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Post Partum Hemorrhage Uterine Rupture

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Title: Author: wangzp Last modified by: user Created Date: 4/1/2008 3:44:08 AM Document presentation format: Other titles – PowerPoint PPT presentation

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Title: Post Partum Hemorrhage Uterine Rupture


1
Post Partum Hemorrhage Uterine Rupture
  • Womens Hospital School of Medicine Zhejiang
    University
  • Wang Zhengping

2
Post partum hemorrhage
3
Post partum hemorrhage
  • Past partum hemorrhage denotes excessive bleeding
    (500ml in vaginal delivery) during the first 24
    hours after delivery
  • Common cause of death and diseases in pregnant
    women globally
  • Leading cause of death in pregnant women in China
  • Incidence 2-3 of total number of deliveries

4
Etiology
  • Uterine atony 70
  • Obstetric lacerations 20
  • Retained placental tissue 10
  • Coagulation1

5
Uterine atony
  • General factors extreme nervousness, sedative,
    anesthesia, tocolytics, weak
  • Obstetric factors prolonged labour, fatigue,
    placenta previa, placenta abruptio, severe anemia
  • Uterine factors uterine muscular fiber
    underdevelopment, such as uterine deformity or
    myoma uterine overstretched, such as macrosomia,
    multiple pregnancy, polyhydramnios

6
Placental factors
  • Incomplete placental separation
  • Retained placenta
  • Placental incarceration(?? )
  • Placental adhesion
  • Placental implantation (accreta, increta,
    percreta)
  • Residual placenta and amniotic membrane

7
Implantation of placenta
8
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10
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12
Birth canal injury
  • Laceration during labour are usually associated
    with
  • Poor vulval elasticity
  • Strong labour force, emergency delivery,
    macrosomia
  • Inadequate skills at assisted vaginal delivery
  • Inadequate cessation of bleeding during
    episiotomy repair, missing out tears at cervix or
    fornices

13
Coagulation disorder
  • Complications associated with obstetric amniotic
    fluid embolism, pregnancy induced hypertensive
    diseases, placenta abruptio and intrauterine
    demise
  • Pregnancy liver disease acute fatty liver,
    severe hepatitis
  • Hematology diseases primary thrombocytopenic
    purpura, aplastic anemia etc

14
Clinical presentation
  • Vaginal bleeding
  • If bleeding occurs immediately after delivery of
    baby, consider birth canal injury
  • If bleeding occurs minutes after delivery of
    baby, consider placenta factors
  • If bleeding occurs minutes after delivery of
    placenta, main reasons are uterine atony or
    retained products of conception
  • Persistent bleeding and blood do not coagulate,
    consider coagulation disorder causing PPH

15
Clinical presentation
  • Vaginal hematoma
  • Shock dizziness, paleness, weak pulse, low blood
    pressure etc

16
Diagnosis
  • Estimation of blood loss
  • Ascertain cause of post partum hemorrhage

17
Estimation of blood loss
  • Visual observation only 50-70 of blood loss
  • Container kidney dish, measuring cup
  • Surface area blood stained 10cmx10cm 10ml
  • Weighing 1.05g 1ml
  • Hctlt30, Hb50-70g/L, blood loss gt1000ml
  • Hourly urine output lt25ml, blood loss gt2500ml
  • Shock index pulse rate/systolic pressure

18
Shock index (SI)
  • SI lt0.5, normal blood volume
  • SI 0.5-1, blood loss lt20, 500-750ml
  • SI 1, blood loss 20-30, 1000-1500ml
  • SI 1.5, blood loss 30-50, 1500-2500ml
  • SI 2, blood loss 50-70, 2500-3500ml

19
Ascertain cause
  • Uterine atony
  • Fundus goes up
  • Uterine consistency soft, water bag like
  • After uterine massage or using oxytocin, uterus
    harden, per vaginal bleeding lessen
  • Categorize into primary and secondary, with
    direct and indirect causes

20
Ascertain cause
  • Placental factors
  • Placenta not delivered within 10 minutes of
    delivery of baby, with massive per vaginal bleed,
    consider placental factors
  • Residual placenta is a common cause of post
    partum hemorrhage
  • Must examine the placenta and membrane carefully

21
Ascertain cause
  • Birth canal injury
  • Cervical tear
  • Vaginal tear
  • Vulval tear

22
Degree of vulval tear
  • Degree I vulval skin and vaginal opening mucosa
    tear, not reaching muscular layer
  • Degree II tear into perineal body muscular
    layer, involving posterior vaginal wall mucosa,
    may extend up on both sides, making it hard to
    recognise original anatomy
  • Degree III external anal sphincter tear, may
    involve vaginal rectal septum and anterior rectal
    wall

23
Degree of vulval tear
24
Ascertain cause
  • Coagulation disorder
  • Patients with blood disorder or DIC caused by
    delivery etc
  • Sustained per vaginal bleeding, non-clotting,
    difficulty in hemostasis
  • May have bleeding at any parts of the body
  • Diagnose based on history, bleeding
    characteristics, platelet count, prothrombin
    time, fibrinogen etc tests

25
Management
  • Principal of management for post partum
    hemorrhage is
  • Rapid hemostasis according to the cause
  • Replenish volume, correct shock
  • Prevent infection

26
Management of uterine atony
  • Remove cause
  • Uterine massage
  • Abdominal fundus massage
  • Abdominal-vaginal bimanual uterine massage
  • Uterotonic agents
  • oxytocin/ ergot derivatives/prostaglandins
  • Uterine packing
  • Pelvis vessel ligation
  • B-Lynch suture
  • Arterial embolism
  • Hysterectomy

27
Uterine massage
28
Management of uterine atony
  • Remove cause
  • Uterine massage
  • Abdominal fundus massage
  • Abdominal-vaginal bimanual uterine massage
  • Uterotonic agents
  • oxytocin/ ergot derivatives/prostaglandins
  • Uterine packing
  • Pelvis vessel ligation
  • B-Lynch suture
  • Arterial embolism
  • Hysterectomy

29
Management of uterine atony
  • Remove cause
  • Uterine massage
  • Abdominal fundus massage
  • Abdominal-vaginal bimanual uterine massage
  • Uterotonic agents
  • oxytocin/ ergot derivatives/prostaglandins
  • Uterine packing
  • Pelvis vessel ligation
  • B-Lynch suture
  • Arterial embolism
  • Hysterectomy

30
Uterine packing
31
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32
Management of uterine atony
  • Remove cause
  • Uterine massage
  • Abdominal fundus massage
  • Abdominal-vaginal bimanual uterine massage
  • Uterotonic agents
  • oxytocin/ ergot derivatives/prostaglandins
  • Uterine packing
  • Pelvis vessel ligation
  • B-Lynch suture
  • Arterial embolism
  • Hysterectomy

33
Pelvis vessel ligation
34
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35
Management of uterine atony
  • Remove cause
  • Uterine massage
  • Abdominal fundus massage
  • Abdominal-vaginal bimanual uterine massage
  • Uterotonic agents
  • oxytocin/ ergot derivatives/prostaglandins
  • Uterine packing
  • Pelvis vessel ligation
  • B-Lynch suture
  • Arterial embolism
  • Hysterectomy

36
B-Lynch suture
37
Management of uterine atony
  • Remove cause
  • Uterine massage
  • Abdominal fundus massage
  • Abdominal-vaginal bimanual uterine massage
  • Uterotonic agents
  • oxytocin/ ergot derivatives/prostaglandins
  • Uterine packing
  • Pelvis vessel ligation
  • B-Lynch suture
  • Arterial embolism
  • Hysterectomy

38
Arterial embolism
39
Management of uterine atony
  • Remove cause
  • Uterine massage
  • Abdominal fundus massage
  • Abdominal-vaginal bimanual uterine massage
  • Uterotonic agents
  • oxytocin/ ergot derivatives/prostaglandins
  • Uterine packing
  • Pelvis vessel ligation
  • B-Lynch suture
  • Arterial embolism
  • Hysterectomy

40
Management of placental factors
  • Retained placenta remove separated placenta
    quickly
  • Residual placenta or membrane curettage
  • Placental adhesion manual removal of placenta
  • Placental implantation never separate
    forcefully, usually hysterectomy

41
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42
Management of laceration
  • Thorough hemostasis
  • Stitch according to anatomical layering
  • First stitch must be 0.5cm above top end
  • When stitching do not leave dead space
  • Avoid stitching through rectal mucosa
  • Manage cervical tear
  • Manage birth canal hematoma

43
Manage cervical tear
44
Management of coagulation disorder
  • First exclude bleeding caused by uterine atony,
    placental factors and birth canal injury
  • Actively transfuse fresh whole blood, platelets,
    fibrinogen or prothrombin complex, clotting
    factors etc
  • If DIC set in, manage DIC

45
Prevention
  • Comprehensive antenatal care, screen for high
    risk factors, intervene accordingly
  • Appropriate labour management
  • Aggressive post partum monitoring 2 hours post
    partum is the peak of post partum hemorrhage,
    patient must be monitored in labour room for 2
    hours

46
Rupture of uterus
47
Definition
  • The body uterine or lower uterine segment happens
    to rupture during late pregnancy or labor
  • Rupture of the pregnant uterus is a obstetric
    catastrophe and major cause of maternal death

48
Etiology
  • Descending of presenting part obstruction narrow
    pelvis, cephalo-pelvic disproportion, soft tissue
    obstruction, fetal malposition, fetal abnormality
  • Inappropriate use of oxytocin?prostaglandin etc
  • Uterine scar fibroidectomy, caesarean section
  • Surgical trauma

49
Clinical presentation
  • Happens at late pregnancy or during labour, more
    during labour
  • Complete rupture and incomplete rupture
  • Spontaneous rupture or traumatic rupture
  • Body rupture or lower segment rupture
  • It is usually a progressive process, separated
    into 2 stages, impending rupture and uterine
    rupture

50
Threatened uterine rupture
  • Obstructed descend of fetal presenting part,
    prolong labor
  • Appearance of pathologic retraction ring
  • Mother shows distress, rapid breathing and heart
    rate, unbearable pain
  • Urination difficulty, hematuria
  • Fetal heart rate change or unclear

51
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53
Complete uterine rupture
  • At the point rupture, patient experiences sudden
    abdominal tearing pain, uterine contraction
    ceases, temporary relieve of abdominal pain
  • Following blood, amniotic fluid, fetus going into
    the abdominal cavity, abdominal pain
    progressively worsen
  • Patient presents with rapid breathing, paleness,
    weak pulse, decreasing blood pressure etc shock
    manifestations

54
Complete uterine rupture
  • Tenderness and rebound tenderness throughout
    abdomen
  • Fetal parts and small uterine body may be easily
    palpable under abdominal wall, disappearing of
    fetal movement and fetal heart
  • Vaginal examination may have fresh bleeding,
    originally dilated cervix becomes smaller, ascend
    of fetal presenting part, if site of rupture is
    low, may be able to palpate uterine wall rupture
    per vaginal

55
Complete uterine rupture
  • Uterine body scar rupture, usually complete
    rupture, no obvious impending rupture
    presentations
  • As the scar tear progressive widens, pain and
    other presentations progressively worsen, but
    might not have typical tearing pain

56
Incomplete uterine rupture
  • Usually seen in lower segment caesarean section
    scar
  • Usual pain symptoms and signs are not obvious,
    may have obvious tenderness at the site of
    incomplete rupture
  • Incomplete rupture involving uterine artery, may
    lead to acute massive bleeding
  • Rupture occurring in lateral uterine walls within
    the broad ligaments, may cause broad ligament
    hematoma, during which a tender mass is palpable
    one side of the uterine body and progressively
    enlarges
  • Irregular fetal heart

57
Diagnosis
  • Typical uterine rupture is easily diagnose based
    in the history, symptoms and signs
  • Incomplete uterine rupture, as signs and symptoms
    are not obvious, diagnosis is difficult.
  • Ultrasound examination may show position between
    fetus and uterus, confirming site of rupture

58
Differential diagnosis
  • 1. Severe placenta abruptio
  • Unbearable abdominal pain, uterine tenderness
  • Disproportion between bleeding volume and degree
    of anemia
  • Ultrasound may shows retro-placental hematoma,
    fetus is intrauterine
  • Usually associated with pregnancy induced
    hypertensive diseases or trauma

59
Differential diagnosis
  • 2. Intrauterine infection
  • Usually seen in premature rupture of membrane,
    prolonged labour, multiple vaginal examination
  • May have abdominal pain and uterine tenderness
    etc
  • Temperature rise
  • Abdominal examination fetus is intrauterine
  • White blood cell and neutrophil counts rise

60
Management of impending uterine rupture
  • Suppress uterine contraction give inhaled
    anesthesia or intravenous generalized anesthesia,
    intramuscular pethidine 100mg etc to relieve
    uterine contraction
  • Oxygen
  • Prepare for emergency surgery
  • Immediate caesarean section, prevent uterine
    rupture

61
Management of uterine rupture
  • Regardless whether fetus is alive, actively
    manage shock and operate soonest possible
  • Type of surgery decided based on maternal
    condition, degree of uterine rupture, duration of
    rupture and degree of infection
  • Tear repair neat tear, no obvious infection
  • Hysterectomy big tear, irregular tear or obvious
    infection, perform subtotal hysterectomy. If tear
    extends to cervix, perform total hysterectomy

62
Management of uterine rupture
  • During surgery carefully inspect cervix, vagina,
    bladder, urethra, rectum and all neighboring
    structures, repair accordingly if damage found
  • Give high dose broad spectrum antibiotics
    perioperatively to prevent infection

63
Transfer
  • Uterine rupture presenting with shock,
    resuscitate immediately on site
  • If transfer is necessary, it must be done under
    the condition where blood transfusion, fluid
    infusion, resuscitation. abdomen must be bandaged
    before transporting

64
Prevention
  • Build more efficient and comprehensive antenatal
    care
  • Patients of high risk should admit 1-2 weeks
    before expected date of delivery
  • Strengthen observation ability of doctors and
    midwives, pick up abnormality during labour
    promptly
  • Strict indication for caesarean section and all
    vaginal surgery, strict surgical steps, avoid
    careless surgery, pick up surgical damage
    promptly
  • Strict indication of usage of oxytocin

65
Thank you
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