Postpartum Hemorrhage

1. Postpartum Hemorrhage Dr. Yasir Katib MB BS, FRCSC

2. Postpartum Haemorrhage • Introduction • Risk Factors • Prevention • Treatment • Pelvic Haematoma • Umbrella Pack • Uterine Inversion

3. PPH - Introduction • Acute blood loss – most common cause of hypotension in obstetrics • Usually occurs immediately before or after placental delivery • Most commonly results when uterus fails to contract - effective haemostasis dependent on contraction of myometrium (compresses severed vessels)

4. PPH - Introduction • Factors Predisposing to Myometrial Dysfunction • Uterine Overdistention • Multiple Pregnancy • Fetal Macrosomia • Hydramnios • Oxytocin-stimulated Labour • Uterine Relaxants • Amnionitis

5. PPH - Introduction • Abnormal placentation • Placenta accreta – attaches directly into myometrium • Placenta increta - extends deep into myometrium • Placenta percreta - through the uterine serosa & even into the surrounding organs • PPH occurs b/c myometrial tissue present at implantation site insufficient to constrict spiral arteries of the uterus. • Attempting to remove the abnormal placenta frequently results in uncontrolled haemorrhage because of large open sinuses in the myometrium.

6. PPH – Risk Factors(Obstetric Haemorrhage >1 L) • Placental abruption • Placenta previa • Multiple pregnancy • Obesity • Retained placenta • Induced labour • Episiotomy • Birth weight > 4 kg

7. PPH – Prevention • Active management of 3rd stage of labour & spontaneous delivery of placenta @ time of C/S • Umbilical cord clamping within 30s of delivery, gentle cord traction, followed by IM or IV oxytocin before delivery of placenta • Oxytocin s length of 3rd stage of labour (~ 5 min) & low incidence of manual removal (2%) • In absence of sig. maternal haemorrhage, additional 30 min of expectant management allow ½ of retained placentas to deliver spontaneously

8. PPH – Tx (Manual) • Manual digital exploration of uterus to r/o possibility of retained placental fragments

9. PPH – Tx (Manual) • If not detected, manual massage of uterus should be started

10. PPH – Tx (Pharmacologic) • At the same time, initial Tx of oxytocin 10-20 U/1000 mL of NS at rates as high as 500 mL in 10 min. • If oxytocin fails, synthetic prostaglandin (Prostin, Upjohn) is 2nd line (0.25 mg IM in deltoid q1-2h X 5 doses) • Ergovine (0.2 mg IM) used to be 2nd line • Misoprostol (1000 g PR) in patients with refractory uterine bleeding shown (O’Brien et al.)

11. PPH – Tx (Surgical) • Inspection for laceration of maternal tissues could be a likely cause of continued vaginal or cervical bleeding • Repair

12. PPH – Tx (Surgical) • 1st degree – involves fourchet, perineal skin & vaginal mucosal membrane • 2nd degree – also involves muscles of perineal body; rectal sphincter remains intact

13. PPH – Tx (Surgical) • 3rd degree – extends not only through the skin, mucous membrane & perineal body, but includes the anal sphincter

14. PPH – Tx (Surgical) • 4th degree laceration – extends through the rectal mucosa

15. PPH – Tx (Surgical) • Cervical laceration – NB to secure base of laceration (often a major source of bleeding); but difficult to suture

16. PPH – Tx (Surgical) • If uterine bleeding not responsive to pharmacologic methods & no vaginal or cervical lacerations present, surgical exploration may be necessary • Laceration of uterine vessels may be found (i.e. longitudinal lacerations of inner myometrium – thought to be an incomplete form of uterine rupture)

17. PPH – Tx (Surgical) • If haemorrhage secondary to atony, vascular ligation often necessary • Hypogastric artery ligation fallen out of favour b/c of prolonged OR time, technical difficulties & inconsistent clinical response • If bilateral uterovarian vessel ligation does not stop bleeding, temporary occlusion of infundibulopelvic ligament (digital pressure or clamps) should be attempted – ligation indicated if this controls bleeding

18. PPH – Tx (Surgical) • Instead, stepwise progression of uterine vessel ligation should be performed • 1st – ligation of ascending branch of uterine arteries (in ~10-15% of atony, unilateral ligation of uterine artery sufficient to control bleeding; bilat will control an additional 75%) • If bleeding persists, should attempt to interrupt blood flow between uterus & infundibulopelvic ligament via ligation of anastomosis of ovarian & uterine artery

19. PPH – Tx (Surgical)

20. PPH – Tx (Radiological) • Advantages – d anaesthetic & surgical risks - identification & selective occlusion of specific vessels - avoid hysterectomy • Could also use transient transcatheter uterine artery balloon for management of extreme haemorrhage

21. PPH – Tx (Radiological) • Successfully used in postpartum bleeding from atony, bleeding from pelvic vessel laceration, post c-section haemorrhage & bleeding associated with extrauterine pregnancy • Complications - postprocedure fever & pelvic infection (most common) - reflux of embolic material in nontargeted pelvic structures

22. PPH – Pelvic Hematoma • Blood loss not always visible • Occasionally, traumatic laceration of blood vessels can lead to pelvic haematoma formation • 3 types • Vulvar • Vaginal • Retroperitoneal

23. PPH – Pelvic Hematoma • Vulvar • D/t laceration of vessels in superficial fascia of either the ant. or post. pelvic triangle • Usual signs : subacute volume loss & vulvar pain • Blood loss limited by Colle’s fascia & urogenital diaphragm & anal fascia • B/c of fascial boundaries, mass extends to skin & visible haematoma results • Tx – volume support & surgical evacuation of blood & clots, pressure bandage, Foley catheter

24. PPH – Pelvic Hematoma

25. PPH – Pelvic Hematoma • Vaginal • Frequently associated with forceps delivery; may be spontaneous • Less common than vulvar • Blood accumulates in plane above level of pelvic diaphragm • Unusual for large amounts of blood to collect • Frequent complaint – severe rectal pressure • Exam – large mass protruding into vagina • Tx – incision of vagina & evacuation (even if delayed Dx)

26. PPH – Pelvic Hematoma

27. PPH – Pelvic Hematoma • Retroperitoneal • Least common • Most dangerous to mother • May not be impressive until sudden onset of hypotension/shock • D/t laceration of one of vessels originating from hypogastric artery • Tx : surgical exploration & ligation of hypogastric vessels unilaterally or bilaterally if needed

28. PPH – Uterine Inversion • Characterized by partial delivery of the placenta, followed by rapid onset of shock ( usually before sig. blood loss) in the mother in the 3rd stage of labour • Can be mistaken for partially separated placenta or aborted myoma • Uncommon but life-threatening event • Incidence : 1/2000 deliveries

29. PPH – Uterine Inversion • Incomplete – if corpus does not pass through cervix • Complete – if corpus passes through the cervix • Prolapsed – if corpus extends through vaginal introitus • Usually occurs in association with a fundally inserted placenta

30. PPH – Uterine Inversion • Tx : fluid therapy & restoration of uterus to N position immediately upon recognition of inversion, without removing the placenta • If initial efforts fail, use of either -mimetic agents or magnesium sulfate should be tried (esp. if severe maternal hypotension) • Occasionally, impossible to reposition uterus vaginally & laparotomy necessary • Once inversion corrected, oxytocic or prostaglandin agents should be given

31. The End