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Post Partum Hemorrhage

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Post Partum Hemorrhage PPH Types: 1- Early PPH: more common. occurs immediately or slowly over the 1st 24 hours. 2- Late PPH: occurs after 24 hours but within 6 weeks ... – PowerPoint PPT presentation

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Title: Post Partum Hemorrhage


1
Post Partum Hemorrhage PPH
2
(No Transcript)
3
Definition Blood loss in excess of 500 ml with
vaginal delivery or in excess of 1000 ml
following delivery by caesarian section.
4
  • Types
  • 1- Early PPH more common.
  • occurs immediately or slowly over the 1st 24
    hours.
  • 2- Late PPH occurs after 24 hours but within 6
    weeks post delivery.

5
  • Causes
  • 1- Uterine atony.
  • 2- Genital tract trauma.
  • 3- Retained placental tissue.
  • 4- Low placental implantation.
  • 5- Coagulation disorders.
  • 6- Uterine inversion.

6
  • Uterine atony
  • Is the cause of 75 to 80 of PPH.

7
  • Factors predisposing to uterine atony
  • 1- Over distention of the uterus.
  • 2- Multiple gestation.
  • 3- Polyhydraminos.
  • 4- Fetal macrosomia.
  • 5- Prolonged labor.
  • 6- Grand multiparity.
  • 7- Oxytocic augmented labor.
  • 8- Preciptious labor.
  • 9- MgSo4 ttt of pre eclampsia.
  • 10- coriamnionitis.
  • 11- Halagenated Anaesthetics.
  • 12- Uterine Leiomyoma.

8
  • Genital tract trauma
  • Second most common cause of PPH.
  • 1- laceration of the cervix and vagina.
  • 2- laceration over the perineal body,
    periurethral area, over the ischeal spines.
  • 3- during low transverse c-section.

9
  • Retained placental tissue
  • 1- Incomplete placental seperation.
  • 2- Partial placental accreta.
  • In ½ the patients with delayed PPH, placental
    reminants are present when uterine curettage is
    performed.

10
  • Low placental implantation
  • This leads to PPH because the lower uterine
    segment has less musculature.

11
  • Coagulation disorders
  • 1- TTP.
  • 2- Amniotic fluid embolism.
  • 3- Abruptio placentae.
  • 4- ITP.
  • 5- Von Willebrands disease.

12
  • Uterine inversion
  • The inside out turning of the uterus during the
    3rd stage of labor due to improper management.

13
Obstetric History
14
Obstetric History
  • Personal data name, age.
  • Gravidity parity abortion ectopic
    pregnancy.
  • Presenting complain.
  • History of current pregnancy.
  • - was the pregnancy planned?
  • - previous booked visit (how many).
  • - regularity of menstrual cycle.
  • - LMP EDD.
  • - GA (40 - present date EDD).

15
  • Events of pregnancy in 1st, 2nd and 3rd
    trimester
  • A) symptoms of pregnancy.
  • B) complication of pregnancy.
  • C) use of drugs and supplement.
  • D) further tests carried out.
  • Past obstetric history.
  • Past gynecological history
  • - menstrual history.
  • - contraceptive \ sexual history.
  • Gynecological surgical history.
  • Past medical history.
  • Surgical history.
  • Drug history \ allergies.
  • Family history.
  • Social history.

16
Obstetric examination
  • General examination.
  • Ex. of the chest.
  • Ex. of the breast.
  • Ex. of the thyroid.
  • Abdominal Ex.
  • Ex. of the lower limb.
  • Special points in the examination fundal height.

17
  • Pelvic examination
  • - inspection.
  • - collection of cytologic specimen.
  • - palpation.
  • - rectal and recto-vaginal examination.

18
Examination in active bleeding
  • Vital signs.
  • Palpation of the fundus.
  • Inspection of vagina and cervix.
  • Pelvic examination.
  • Manual exploration of uterine cavity.

19
Initial management of PPH
20
  • check patient status.
  • early recognition of PPH.
  • monitor vital signs and oxygen.
  • establish IV access, place urinary catheter.
  • Baseline lab value.
  • Alert anesthesia and blood bank.
  • Central hemodynamic monitoring.
  • Correct anemia and coagulation disorders and
    blood products.

21
Determine underlying cause of PPH
  • Examine the uterus, placenta and genital tract.
  • Etiology will determine further management.

22
Uterine Atony
  • By manual massage and/or compression, exclude
    retained placental fragments, uterine rupture.
  • Medical Uterotonic therapy
  • 1- rapid oxytocin infusion IV, IM or
    intramyometially.
  • 2- methylergonovine.
  • 3- 15-methyl-prostaglandin F 2 alpha IM or IMM.
  • 4- Dinoprostone PEG2 rectally.

23
  • If no response to above management consider
  • 1- uterine packing.
  • 2- angiography and embolization.
  • 3- explorative laparotomy with surgical options
  • - vessel ligation.
  • - hysterectomy.

24
Lower genital tract laceration
  • Cervical, vaginal or perineal tears.
  • Determine source of bleeding.
  • Establish surgical hemostasis.
  • Evacuate hematoma.
  • If not responsive to above consider surgical
    options - uterine packing
  • - artery ligation.
  • - hysterictomy.

25
Retained placental fragments
  • Manual exploration and removal.
  • Curettage.

26
Abnormal placentation
  • Placenta accreta.
  • Conservative surgery curettage, local repair.
  • Further surgical management
  • - laparotomy.
  • - artery ligation.
  • - hysterictomy.
  • Consider angiography and embolization.

27
Uterine inversion
  • Immediate intravascular volume expansion with IV
    crystalloids.
  • Surgical procedure may be required.
  • Uterine rupture
  • Laparotomy.
  • Repair of scar or hysterectomy.

28
Thank you
  • Done by.. Group
  • E1
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