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Postpartum hemorrhage

Postpartum hemorrhage. Postpartum hemorrhage. Blood loss > 500 ml for vaginal delivery >1000 ml for caesarean section (Pritchard et al , 1962) (WHO) After completion of the third stage of labor Inaccurate estimated blood loss, underreporting.

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Postpartum hemorrhage

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  1. Postpartum hemorrhage

  2. Postpartum hemorrhage • Blood loss • > 500 ml for vaginal delivery • >1000 ml for caesarean section (Pritchard et al, 1962) (WHO) • After completion of the third stage of labor • Inaccurate estimated blood loss, underreporting Michael A Belfort, MBBCH, MD, PhD, FRCSC, FRCOG. Overview of postpartum hemorrhage.

  3. Postpartum hemorrhage • >10% change in hematocrit (Combs et al, 1991) • Need for blood transfusion (Combs et al, 1991) • Excessive bleeding that makes the patient symptomatic • Potential to produce hemodynamic instability (>10% of total blood volume) Michael A Belfort, MBBCH, MD, PhD, FRCSC, FRCOG. Overview of postpartum hemorrhage.

  4. Symptom related to  blood loss with postpartum hemorrhage

  5. Postpartum hemorrhage • Primary PPH • 4–6% of pregnancies • Occurring within first 24 hours of delivery • Secondary PPH • Occurring between 24 hours and 6–12 weeks postpartum Michael A Belfort, MBBCH, MD, PhD, FRCSC, FRCOG.Overview of postpartum hemorrhage ACOG Practice Bulletin No.76: Postpartum Hemorrhage .Obstet Gynecol. 2006 ; 108(4): 1039-47

  6. 80% or more of cases

  7. Etiology of PPH SOGC clinical practice guideline : Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. JOCG. 2009; 235: 980-93.

  8. แนวทางการวินิจฉัยเพื่อหาสาเหตุของภาวะตกเลือดหลังคลอดระยะแรก

  9. แนวทางการวินิจฉัยเพื่อหาสาเหตุของภาวะตกเลือดหลังคลอดระยะแรก

  10. Management

  11. Step 1Initial Assessment and treatment Resuscitation • Call for help • Large bore IV • ABC • O2 supplement • Vital sign, I/O • Foley catheter Assess Etiology - Explore uterus (tone,tissue) - Explore LGT (trauma) - Review Hx (thrombin) - Observed bleeding Laboratory test - CBC - Coagulation - Group and cross Step 2 : Directed Therapy Trauma - Correct inversion - Repair laceration - Repair hematoma Tone - Massage - Uterotonic Drugs Thrombin - Anticoagulation - Replace factor Tissue - Manual removal - Curettage Adapted from : WHO guidelines for the management of postpartum haemorrhage and retained placenta, 2009.

  12. Step 3 : Intractable PPH Get Help - Large bore iv - Anesthesiologist - Lab and ICU Local Control - Manual compression +/- pack uterus +/- uterine tamponade +/- embolization BP & Coagulation - Crystalloid - Blood product Step 4 : Surgery Repair laceration Ligate vessels - Uterine/ ovarian vessel - Internal iliac artery Hysterectomy Step 5 : Post Hysterectomy Bleeding Abdominal packing Angiographic Embolization Adapted from : WHO guidelines for the management of postpartum haemorrhage and retained placenta, 2009.

  13. Medical Management

  14. ACOG Practice Bulletin No.76: Postpartum Hemorrhage .Obstet Gynecol. 2006 ; 108(4): 1039-47

  15. RTCOG Guideline October 2011. Management of atonic postpartum hemorrhage

  16. RTCOG Guideline October 2011. Management of atonic postpartum hemorrhage

  17. ยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัวยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัว

  18. ยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัวยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัว

  19. ยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัวยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัว

  20. ยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัวยาที่ใช้รักษาภาวะมดลูกไม่หดรัดตัว

  21. Bimanual uterine compression

  22. Compression of abdominal aorta

  23. Tamponade and Surgical Management

  24. Uterine tamponade Temporarily control active PPH due to uterine atony which not responded to medical treatment ACOG Practice Bulletin No.76: Postpartum Hemorrhage .Obstet Gynecol. 2006 ; 108(4): 1039-47

  25. Tamponade balloon

  26. Bakri Balloon Tamponade ใส่น้ำได้ 300-500 มิลลิลิตร

  27. Surgical Management

  28. B-lynch Technique Compression suture

  29. B-lynch Technique Compression suture

  30. Cho techniqueCompression suture

  31. Uterine artery ligation

  32. Umbrella packing

  33. Uterine artery embolization

  34. Birth canal laceration

  35. Birth canal laceration • Perineal tear • Vaginal tear • Cervical tear

  36. Perineal tear repair • Principle : ensure that first stitch suture inserted above apex of the tear or episiotomy wound • Continous polyglactin/ polyglycolic acid suture on tapercut needle • Obliterated dead space and taking care that sutures not too tightly • If dead spaces cannot be closed securely : Vg packing B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract.Sapiens Publishing, 2006.

  37. Vaginal tear repair • Superficial tear : similar to perineal tear • Deeper tear : • Identified bleeding vessel and ligated it • Any significant dead space or tear too friable to accept suturing >> packing • Repaired should be done under adequate anesthesia B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract.Sapiens Publishing, 2006.

  38. Vaginal tear repair • Vaginal packing using gauze : common method to achieve temponade • Vaginal packing with thrombinsoaked pack : closure of all laceration has not been possible • Risk of raw surface will rebleeding when removed packing : using sterile plastic bag inserted with providoneiodine-soaked pack • Left packing for 24-36 hr with retained Foley’s catheter and ATB prophylaxis B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract.Sapiens Publishing, 2006.

  39. Cervical tear • Superficial lacerations of the cervix can be seen on close inspection in more than half of all vaginal deliveries. • Most of these are less than 0.5 cm and seldom require repair (Fahmy, 1991). • Deeper lacerations are less frequent, but even these may be unnoticed. • Due to ascertainment bias, variable incidences are described. Williams Obstetrics, 24th Edition - Cunningham, Leveno, Bloom et al

  40. Cervical tear • not usually problematic unless • hemorrhage • extend to the upper third of the vagina. • Rarely, the cervix may be entirely or partially avulsed from the vagina —colporrhexis—in the anterior, posterior, or lateral fornices. • sometimes follow • difficult forceps rotations • forceps blades applied over the cervix. Williams Obstetrics, 24th Edition - Cunningham, Leveno, Bloom et al

  41. Cervical tear • In some women, cervical tears reach into lower uterine segment and involve the uterine artery and its major branches. • They occasionally extend into the peritoneal cavity. • The more severe lacerations usually manifest as external hemorrhage or as a hematoma, however, they may occasionally be unsuspected. Williams Obstetrics, 24th Edition - Cunningham, Leveno, Bloom et al

  42. Cervical tear Melamed N et al. Intrapartum cervical lacerations: characteristics, risk factors, and effects on subsequent pregnancies. AJOG. 2009 ;200: 388e1-4.

  43. Cervical tear repair • Laparotomy : tear extending above internal os • Packing with pressure : small, or non bleeding laceration • Cervical tear with active bleeding or longer than 2 cm may be repaired • Absorbable suture material

  44. Gasp edges of most caudal part of laceration with ring forceps B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract.Sapiens Publishing, 2006.

  45. Suture with interrupted or figure of eight stitch • Held with hemostat to bring down into view next part to repair B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract.Sapiens Publishing, 2006.

  46. Suture to the apex of the laceration • Observed of laceration for a few minutes to ensure secure hemostasis B-Lynch C et al. A textbook of postpartum hemorrhage: bleeding from the lower genital tract.Sapiens Publishing, 2006.

  47. Prevention of PPH • Active management of third stage of labor • Assisted expulsion of placenta • Prevent of decrease blood loss SOGC clinical practice guideline : Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. JOCG. 2009; 235: 980-93.

  48. Active management of 3rd stage of labor The Cochrane Review concluded that active management reduced risks of the following • maternal blood loss • postpartum hemorrhage exceeding 500 mL • prolonged third stage labor

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