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Postpartum Hemorrhage

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Title: OB-PED-MED-SERG Author: Microsoft Last modified by: USER Created Date: 1/11/2006 9:58:26 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Postpartum Hemorrhage


1
Postpartum Hemorrhage
  • Pramote Srikaew MD.
  • Dip.Thai Broad of OB-GYN,
  • Dip.Thai Broad of preventive medicine

2
Postpartum hemorrhage
  • Definition loss 500 ml or more of blood after
    vaginal delivery or 1000 ml or more after
    cesarean delivery
  • Normal pregnancy-induced hypervolumia 30-60 or
    1-2 L
  • Normal control of hemorrhage of placenta site
    contraction and retraction of myometrium to
    compress the vessels

3
Cause of PPH
  • Uterine atony
  • overdistended uterus-large fetus, twins,
  • hydramnios
  • prolong labor
  • very rapid labor
  • Oxytocin-induced or augmented labor
  • choriamnionitis
  • some general anesthesia-halogenated
  • hydrocarbon

4
Uterine Atony
5
Cases of PPH
  • Retained Placental tissue
  • avulsion cotyledon
  • Succenturiated lobe
  • Abnormally adherrent-accreta,
  • increta,percreta

6
Causes of PPH
  • Uterine Inversion
  • Rupture uterus
  • Lacerations and hematoma
  • Episiotomy extensions
  • Lacerations of perineum, vagina
  • or cervix

7
Uterine Atony
  • Atonic uterus is flaccid and not firm to
    palpation
  • If bleeding persists despite a firm,
    well-contracted uterus, the cause of hemorrhage
    in most likely from laceration

8
Oxytocin
  • If uterus is not firm, vigorous fundal massage is
    indicated
  • 20 U of oxytocin in 1000 mL of RLS or NSS I.V. 10
    mL/min(200 mU/min) with uterine massage
  • Oxytocin should never be given undiluted bolus
    dose as serious hypotension or cardiac
    arrhythmias

9
Ergot Derivatives
  • Methylergonovine(Methergine), 0.2 mg, I.M. or
    I.V.
  • If give i.v. may cause dangerous hypertension
    especially in the woman with preeclampsia

10
Prostaglandins
  • 15-methyl derivative of PGF2alpha (Hemabate)
  • Initial dose 250 mcg(0.25mg) i.m.
  • Repeat if necessary at 15-90 minute interval
  • Maximum of eight dose
  • Pulmonary airway and vascular constriction, side
    effects include diarrhea, hypertension, vomiting,
    fever, and tachycardia

11
Management of bleeding Unresponsive to Oxytocin
  • Employ bimanual uterine compression
  • Obtain help
  • Begin blood transfusion,
  • Explore the uterine cavity manually for retained
    placental fragment or laceration
  • Thoroughly inspect the cervix and vagina after
    adequate exposure
  • Add second large-bore I.V. catheter
  • Foley catheter is inserted to monitor urine output

12
Uterine temponade
13
Bimanual compression
14
B-Lynch uterine compression
15
B-Lynch ligation at BKLH
16
Postpartum hysterectomy
17
???????????????????? ??????
  • ??????????????????????????????????????????
    ????????
  • ??????
  • ?????????????????????????
  • ??????????????????????
  • ??????????????????????
  • Blood Bank ???????
  • ??????????????????????????????????????????????

18
ANC
  • Identify risk for PPH
  • Uterine atony macrosomia , twins, hydramnios
  • Rupture uterus previous C/S, myomectomy
  • Abnormal adherent Previous C/S, D_at_C
  • Placenta previa
  • Should be take blood for blood group, counseling
    for risk of PPH

19
Labor Room
  • admit check ??? identify ??????????????? PPH
  • ???????????????? lab ????? confirm ??????? blood
    bank ?? group ??????????
  • ???????????????? PPH ?????????????????
  • ?????????????????????????????
  • ??????????????????????????????????
  • ?????????????? induction of labor ??????
  • ?? case prolong labor
  • ?? case ???????????(precipitate labor)
  • ?????????
  • ?????????????????????????????????

20
????????????????
  • ??????????????? ??? oxytocin 10 U im.
    ???????????????? controlled cord traction
  • ???? ??? methergin .2 mg im. ???? iv.??????????
  • ??????????????????????????????????????????????????
    ???????????????????????? ????? ??????????????? 30
    ????
  • ?????????????????????????????? ??????????????
    ???????????????????? 15 ????
  • ??????????????????? uterine massage
    ??????????????? uterine massage ?????

21
????????????????
  • ???????????????????????????????????????????
    methergin 1 dose ???? ??? dose ??? 2 ???
  • ???????????????? ???????????? ????? x-macth
    ?????? i.v. catheter ???? RLS ??? oxytocin 20 U
    i.v. 10 mL/min ?????????????????
  • ?????????????????????????????????????????????
    explored vagina, cervix ??? uterine cavity
  • ????????????????? ????? Cytotec 2-4 tablets
    rectal suppository ????????????????
  • ????????????????????? Nalador 1amp NSS 100 cc
    i.v. ?? 30 ???? ??? retained foley cath. ????
    i.v.??????? 2 ???? RLS ???? NSS

22
?????????????
  • ???????????? PPH ??case ??? set C/S indication
    previous C/S, placenta previa, abruptio placenta,
    CPD , ????????? preeclampsia, failed induction,
    twins, high parity, chrioamnionitis
  • ?????? oxytocin, methergin, ??? naladol ????????
  • ???????????? hypogastic artery ligation
    ????cesarean hysterectomy ????????

23
????????
  • Observed uterine atony ??????????????? 24 ???????
    ????????????????????????????? detect uterine
    atony ??? 15 ???? ????????????????? detect
    uterine contraction ??? 1-2 ??.???????????????????
    ???
  • Blood for HCT ??????????????? 4 ??.
    ???????????????
  • ??????????????? prepereal infection
  • ????????????????? Sheehan syndrome failure of
    lactation

24
????????????????????????????????????????
  • ?????????????? Sheehan syndrome ??????????
    ??????????????? breast atrophy, loss of pubic and
    auxiliary hair, hypothyroidism ??? adrenal
    cortical insufficiency
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