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POST PARTUM HAEMORRHAGE

POST PARTUM HAEMORRHAGE. ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU, MD, PhD. Obstetric h emorrhage First cause of maternal mortality accounting for 25 – 50 % of maternal deaths. POST P ARTUM HAEMORRHAGE accounts for the majority of the cases of obstetric hemorrhage the other causes :

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POST PARTUM HAEMORRHAGE

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  1. POST PARTUM HAEMORRHAGE ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU, MD, PhD

  2. Obstetric hemorrhage First cause of maternal mortality accounting for 25 – 50 % of maternal deaths POSTPARTUMHAEMORRHAGE • accounts for the majority of the cases of obstetric hemorrhage • the other causes: antepartum hemorrhage, abortion, ectopic pregnancy and ruptured uterus.

  3. POSTPARTUM HAEMORRHAGE . . . the most common and severe type of obstetric haemmorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.

  4. MAGNITUDE OF THE PROBLEM PPH - A world of difference Year Developed Developing Countries Countries 1930 1:3000 Births Not Available 1950 1:20,000 Not Available 1980 1:60,000 1:1000 2000 1:100,000 1:5000

  5. POST PARTUM HAEMORRHAGE DEFINITION: Blood loss of > 500-600ml per vaginum during the first 24hrs after the delivery of the baby. Risk of maternal Mortality & Morbidity are 50 times more after PPH

  6. ASSESSMENT OF BLOOD LOSS AFTER DELIVERY • Difficult • Visual estimation (Subjective & Inaccurate) • Underestimation is likely • Clinical picture -Misleading • Many mothers -Malnourished, Anaemic, Small built, Less blood volume

  7. MECHANISM OF HAEMOSTASIS AFTER DELIVERY • Uterine contraction & retraction • Platelet aggregation  clot formation

  8. ETIOLOGY of PPH • Uterine atony (80%) • Retained Placenta • Trauma to genital tract • Coagulation disorders

  9. MECHANISM OF HAEMOSTASIS AFTER DELIVERY • TONUSIf the uterus is not contracted, the blood vessels are not compressed.

  10. 1. UTERINE ATONY RISK FACTORS • Overdistension of uterus • Induction of labour • Prolonged / precipitate labour • Anaesthesia (halogenated) & analgesia • Tocolytics • Maternal hypotension • Grand multiparity • Mismanagement of 3rd stage of Labour • Full bladder

  11. 2. RETAINED PLACENTAL REMNANTS RISK FACTORS • Simple adhesion • Morbid adhesion → Placenta accreta, increta or percreta

  12. 3. TRAUMA TO THE GENITAL TRACT RISK FACTORS • Large episiotomy & extensions • Tears & lacerations of perineum, vagina or cervix • Hematoma • cause→ delivery before full dilatation of the cervix (by forceps, breach extraction, forcible expulsive efforts, abuse of oxytocin)

  13. 4. COAGULATION DISORDERS RISK FACTORS • Abruptioplacentae • Retention of dead fetus • Amniotic fluid embolism • Severe PE/ Eclampsia • Sepsis: PROM • Massive blood loss • Massive blood transfusion • Hepatitis

  14. SYMPTOMS & SIGNS

  15. 1. UTERINE ATONY DIAGNOSTIC • Hemorrhage • “internal”(in the uterus) → the fundus rises, the uterus is soft,no Pinard's globus; • external hemorrhage; • mixed hemorrhage

  16. 2. RETAINED PLACENTAL REMNANTS DIAGNOSTIC • inspection of the placenta and membranes →missing placental or membrane fragments

  17. 3. TRAUMA TO THE GENITAL TRACT DIAGNOSTIC 1. Perineal and vaginal tears Four degrees of perineal laceration • 1-st degree→ the skin of the fourchette, the underlying muscle is exposed; • 2-nd degree→ the posterior vaginal wall and the perineal muscles (anal sphincter - no damage); • 3-rd degree→ the anal sphincter is torn, the rectal mucosa is intact; • 4-th degree→ the anal canal is damaged- up to the rectum.

  18. 3. TRAUMA TO THE GENITAL TRACT DIAGNOSTIC 2. Vaginal laceration - a difficult delivery (e.g. forceps delivery), inspection → the apex of the tear. 3. Cervical tears • bright red bleeding continued when contracted uterus; • lithotomy position, a large speculum in the vagina, the anterior and posterior cervical lips are grasped by two forceps. • Classification • in the vaginal part of the cervix; • above the vaginal part of the cervix (can extend to lower segment)

  19. TRAUMACERVIX TEAR

  20. 4. COAGULATION DISORDERS DIAGNOSTIC • release of thromboplastine → change in the mechanism of the coagulation • continuous hemorrhage with fresh blood that does not coagulate and forms no clots; • signs of shock and hypovolemia.

  21. PREVENTION • Regular antenatal care • Identification of high risk cases • Correction of anemia, PE • Delivery in hospital with facility for Emergency Obstetric Care. • Local / Regional anaesthesia • ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR • Post partum period - Observation, Oxytocin

  22. ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR (WHO-1989) • Oxytocin - Routine use in third stage  blood loss  by 30-40% • Oxytocin • Ergometrine • PG • Early cord clamping • Controlled cord traction • Inspection of placenta & lower genital tract

  23. MANAGEMENT OF PPH • TEAM- Obstetrician, Anesthesiologist, Hematologist and Blood Bank • Correction of hypovolemia • Ascertain origin of bleeding • Ensure uterine contraction • Surgical management • Management of special situation

  24. MANAGEMENT OF PPH ENSURE UTERINE CONTRACTION • Palpate fundus • Uterine massage • Bimanual compression • Compression of aorta against sacral promontory

  25. OXYTOCICS MANAGEMENT OF PPH • Oxytocin - Bolus of 10 units IV followed by Continuous Infusion • Carbetocine • Ergometrine • Prostaglandins

  26. OTHER MODES MANAGEMENT OF PPH • Anti Shock Treatment • UTERINE PACKING • UTERINE TAMPONADE • Large bulb Foleys

  27. SURGICAL TREATMENT MANAGEMENT OF PPH Depends on • Extent & cause of haemorrhage • General condition of patient • Future reproduction • Experience & skill

  28. SURGICAL TREATMENT MANAGEMENT OF PPH • Repair of trauma if any • Uterine a. ligation + Utero ovarian a. ligation • Internal Iliac a. ligation • Hysterectomy • Angiographic embolisation

  29. RETAINED PLACENTAL FRAGMENTS MANAGEMENT OF PPH • Examination (under anesthesia) & manual +/- curettage removal • If placenta accreta • Observation • Cytotoxic drugs- Methotrexate • Hysterectomy

  30. MANAGEMENT OF DISSEMINATED INTRAVASCULAR COAGULATION MANAGEMENT OF PPH • Fresh blood transfusion • Blood products • Cryoprecipitate • Fresh frozen plasma • Platelet concentrate

  31. MORBIDITY & MORTALITY from PPH • Shock & DIC • Renal Failure • Puerperal sepsis • Lactation failure • Blood transfusion reaction • Thromboembolism • Sheehan’s syndrome • >25% Maternal deaths are due to PPH

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