1 / 63

LATE POST-PARTUM HEMORRHAGE

LATE POST-PARTUM HEMORRHAGE. DR.FARIBA BEHNAMFAR DR.FAHIMEH SABET. خدایا شروع سخن نام توست وجودم به هر لحظه آرام توست دل از یاد و نامت بگیرد قرار خوشم چونکه باشی مرا در کنار. CASE PRESENTATION. CASE 1 38 y , G 2 L 1(NVD) PMH , PDH ,PSH – PNC : complete

tmurray
Download Presentation

LATE POST-PARTUM HEMORRHAGE

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. LATE POST-PARTUM HEMORRHAGE DR.FARIBA BEHNAMFAR DR.FAHIMEH SABET

  2. خدایا شروع سخن نام توستوجودم به هر لحظه آرام توستدل از یاد و نامت بگیرد قرار خوشم چونکه باشی مرا در کنار

  3. CASE PRESENTATION

  4. CASE 1 38 y , G 2 L 1(NVD) PMH , PDH ,PSH – PNC : complete Screening test , sonographies over pregnancy : NL Without any problem during pregnancy C.C : cough in last month of pregnancy

  5. increase cough diphenhydramine administered • Because of progressive insupportable process of cough hospitalization at 37 w of GA for elective termination • Labor phases was NL / NVD was done without problem /female neonate ,2700 gr,NL • Coughing Continuous after delivery

  6. 20 d @ NVD she refer to her doctor for abnormal Continuous & abnormal VB reassurance • She come back again 51 d @ delivery for abnormal Continuous VB TVS by her docter : ET:13 mm , Uterus :NL

  7. She didn’t com back till 2m after the last visit ( 3.5 m @ delivery ) when severe dyspnea expire

  8. What was diagnosis

  9. autopsy • Firm tissue within the uterus • Multiple firm masses within the lungs

  10. histopathology • Lung : Proliferation of neoplastic cells with hyperchromatic , misshape nuclei , abundant mitosis & hemorrhage & necrosis • Uterus : neoplastic cellular sheets with severe anaplasia & hyperchromatic , misshape nuclei , abundant mitosis & hemorrhage & necrosis

  11. CASE 2 • 33 y , G 1 • PMH :Hx of episodic PCB from 4 m before pregnancy,10y primary infpregnancy with IVF • PS 1y before pregnancy  NL • PDH – ,PSH :Dxlaparascopy+hystroscopy 2yr ago • PNC : complete • Screening test , sonographies over pregnancy : NL • Recurrent mild VB during pregnancymore rest & progesterone

  12. C/S at 36 W because of sever VB (Dx : probable abruption) • After C/S decreased VB but continuous till 2 m which she admitted for severe VB • HCG - , sono : NL • Spaculum exam : A 4 cm ulcerative mass with vaginal & Lt parametrium & LT pelvic side wall involvementperform biopsy , vaginal pack & other diagnostic evaluation

  13. What was diagnosis

  14. CERVICAL CANCER STAE III B • Referred for chemoradiation • 5m after chemoradiation vagimal mass & rectovaginal fistula  advised for pelvic excentration  refused • 3 m later ---> expired

  15. iNCIDENCE of late pph 0.2 to 2 percent of postpartum women in high-income countries DEFINITION Any significant uterine bleeding occurring between 24 hours and 12 weeks postpartum

  16. ETHIOLOGY

  17. ●Retained products of conception ●Subinvolution of the placental bed, and/or Infection ●Inherited or acquired bleeding diatheses ●Pseudoaneurysm of the uterine artery ●AVM ●Choriocarcinoma ●Undiagnosed carcinoma of the cervix ●Adenomyosis ●Infected polyp or submucosal fibroid ●Uterine diverticulum ●Excessive bleeding with resumption of menses ●Hypoestrogenism ●Dehiscence of a cesarean scar

  18. DIAGNOSTIC EVALUATION

  19. HISTORY • past obstetric history • Hx of menorrhagia/personal or family history of excessive or unusual bleeding signs or symptoms of uterine infection • PMH,PDH • Risk factors • Hx of attendant symptoms

  20. Physical examination • Spaculum exam • Bimanual exam • Abdominopelvic exam • Vital sign • Review of system

  21. Lab data ●Complete blood count ●PT,PTT,Fib ●HCG– In women with bleeding many weeks after delivery, useful for evaluating for choriocarcinoma, retained products of conception, or even a new pregnancy. (disappear 7-60 d @ delivery)

  22. Lab data ● If the diagnosis is uncertain after the history, physical examination, ultrasound imaging, and laboratory evaluation, then additional testing includes: FSH, LH, TSH, estradiol, and progesterone to rule out a possible hypoestrogenic state and to determine the cause

  23. Imaging • Pelvic  Ultrasound (including color and spectral flow Doppler) of the uterus • Infection— US findings are often nonspecific The uterus may have a thickened, heterogenous endometrium or show normal postpartum findings, such as intracavitary debris, fluid, or gas. • Subinvolution—hypoechoictortuous vessels along the inner third of the myometrium 

  24. Retained products of conception — solid, echogenic intracavitary mass that extends to the endometrium with high-velocity, low-resistance arterial flow in the mass  AVM — multiple hypoechoic or anechoic serpentine spaces within the myometrium, with turbulent flow on color Doppler and high-velocity and low-resistance flow on spectral analysis

  25. Choriocarcinoma –a mass enlarging the uterus, with a heterogeneous appearance with areas of necrosis and hemorrhage usually hypervascular on color Doppler • Chest imaging if indicated

  26. MANAGEMENT

  27. Unstable Hamodynamically status

  28. Subinvolution —uterotonic agents : ●Methylergonovine (0.2 mg intramuscularly, repeated every two to four hours up to three doses) OR ●Carboprosttromethamine(250 mcg IM; up to 8 doses at intervals at least 15m apart) OR ●Oxytocin infusion  ●Plus antibiotics

  29. Retained products of conception — Medical or  Surgical procedures (dilation and curettage, suction curettage) Vascular lesions — Selective arterial embolization Hypoestrogenism — IV estrogen (20 to 40 mg) Q 4h. when bleeding is controlled, one final dose of estrogen IV, & then OCP with 35 mcg EE BID for 4 to 5 days, tapering to one pill daily. OR:

  30. OCP with 35 mcg EE Q 6 h until the bleeding is controlled, then tapered on consecutive days to 35 mcg every eight hours, every 12 hours, and then daily

  31. Choriocarcinoma —highly malignant tumor of trophoblast. Patient present with vaginal bleeding or rarely with distant metastasis. Choriocarcinomacoexisting or after a “normal” pregnancy has an incidence one per 160 000 pregnancies The most common presentation is VB but symptoms related to metastasis like hemoptysis or cough have been reported Maternal choriocarcinoma is usually diagnosed in symptomatic patients with metastases.

  32. The diagnosis based upon elevated hCG, with the exclusion of any other explanation than GTN. • serum hCG levels are sensitive and specific for diagnosis. • elevated hCG with findings on examination or imaging suggest metastatic diseasediagnosis. • is sufficient for diagnosis even if there is no uterine enlargement or metastatic disease. • Biopsy is contraindicated.

  33. hCGis not routinely done @ term pregnancies and (hCG and US) only done based on symptom. • Simple macroscopic examination of the placenta after delivery can identify suspicious placental areas appears like white nodules and infracted areas in the placental mass.

  34. Choriocarcinoma detected on placental gross examination in otherwise unremarkable pregnancies thus All placentas should undergo a basic examination including color, length of umbilical cord, number of cord vessels. Complete gross and histopathologic examination of the placenta should be obtained when clinically indicated by adverse maternal, fetal, or neonatal outcome.

  35. so • In cases where Dx is not done immediately postpartum by pathology , at more than a month after delivery only clinical and laboratory exam (very high levels of β-HCG) can diagnose • Persistent elevation of serum β-HCG following any non-molar pregnancy, may be due to development of choriocarcinoma or PSTT

  36. trEatment • Gestational choriocarcinoma responds very well to chemotherapy. • EMA-CO is the most commonly used combination chemotherapy to treat high-risk gestational trophoblastic neoplasia

More Related