Postpartum hemorrhage for undergraduate

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• Postpartum Hemorrhage

Dr Manal Behery Assistant professor ,Zagazig
University 2013
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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

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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

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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.

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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)

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Measuring Blood Loss in PPH THE BRASSS-V
DRAPE
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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

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CAUSES OF PPHFOUR Ts

• TONE
• TRUAMA
• TISSUE RETENSION
• THROMBIN
• BUT MOST IMPORTANT IS

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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

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TRUMA Obstetric OR OPERATIVE 7 of causes

• Obstetric Trauma
• - Uterine Rupture
• - Lacerations of the Birth Canal
• - Operative Trauma
• Cesarean sections
• Episiotomies
• Forceps, Vacuums, Rotations

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Tissue retension Abnormal placentaion

• - Placenta Previa
• - Abruptio Placentae
• - Accreta, increta, percreta
• - Vasa previa

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Thrombin Coagulation Defects2-3 of causes

• - Sepsis
• - Amniotic Fluid Embolism
• - Abruptio Placentae associated
• coagulopathy
• - HELLP Syndrome
• - Dilutional Coagulopathy
• - Inherited Clotting Disorders
• - Anticoagulant Therapy

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Prevention of Postpartum Hemorrhage

• Oxytocin
• With or soon after delivery
• Cord traction
• Continues tension
• Gentle pull with contraction
• Uterine massage after placental delivery

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• 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

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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

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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.

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MANAGEMENT of Uterine atony

• Explore uterus for retained placental tissue.
• Uterine massage
• 3Firm bimanual compression

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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

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Vaginal exploration

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

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Vaginal exploration cont
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Uterine inversion restitution
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Vaginal exploration cont Intrauterine balloon
Cather
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Bakri Balloon is a tamponade technique that can
be used for PPH.
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When medical managament fails

• SURGICAL MANAGEMENT
• Uterus conserving NEED OF TIME
• Definitive - Hysterectomy

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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

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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.

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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

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Pre embolization vs. .post embolization
Pre Embolization
Post Embolization
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Laparotomy for Obstetric Hemorrhage

• - Bleeding at Cesarean section
• - Torrential Hemorrhage
• - Pelvic hematoma (expanding)
• - Bleeding uncontroled by other
• means

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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

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B-Lynch suture vs Modified B-Lynch Suture
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Anterior view of uterus showing modified B-Lynch
Technique
posterior view of uterus showing modified B-Lynch
Technique
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OTHER COMPRESSION SUTURES

• Hayman Uterine Compression Suture

• Chos Multiple Square Suture

Global Stitch By Dr. Gunasheela Bangalore
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COMPLICATIONS
NIL - IF DONE PROPERLY TOO TIGHT
COMPRESSION --
CUT THROUGH
STITCH UTERINE NECROSIS
INTRAPERITONEAL BLEED
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Uterine artery ligation

• http//t3.gstatic.com/images?qtbnANd9GcQOaGGcLP1
  wYmyIsIQ8fyhFBBwhABO3K3uFHL4V7Dfd51ePIddvGg

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Sutures are placed to ligate the ascending
uterine artery and the anastomotic branch of the
ovarian artery.
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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

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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 .

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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.

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Classic Symptoms of Uterine Rupture

• Fetal distress
• Vaginal bleeding
• Cessation of labor
• Shock
• Easily palpable fetal parts
• Loss of uterine catheter pressure

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Management of Uterine Rupture

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

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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

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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

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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

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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.

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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.

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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.

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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.

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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?

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THANK YOU