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POST PARTUM HAEMORRHAGE - A Challenge To Safe Motherhood

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Title: PPH Subject: Post Partum Haemorrhage Author: Dr.S.N.Panda Keywords: Post Partum Haemorrhage, PPH, Maternal Death Last modified by: jd Created Date – PowerPoint PPT presentation

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Title: POST PARTUM HAEMORRHAGE - A Challenge To Safe Motherhood


1
POST PARTUM HAEMORRHAGE - A Challenge To Safe
Motherhood
Dr. Arati Patnaik, M.D.
Prof..S.N.panda, M.S.
Department of of Obstetrics Gynaecology
M.K.C.G. Medical College, Berhampur, INDIA
2
WEL COME TO
Taj Mahal
Taj Mahal-One of the seven wonders of the world,
One of the Greatest monuments, dedicated to the
memory of Queen Mumtaz who died in child birth,
by her husband Emperor Sahajahan, is a
testimony and a grim reminder of the tragedy of
maternal mortality, that can befall any women in
childbirth.
3
Obstetric Haemorrhage --- Ranks as the First
cause of maternal mortality accounting for 25
50 of maternal deaths
POST PARTUM HAEMORRHAGE though preventable,
accounts for the majority of the cases of
obstetric haemorrhage, the other causes being
antepartum haemorrhage, abortion, ectopic
pregnancy and ruptured uterus.
4
POST PARTUM HAEMORRHAGE
. . . the most common and severe type of
obstetric haemorrhage, is an enigma even to the
present day obstetrician as it is sudden, often
unpredicted, assessed subjectively and can be
catastrophic. The clinical picture changes so
rapidly that unless timely action is taken
maternal death occurs within a short period.
5
Direct Causes () of Mat.Mort. in selected
countries
MAGNITUDE OF THE PROBLEM
Country MMR Haemorrhage Sepsis Toxaemia Abortion Obstructed Labour
INDIA 874 18 14 16 14 03
Bangladesh 600 22 03 19 31 09
Ethiopia 566 6 2 6 25 4
Tanzania 678 18 15 03 17 --
Zambia 118 17 15 20 17 --
USA 15 10 08 17 06 03
World watch paper 102Jacobson JL ed, 1991
MMR Maternal Mortality Rate / 100000 live
births
6
Causes of Mat.Mort. In India
MAGNITUDE OF THE PROBLEM
Cause Reg.Gen. India (1992) FOGSI (1982)
Haemorrhage 23.7 22.3
Toxaemia 15.2 10.7
Puerperal Sepsis 08.1 28.4
Anaemia 19.4 -
Obstructed Labour 07.1 -
Abortion 11.8 -
Others 14.7 -
7
MAGNITUDE OF THE PROBLEM
8
MAGNITUDE OF THE PROBLEM
PPH - A world of difference
  • Year Developed Developing
  • Countries Countries
  • 1930 13000 Births Not Available
  • 1950 120,000 Not Available
  • 1980 160,000 11000
  • 2000 1100,000 15000

9
POST PARTUM HAEMORRHAGE
  • DEFINITION -
  • Blood loss of 500ml or more per vaginum during
    the first 24hrs after the delivery of the baby.

Risk of Maternal Mortality Morbidity are 50
times more after PPH
10
ASSESSMENT OF BLOOD LOSS AFTER DELIVERY
  • Difficult
  • Mostly Visual estimation (So, Subjective
    Inaccurate)
  • Underestimation is likely
  • Clinical picture -Misleading
  • Our Mothers-Malnourished, Anaemic, Small built,
    Less blood volume

11
MECHANISM OF HAEMOSTASIS AFTER DELIVERY
  • Uterine contraction retraction
  • Platelet aggregation ? clot formation

12
Why PPH ?
  1. Uterine atony (80)
  2. Retained Placenta
  3. Trauma to genital tract
  4. Coagulation disorders
  5. Uterine inversion

13
1. UTERINE ATONY
RISK FACTORS
  • Over distension of uterus
  • Induction of labour
  • Prolonged / precipitate labour
  • Anaesthesia (halogeneted) analgesia
  • Tocolytics
  • APH
  • Grand multiparity
  • Mismanagement of 3rd stage of Labour
  • Full bladder

14
2. RETAINED PLACENTA
  • Simple adhesion
  • Morbid adhesiongtAccreta, Increta Percreta

3. TRAUMATIC
  • Large episiotomy extensions
  • Tears lacerations of perineum, vagina or cervix
  • Haematoma
  • Uterine rupture

15
4. COAGULATION DISORDERS
  • Abruptio placentae
  • Sepsis IUD,PROM
  • Massive blood loss
  • Massive blood transfusion
  • Severe PET/ Eclampsia
  • Amniotic fluid embolism
  • Hepatitis

16
5. UTERINE INVERSION
?Incomplete Inversion- Fundus felt through the Cx
Complete Inversion with placenta accreta attached
to the fundus?
  • Mostly iatrogenic due to mismanagement of 3rd
    stage - strong traction on the cord with a
    relaxed uterus / adherent placenta.

17
SYMPTOMS SIGNS
Blood loss ( B Vol) Systolic BP ( mm of Hg) Signs Symptoms
10-15 Normal postural hypotension
15-30 slight fall ?PR, thirst, weakness
30-40 60-80 pallor,oliguria, confusion
40 40-60 anuria, air hunger, coma, death
18
PREVENTION
  • Regular ANC
  • Correction of anaemia
  • Identification of high risk cases
  • Delivery in hospital with facility for Emergency
    Obstetric Care.
  • Otherwise transport to the nearest such hospital
    at the earliest.
  • Keep speedy transport available
  • Local / Regional anaesthesia
  • ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR
  • 4th Stage of labour - Observation, Oxytocin

19
ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR
(WHO-1989)
  • Oxytocics - Routine use in third stage ? blood
    loss ? by 30-40
  • 10 Units Oxytocin IV bolus
  • Syntometrine 1 Amp IV
  • Ergometrine 1 Amp IV
  • Carboprost ( better than Ergometrine) 0.125
    0.25 Mg IM
  • Early cord clamping
  • Controlled cord traction
  • Inspection of placenta lower genital tract

20
MANAGEMENT OF PPH
  • TEAM- Obstetrician, Anesthesiologist,
    Haematologist and Blood Bank
  • Correction of hypovolaemia
  • Ascertain origin of bleeding
  • Ensure uterine contraction
  • Surgical management
  • Management of special situation

21
CORRECTION OF HYPOVOLEMIA
MANAGEMENT OF PPH
  • Large bore IV line (two)
  • Crystalloids (RL)-3ml / ml of blood loss
  • Urine output (desired) 30ml / hr
  • Whole blood / pack cell

22
ENSURE UTERINE CONTRACTION
MANAGEMENT OF PPH
  • Palpate fundus
  • Uterine massage
  • Bimanual compression
  • Compression of Aorta against sacral promontory
  • Foleys catheters

23
OXYTOCICS
MANAGEMENT OF PPH
  • Oxytocin
  • Bolus of 10 units IV followed by Continuous
    Infusion 100 mu / min
  • Ergometrine 0.2 - 0.5mg IV
  • Prostaglandins-
  • Carboprost- 0.25mg start, Rpt.15-30 min, Maximum
    2.0mg, Route-IM / intramyometrial
  • Sulprostone- 400-600 micro gm

24
OTHER MODES
MANAGEMENT OF PPH
  • M.A.S.T (Military Anti Shock Treatment)
  • UTERINE PACKING
  • UTERINE TAMPONADE
  • Large bulb Foleys
  • Sangstaken Blakemore tube

25
SURGICAL TREATMENT
MANAGEMENT OF PPH
  • Depends on
  • Extent cause of haemorrhage
  • General condition of patient
  • Future reproduction
  • Experience skill

26
SURGICAL TREATMENT
MANAGEMENT OF PPH
  • Repair of trauma if any
  • Uterine A. ligation
  • Utero ovarian A. Ligation
  • Internal Iliac A. Ligation
  • Brace suturing of Uterus
  • Hysterectomy
  • Angiographic embolisation

27
RETAINED PLACENTA
MANAGEMENT OF PPH
  • EUA Manual Removal
  • If Placenta accreta-
  • Observation
  • Cytotoxic drugs- Methotrexate
  • Hysterectomy

28
ACUTE INVERSION OF UTERUS
MANAGEMENT OF PPH
  • Manual replacement-
  • Under GA / Uterine relaxant
  • Hydrostatic method
  • Surgical method ( Usually delayed procedure)

29
MANAGEMENT OF DIC
MANAGEMENT OF PPH
  • Fresh blood transfusion
  • Blood products
  • Cryoprecipitate
  • Fresh frozen plasma
  • Platelet concentrate

30
MORBIDITY MORTALITY from PPH
  • Shock DIC
  • Renal Failure
  • Puerperal sepsis
  • Lactation failure
  • Blood transfusion reaction
  • Thromboembolism
  • Sheehans syndrome
  • gt25 Maternal deaths are due to PPH

31
  • Intelligent anticipation, skilled supervision,
    prompt detection and effective institution of
    therapy can prevent disastrous consequences of
    PPH.

THANK YOU
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