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Postpartum Hemorrhage

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Postpartum Hemorrhage Christopher R. Graber, MD Salina Women s Clinic 21 Feb 2012 Overview Background Etiology of postpartum hemorrhage Primary Secondary Risk ... – PowerPoint PPT presentation

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Title: Postpartum Hemorrhage


1
Postpartum Hemorrhage
  • Christopher R. Graber, MD
  • Salina Womens Clinic
  • 21 Feb 2012

2
Overview
  • Background
  • Etiology of postpartum hemorrhage
  • Primary
  • Secondary
  • Risk factors
  • Evaluation and management
  • Medical
  • Surgical

3
Background
  • Severe bleeding is 1 worldwide cause of maternal
    death
  • 140,000 women die each year from hemorrhage
  • 1 every 4 minutes
  • Other serious sequelae
  • ARDS, coagulopathy, shock, loss of fertility
  • Hemorrhage frequently occurs without any warning

4
Background
  • Physiologic changes during pregnancy
  • Increase in plasma volume by 40
  • Increase red cell mass by 25
  • Definition of postpartum hemorrhage
  • 500 mL after vaginal delivery
  • 1000 ml after cesarean delivery

5
Etiology Primary Hemorrhage
  • Primary hemorrhage occurs in 1st 24 hours
  • Occurs in 4-6 of pregnancies
  • Caused by The Four Ts
  • Tone atony (80 of all cases)
  • Tissue retained POC, accreta, uterine inversion
  • Trauma cervical or vaginal laceration, rupture
  • Thrombic events defects in coagulation
  • Inherited or acquired

6
Etiology Secondary hemorrhage
  • Secondary hemorrhage occurs 24h to 6-12w
  • Causes include
  • Subinvolution of pacental site
  • Retained POC
  • Infection
  • Inherited coagulation defects

7
Risk Factors
  • Prolonged labor (also augmented labor)
  • Rapid labor
  • History of postpartum hemorrhage
  • Preeclampsia
  • Distended uterus
  • Macrosomia, twins, polyhydramnios
  • Chorioamnionitis
  • Operative delivery

8
What to Do Next?!
9
What to Do Next?!
  • Postpartum hemorrhage is a sign, not a diagnosis
    find out what is causing bleeding
  • Calmly work your way through the list of possible
    causes
  • If you get to the end of the list and dont have
    an answer then start again at the top of the list
  • Call for help if needed
  • Extra nurses, anesthesia, Ob/Gyn

10
Initial Evaluation
  • Atony is the most common cause for bleeding
  • Pelvic exam, uterine massage, expel clots
  • Manual exam of the uterus
  • Yes, put your whole hand and arm inside
  • Consider draining the bladder
  • Examine for lacerations
  • Consider move to OR for lighting exposure
  • Ask about history of clotting disorders

11
Medical Management
  • Uterotonic medications
  • Pitocin 10-40 units IV, continuous
  • Methergine (methylergonovine) 0.2mg IM
  • Repeat q2-4h, avoid in hypertension
  • Hemabate (15-methyl PGF2a) 0.25mg IM
  • Repeat q15min, avoid in asthma
  • Higher risk of side-effects diarrhea, fever,
    tachycardia
  • Cytotec (misoprostol, PGE1) 800-1000mcg PR

12
Medical Management
  • Uterine tamponade
  • Packing with guaze
  • Can soak with thrombin
  • Intrauterine foley catheter
  • One or more bulbs, 60-80ml of saline
  • Bakri tamponade balloon
  • 300-500ml of saline

13
(No Transcript)
14
Surgical Management
  • Consider surgical management when uterotonic
    agents ( tamponade) dont work
  • Uterine curettage
  • Exploratory laparotomy
  • Hypogastric artery ligation
  • Bilateral uterine artery ligation (OLeary
    sutures)
  • B-Lynch technique
  • Hysterectomy

15
Surgical Management
16
Other Considerations
  • Placenta accreta
  • Risk factors placenta previa, prior CD,
    Ashermans syndrome, prior myomectomy
  • 40 risk if 2 prior CD placenta previa
  • If known, consider delivery at tertiary center
  • Arterial embolization
  • Not for acute cases

17
Other Considerations
  • Uterine inversion
  • If occurs prior to placental delivery, do Not
    remove the placenta
  • Replace fundus with firm pressure upwards
  • Uterine relaxation may be required
  • Terbutaline, nitroglycerine, anesthesia
  • Consider activation of massive transfusion
    protocol

18
Review .
  • Stay Calm!
  • Tone, Tissue, Trauma, Thrombin
  • Postpartum hemorrhage is a symptom, not a
    diagnosis find a diagnosis
  • Return to bedside if more than 1 dose of
    uterotonic medication is given by phone

19
Questions?
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