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Postpartum Hemorrhage

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Title: Postpartum Hemorrhage


1
Postpartum Hemorrhage
  • Pongsun Puntachai , MD
  • OB GYN Department
  • Sanpasittiprasong hospital , Ubon Ratchathani

2
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3
Definition
  1. Blood loss gt 500 ml after 3rd stage of labor
    after vaginal delivery
  2. Blood loss gt 1000 ml after cesarean section

4
Classification
  1. Early PPH ? ???????????? 24 ???????????????
  2. Late PPH ? ???????????? 24 ???????????? 12
    ??????? ????????

5
Etiology
  • Early PPH
  • - Uterine atony
  • - Retained placental fragments
  • - Retained placenta
  • - Genital tract lacerations
  • - Placental adherence
  • - Uterine inversion
  • 2. Late PPH
  • - Endometritis
  • - Retained placental
  • fragments
  • - Disorders of coagulation

6
  • Uterine atony

The most common cause of early PPH
  • Normally, contraction of the uterine muscle
    compresses the vessels and reduces flow

7
  • Definition
  • A condition in which the uterine corpus does not
    constrict properly
  • Continued blood loss from the placental site

8
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9
Risk factors
  • Overdistended uterus ? multiple pregnancy,
    hydramnios, macrosomia
  • Fatiqued uterus ? precipitated labor, prolonged
    labor, multiparity, drug eg. Oxytocin
  • Intrauterine infection ? prolonged PROM
  • Abnormal uterus ? myoma uteri, uterine anomaly

10
Diagnosis
  • ???????????????????????? ?????????????????
  • ???????????????????????????? 3

11
  • Management

1. Uterine massage 2. Medical treatment
12
?? ???? ?????????? ?????????????? ??????????
Oxytocin (syntocinon) -20 ?????/???????? 1 ??????????????? 60 ???/???? -10 ?????????????? ?????????????? oxytocin ?????????? 3 ???? ????????? ????????????????? ???????? ??????? ?????
Methylergometrine maleate (Methergine) 0.2 ?????????????????????????????????? 0.1 ????????? ( 5 ?????) ????????????????????????? ??????????????? ???????? ??????? ??????????????? ?????
Sulprostone (Nalador) 500 ??????????????????? 1 ??????? 1500 ????????? ?? 24 ??????? ???????? ??????? ??????? ???????? ????? ???????? ??????????? ???????? ?????????? ?????? ????????????????? ?????????? ?????? ????? ????? ?????? ???????????????
Misoprostol (Cytotec) 800 ???????????????????? - ???????? ????? ?????????? prostaglandin
13
  • 3. ????????????????? ?????????????????????????????
    ?????????????? ??????????????????? ??????
  • 3.1 ????????????????????????
  • 3.2 ??????????????????????????????
    ????????????????????????????????????????????
    crystalloid ??? oxytocin
  • 3.3 ????????
  • 3.4 ?????????????????????????????
    ?????????????????????????????? ?????????????????
  • 3.5 ?????????????? ????????????????
  • 3.6 ??????????????????????? ????????????????????
    ???????????????? shock

14
  • 4. Resuscitation
  • 5. Bimanual
  • uterine
  • compression

15
  • 6. Surgery e.g.
  • 6.1 ?????????????
  • - internal iliac artery ligation
  • (hypogastric ligation)

16
  • - uterine artery ligation

17
  • - Selective arterial embolization

18
  • - Uterine compression suture (B-Lynch)

19
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20
  • 6.2 ????????????????
  • - Hysterectomy

21
  • Retain placenta
  • Definition ???????????????????????????????????
  • Normally after the placenta is delivered, uterus
    contracts down to close off all the blood vessels
    inside the uterus.
  • But in retained placenta, the uterus cannot
    contract properly, so the blood vessels inside
    will continue to bleed

22
  • Etiology
  • 1.Retained placental fragments
  • - ????????????????????????????
  • - ???????????? (placenta succenturiata)
  • - ?????? placenta adherence

2.Retained placenta - ?????? placenta
adherence - ?? Constriction Ring ,cervical clamp

23
  • Retained placental fragments

Diagnosis - Ultrasound - ????????????????????
?
Treatment - Uterine curettage
24
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25
  • Retained placenta

Diagnosis ?????????????? 30 ????
Treatment - Manual removing
26
  • Manual removing
  • Blood,Fluid
  • Empty bladder
  • Antibiotic (Ampicillin Metronidazole)
  • ??????????? (manual removal under anaesthetic)

27
2.????????????????????????????????????????????????
1.??????????????????????
28
3.????????????????????????????????????? fixed
????????
4.?????????? ??????????????????????????
29
  • Genital tract lacration
  • Etiology
  • Precipitated labor
  • OB procedures
  • Breech delivery
  • Inappropriate episiotomy

30
  • Diagnosis
  • ????????????
  • ??????????????????? ???????????????????????
  • ???????????????

31
Vaginal tear
  • Usually longitudinal
  • Forceps or vacuum operation, but they may even
    develop with spontaneous delivery
  • Lacerations of the anterior vaginal wall in close
    proximity to the urethra are relatively common

32
  • Management
  • They are often superficial with little to no
    bleeding,and repair is usually not indicated
  • If lacerations are large enough to require
    extensive repair, difficulty in voiding can be
    anticipated and an indwelling catheter placed

33
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34
  • Cervical tear
  • Usually, less than 0.5 cm. and upper third of
    the vagina ? no need for repair
  • - Deep cervical tears require surgical repair

35
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36
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37
  • Placenta adherence
  • Definition
  • ?????????????????????????????????????????????????
    ???????? trophoblast cell ???????????????
    decidual basalis ?????????? fibrinoid

38
  • Classification
  • Placenta accreta ???????????????????????????????
    ???
  • Placenta increta ????????????????????????????????
    ????????
  • Placenta percreta ???????????????????????????????
    ?????????????????? serosa ????????

39
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40
  • Risk factors
  • -Placenta previa
  • -Previous cesarean section
  • -Previous curettage
  • -Multiparity

Diagnosis -Ultrasound -MRI
41
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42
Management
  • 1. Supportive therapy
  • - Blood replacement therapy
  • - Intravenous fluid
  • 2. ??????????????????????????? placenta accreta
    ??????????????????????????????????
  • 3. Hysterectomy

43
  • 4. Alternative treatment
  • - Uterine artery embolization
  • - Uterine artery or internal iliac artery
    ligation

44
  • Uterine inversion

45
  • Definition
  • ??????????????????????????????????????????????
  • Risk factors
  • 1.??????????????????
  • 2.??????????????????????
  • 3.?????????????? ????????????????? ???? placenta
    accreta
  • 4.???????????????????????????
  • 5.???????????????? ??????????????????

46
  • Classification
  • 1.First degree ????????????????????????????????
    ????????????
  • 2.Second degree ????????????????????????????????
    ????????????????????????
  • 3.Third degree ?????????????????????????????????
    ?(complete version)
  • 4.Fourth degree ??????????????????????????????

47
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48
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49
  • Diagnosis
  • 1.??????????????????
  • 2.???????????????????????????????????????????
  • ( cup-like defect )
  • 3.????????????
  • 4.????? ultrasound

50
  • Management
  • Conservative treatment
  • IV fluid , blood transfusion
  • Anesthesia (halothane) and push
  • Remove the retained placenta then push back the
    uterus
  • Oxytocin and stop halothane immediately
  • Observation for hemorrhage and recurrent uterine
    inversion
  • If failed conservative treatment, surgery may be
    indicated

51
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52
  • Surgical treatment
  • Huntington maneuver ?????????????????????????
    Allis ???? Babcock forceps ??? round ligament
    ????????????????????????????
  • Haultian maneuver ????????????????????
    ???????????????????????????????? midline
    ??????????????????????????????????????????????????
    ???????? ??????????????????????

53
  • Huntington maneuver

54
  • Haultian maneuver

55
  • Late PPH
  • Etiology
  • - Endometritis
  • - Retained placental
  • fragments
  • - Disorders of coagulation

56
  • Diagnosis
  • - ??????????
  • - ????????????????????????????
  • - ????????????????????????????
  • - ????????????
  • - ?????????
  • - ????????????????????????

57
  • Initial treatment
  • ????????????????????????????????????
  • ????????????????????????????
  • ??????????????

58
Endometritis
  • Gram-negative enteric bacteria
    E.coli,Klebsiella,Enterobacter,Pseudomonas,Serrati
    a
  • Gram-negative anaerobes Bacteroides
  • Gram-positive bacteria S. pyogenes
  • Viruses Varicella
  • - Fungal infection

59
Disseminated intravascular coagulopathy(DIC)
  • ?????

??? Coagulating factor
Coagulating factor
Hemorrhage
60
  • Risk factors
  • Cesarean delivery
  • Prolonged rupture of membrane gt24 hrs.
  • Prolonged labor with multiple vaginal
    examinations
  • Prolonged internal fetal monitoring
  • Maternal anemia

61
  • Sign and symptom

- ??????????????????????? ??????? 2 ??????? -
????????????????????? - ??? - ????????????????????
? - ?????
Lab investigation - Increased WBC
62
  • Management
  • 1. Ampicillin 2 gm iv q 6 hrs
  • Gentamicin 5 mg/kg iv q 24 hrs
  • Metronidazole 500 mg iv q 8 hrs
  • 2. Clindamycin 600 mg iv q 6 hrs
  • Gentamicin 5 mg/kg iv q 24 hrs

63
  • ?????????????????????
  • ????????????????????????????????????????????????
    ????????????????????????????????????
  • ????????????????????
  • - ????????????????????????????????
  • - ???????????????????????????????????
  • - Gas gangrene ????????
  • - ????????????????????????????????????

64
  • Retained placental fragments
  • - Curettage

65
  • Uncontrolled late PPH
  • - Uterine vessel ligation
  • - Internal iliac artery ligation
  • - Hysterectomy

66
  • ???????????????????????????
  • - ???????????????
  • - ?????????????????? 2-3 ???????
  • - ???????????????????? Sheehan syndrome

67
  • Active management
  • of the third stage of labour

68
  • 1.??? oxytocin 10 unit im. ????????????????????
    ????????????????????????????? ????????????????????
    ???????????????????????????????????????????
  • 2. ??? Clamps ???????????? ??????????????????
  • 3. ??????????????? controlled cord traction
    ?????????????????????????? ???????????????????????
    ???????
  • 4. ?????????????????????????????????? ?????????
    counter traction ????????????????????????????
    ??????????????????????

69
  • 5. ??????????????????????????????
    ?????????????????????????????
  • ????????????????????
  • 6. ?????????????????? ????????????????????????????
    ?? ?????????????????????????????
  • 7. ??????????????????????????????????? ?????????
    15 ???????????????????
  • 8. ???????????????????????? ???????????????

70
  • ??????????????????????????????????
    ??????????????????????????

71
Thank you
  • Pongsun Puntachai , MD
  • OB GYN Department
  • Sanpasittiprasong hospital , Ubon Ratchathani
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