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Postpatrum Hemorrhage and Third Stage Emergencies

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... Coagulopathy Pre-existing conditions ITP, von Willebrands Coagulaopthic: Obstetric-related Hypertension disorders, HELLP Abruption Fetal demise Sepsis Drugs ... – PowerPoint PPT presentation

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Title: Postpatrum Hemorrhage and Third Stage Emergencies


1
Postpatrum Hemorrhage and Third Stage Emergencies
2
Postpartum Hemorrhage
  • 3-5 of vaginal deliveries
  • Definition gt500ml blood loss
  • Potentially serious complications for mother
  • Common cause of maternal morbidity and mortality
    worldwide

3
PPH Risk Factors
  • Antepartum
  • Pre-eclampsia
  • Multiparity
  • Multiple gestation
  • Previous postpartum hemorrhage
  • Previous cesarean section
  • Intrapartum
  • Prolonged third stage (gt30 mins)
  • Arrest of descent
  • Episiotomy
  • Lacerations cervical, vaginal, perineal
  • Assisted delivery forceps, vacuum
  • Augmented labour

4
Causes of PPH The Four Ts
  • Tone (70)
  • Trauma (20)
  • Tissue (10)
  • Thrombin (1)

5
PPH Resuscitative Measures
  • Call for help
  • Airways, Breathing, Circulation
  • Two large-bore IVs
  • Oxygen
  • Stat labs type cross, hb, coags
  • Consider transfusion

6
Treatment Approach for PPH
  • Catheterise bladder
  • Uterine massage
  • Oxytocics
  • Inspect for lacerations
  • Surgical intervention

7
Tone Uterine Atony
  • Most common cause of PPH
  • Initial step bimanual uterine massage and
    compression
  • Oxytocic agents
  • Oxytocin
  • Methylergometrine
  • Prostaglandins

8
Oxytocin
  • Drug of choice
  • 10 40 units in 1 litre at 250 cc/hr
  • 1M (10 units) or IV infusion
  • No contraindications
  • Hypotension with IV push

9
Ergot Alkaloide
  • Ergometrine 0.25 mg
  • IM only
  • Contraindicated in hypertension

10
Prostaglandins
  • 15-methyl prostaglandin F2a
  • carboprost, Hemabate
  • 0.25 mg IM or intramyometrial
  • Side effects nausea, diarrhea, flushing,
    headache
  • Contraindication hypersensitivity
  • Caution asthma, HTN, cardio- pulmonary disease

11
Trauma
  • Uterine inversion
  • Uterine rupture
  • Vaginal or cervical lacerations
  • Hematoma
  • Perineal tears

12
Uterine Rupture
  • Associated with uterine surgery
  • Suspect if
  • vaginal bleeding
  • abdominal tenderness
  • maternal tachycardia
  • signs of shock are out of proportion to viable
    blood loss

13
Uterine Inversion
  • Rare, but important to recognize quickly
  • Suspect if shock disproportionate to blood loss
  • Replace uterus immediately or after resuscitation
  • Watch for vasovagal reflex

14
Tissue
  • Retained placenta
  • Not delivered within 30 minutes
  • 3 of deliveries
  • Retained placental fragments
  • Invasive placenta

15
Manual Placental Removal
  • Cease uterine massage
  • Identify cleavage plane
  • Cup cotyledons in palm
  • Explore uterine cavity
  • Give oxytocin

16
Thrombin - Coagulopathy
  • Pre-existing conditions
  • ITP, von Willebrands
  • Coagulaopthic Obstetric-related
  • Hypertension disorders, HELLP
  • Abruption
  • Fetal demise
  • Sepsis
  • Drugs (e.g. asprin)

17
Coagulation Lab Studies
  • FBC with platelet count
  • PT-INR, aPPT
  • Fibrinogen level
  • FDP / D-dimer

18
PPH Summary
  • Unpredictable be prepared
  • Uterine atony is the main cause
  • Remember 4-Ts
  • Tone, Trauma, Tissue, Thrombin
  • Consider active management of the third term
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