood loss tend to be
    complex.
  • (include weighing soaked clothes and pads,
    collection into pans etc., Acid haematin
    techniques, Spectrophometric technics and
    measuring plasma volume changes)

6
Measuring Blood Loss in PPH THE BRASSS-V
DRAPE
7
Advantages of Brasss-V
  • Simple and practical
  • Low cost ( Plastic)
  • Accurate
  • Objective
  • Can be used in a wide
  • range of settings
  • Provides a hygienic delivery surface

8
CAUSES OF PPHFOUR Ts
  • TONE
  • TRUAMA
  • TISSUE RETENSION
  • THROMBIN
  • BUT MOST IMPORTANT IS

9
ToneUterine Atony90of causes
  • - Uterine over distension
  • Polyhydramnios, Multiple gestations, Macrosomia
  • Prolonged labor uterine fatigue
  • Precipitory labor
  • High parity
  • Chorioamnionitis
  • Retained product of conception
  • Halogenated anesthetic

10
TRUMA Obstetric OR OPERATIVE 7 of causes
  • Obstetric Trauma
  • - Uterine Rupture
  • - Lacerations of the Birth Canal
  • - Operative Trauma
  • Cesarean sections
  • Episiotomies
  • Forceps, Vacuums, Rotations

11
Tissue retension Abnormal placentaion
  • - Placenta Previa
  • - Abruptio Placentae
  • - Accreta, increta, percreta
  • - Vasa previa

12
Thrombin Coagulation Defects2-3 of causes
  • - Sepsis
  • - Amniotic Fluid Embolism
  • - Abruptio Placentae associated
  • coagulopathy
  • - HELLP Syndrome
  • - Dilutional Coagulopathy
  • - Inherited Clotting Disorders
  • - Anticoagulant Therapy

13
Prevention of Postpartum Hemorrhage
  • Oxytocin
  • With or soon after delivery
  • Cord traction
  • Continues tension
  • Gentle pull with contraction
  • Uterine massage after placental delivery

14
  • Goals of Therapy
  • Maintain the following
  • Systolic pressure gt90mm Hg
  • Urine output gt0.5 mL/kg/hr
  • Normal mental status
  • Eliminate the source of hemorrhage
  • Avoid overzealous volume replacement that may
    contribute to pulmonary edema

15
Management Protocol
  • Examine the uterus to rule out atony
  • Examine the vagina and cervix to rule out
    lacerations repair if present
  • Explore the uterus and perform curettage to rule
    out retained placenta

16
On recognition of Hemorrhage
  • Initiate volume replacement with lactated ringers
    or normal saline.
  • Alert blood bank and surgical team.
  • Control the blood loss.
  • Initiate decisive therapy.
  • Monitor for complications.

17
MANAGEMENT of Uterine atony
  • Explore uterus for retained placental tissue.
  • Uterine massage
  • 3Firm bimanual compression

18
management of uterine atony Cont
  • 4-Ecobolics uterotonic agents
  • Oxytocin infusion, 40 units in 1 liter of D5RL
  • Methergine 0.2 mg IM
  • 15-methyl prostglandin F2a, 0.25 to 0.50 mg
    intramuscularly may be repeated
  • , PGE1 200 mg, or PGE2 20 mg are second line
    drugs in appropriate patients

19
Vaginal exploration
  • General anesthesia usually best
  • Uterine cavity manual exploration for retained
    placenta / uterine rupture

20
Vaginal exploration cont
21
Uterine inversion restitution
22
Vaginal exploration cont Intrauterine balloon
Cather
23
Bakri Balloon is a tamponade technique that can
be used for PPH.
24
When medical managament fails
  • SURGICAL MANAGEMENT
  • Uterus conserving NEED OF TIME
  • Definitive - Hysterectomy

25
MANAGEMENTcont
  • If Hemorrhage is not controlled by medications,
    massage, manual uterine exploration, or suturing
    lacerations in the birth canal,
  • then surgical or radiological options must be
    considered. At this time, start
  • Packed red blood cell transfusion
  • Foley catheter and monitor urine output

26
Selective Artertial Embolization
  • If the patient is stable
  • and bleeding is not torrential,
  • and if interventional radiology is available,
  • then pelvic arteriography may show the site of
    blood loss and therapeutic arterial embolization
    may suffice to stop the bleeding.

27
Uterine artery embolization
  • Real time X-Ray (Fluoroscopy)
  • Gelatin Sponges are injected
  • into the bleeding vessel until
  • stasis of flow in target vessel is
  • achieved.
  • Acess via RTfemorals
  • to internal iliac and
  • subsequently the uterine arteries

28
Pre embolization vs. .post embolization
Pre Embolization
Post Embolization
29
Laparotomy for Obstetric Hemorrhage
  • - Bleeding at Cesarean section
  • - Torrential Hemorrhage
  • - Pelvic hematoma (expanding)
  • - Bleeding uncontroled by other
  • means

30
AT laparotomy
  • Consider vertical abdominal incision
  • General anesthesia usually best
  • Get Help!
  • Avoid compounding problems by making major
    mistakes
  • Direct manual uterine compression / uterotonics
  • Direct aortic compression
  • Modified B-Lynch Suture for atony 2 chromic
  • Ligation of uterine and utero-ovarian vessels 1
    chromic

31
B-Lynch suture vs Modified B-Lynch Suture
32
Anterior view of uterus showing modified B-Lynch
Technique
posterior view of uterus showing modified B-Lynch
Technique
33
OTHER COMPRESSION SUTURES
  • Hayman Uterine Compression Suture
  • Chos Multiple Square Suture

Global Stitch By Dr. Gunasheela Bangalore
34
COMPLICATIONS
NIL - IF DONE PROPERLY TOO TIGHT
COMPRESSION --
CUT THROUGH
STITCH UTERINE NECROSIS
INTRAPERITONEAL BLEED
35
Uterine artery ligation
  • http//t3.gstatic.com/images?qtbnANd9GcQOaGGcLP1
    wYmyIsIQ8fyhFBBwhABO3K3uFHL4V7Dfd51ePIddvGg

36
Sutures are placed to ligate the ascending
uterine artery and the anastomotic branch of the
ovarian artery.
37
Internal iliac (hypogastric) artery ligation
  • 50 success rate
  • Desirous of children
  • Experience of surgeon
  • Steps
  • Palpate common iliac
  • bifurcation
  • Ligate at least 2-3 cm
  • from bifurcation
  • 1 silk. Do not divide
  • vessel

38
Repaire of cervical laceration
  • Palpate uterine cavity to assure its integrity
  • Full thickness mucosal repair above the apex
  • Contionous interlocking absorbable sutures
  • Hematoma incised,clot removed,bleeding vessels
    ligated ,oblitrate defect with interlocking
    sutures
  • Antibiotics vaginal pack for 24 hours .

39
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40
Uterine Rupture
  • Prior Cesarean section 1-2
  • Modern obstetrics 1/10,000 to
  • 1/20,000 in unscarred uterus
  • In Neglected labors, this accounts
  • for many maternal deaths where
  • modern obstetrical care is not available.

41
Classic Symptoms of Uterine Rupture
  • Fetal distress
  • Vaginal bleeding
  • Cessation of labor
  • Shock
  • Easily palpable fetal parts
  • Loss of uterine catheter pressure

42
Management of Uterine Rupture
  • Laparotomy
  • Debride and repair in 2-3 layers of Maxon/PDS
  • Subtotal Hysterectomy
  • Total Hysterectomy

43
Management of Abnormal Placentation
  • Diagnosis of exclusion after adressing tone and
    truma
  • Curettage of uterine cavity
  • Localized resection and uterine repair
    (Vasopressin 1cc/10cc N.S-sub endometrial)
  • Leave placenta in situ
  • If not bleeding Methotrexate
  • Uterus will not be normal size by 8 weeks
  • Uterine, utero-ovarian, hypogastric artery
    ligation
  • Subtotal/ total abdominal hysterectomy

44
Post-Hysterectomy Bleeding
  • Patient usually has DIC Rx with whole blood,
    FFP, platelets, etc.
  • Transvaginal or transabdominal
  • (pelvic) pressure pack
  • Bowel bag with opening pulled through vagina
    cuff/ abd. Wall
  • Stuff with 4 inch gauze tied end-to-end until
    pelvis packed tight

45
Military Anti-Shock Trousers (MAST)
  • Increases pelvic and abdominal pressure to reduce
    bleeding
  • Can use at any point in the procedure
  • Used when exploration is to be avoided

46
Secondary PPH
  • Defined as excessive bleeding 24 hrs to 12 weeks
    postpartum.
  • Incidence is about 1 percent of women.
  • Theory is that thought to be atony or
    subinvolution of placental site from retained
    products or infection.

47
Management of Secondary PPH
  • Evaluate for underlying disorders
    (coagulopathies).
  • For atony give uterotonics.
  • If large amount of bleeding, fever uterine
    tenderness, or foul smelling discharge treat for
    endometritis.
  • Consider suction currettage.

48
Case 1
  • A 22y/o G1P0 was delivered by vaccum assisted
    vaginal delivery approximately 2 hours ago. She
    was induced for mild preeclampsia at 37 weeks and
    required pitocin augmentation for several hours
    prior to needing an operative vaginal delivery
    for fetal distress. She had a second degree
    laceration that was repaired, but she has soaked
    a whole pad in the last 15 minutes and the nurse
    would like you to evaluate her.

49
Case 2
  • A 22 yo G4P3 approximately 4 days s/p delivery
    presents at OB triage and mentions to you that
    she feels lightheaded and has been having
    bleeding at about a pad an hour for the last 2
    days.

50
Case3
  • A 34yo G6P6 patient at term has just delivered
    a 4000gm infant after second stage of labor
    lasting 3 ½ hours. The placenta delivered
    spontaneously and the patient is bleeding
    briskly.
  • What is most probable cause?
  • What the next step?

51
THANK YOU
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