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Postpartum hemorrhage
(PPH)
Getachew Shiferaw(MD)
June 2011
Objective
• Describe the significance of postpartum
hemorrhage
• Discuss the causes of postpartum hemorrhage
• Discuss the prevention of postpartum
hemorrhage
• Describe the management of postpartum
hemorrhage
• Describe uterine inversion & its management
Introduction
WARNING: Rapid action in response to PPH is
critical!
More than half of all maternal deaths occur
within 24 hours of childbirth, mostly due to
excessive bleeding.
Uterine atony is the major factor of postpartum
hemorrhage (PPH) which causes more than one-
quarter of all maternal deaths worldwide
Classification of PPH
• Primary (early) PPH
–Third stage hemmorhage (before
placental delivery )
–True PPH (after placental delivery)
• Secondary ( late ) PPH
PRIMARY ( EARLY ) PPH
• Problems associated with the definition of
PPH
– Estimation of blood loss is very difficult &
inaccurate
– Definitions are not universally accepted
– Even less amount of bleeding can lead to
complications
• eg. anemia , pre-eclampsia
Currently accepted definitions of
primary PPH
• Blood loss per vaginum in excess of 500 ml
after vaginal delivery or > 1000 ml after CS in
the 1st 24 hours
• A HCT change of 10 % from the previous level
• Bleeding resulting in derrangement of the vital
signs & a need for RBC transfusion
Secondary ( late ) PPH
• Is defined as bleeding occuring between 24
hours and 6 weeks after delivery
Primary PPH
• The two most common causes of primary PPH
are
–uterine hemorrhage
–lacerations of the genital tract
• 4T`s : Tone, Tissue, Trauma, Thrombin
Predisposing factors & causes of
primary PPH
I. Bleeding from placental implantation site
i. Uterine atony
• overdistended uterus -
(hydramnios , multifetal pregnancy ,fetal
macrosomia )
• prolonged labor
• precipitate labor
• previous PPH due to atony !!!
• high parity
• General anesthesia E.g. Halothane
• chorioamnionitis
• Oxytocin induction or augumentation
• Uterine hypoxia eg. hypotension
• Mismanagement of the third stage
• Operative vaginal or abdominal deliveries
ii. Retained placental tissue
• succenturate lobe
• pieces of cotyledon
• abnormally adherent placenta (accreta ,increta &
percreta)
II. Trauma to the genital tract
• Large episiotomy
• Lacerations of the perineum , vagina & cervix
• Uterine tupture
III. Uterine inversion
IV. Coagulation abnormalitities
– Hypofibrinogenemia
– Thrombocytopenia
– DIC
Diagnosis & clinical findings
• The diagnosis is usually simple unless there is
unrecognized intrauterine or intravaginal
blood collection or uterine rupture
(intraperitoneal bleeding )
Management of PPH
• Prevention is the most important aspect of
management
– Prevent Prolonged Labor
– Active Management of the Third Stage of Labor
– Avoid perineal/vaginal trauma
– Monitor closely
ICM/FIGO Joint Statement on Active Management of
the Third Stage of Labor (AMTSL)
• AMSTL has been proven to reduce the
incidence of postpartum hemorrhage, reduce
the quantity of blood loss and reduce the use
of transfusion
• AMSTL should be offered to all women who
are giving birth
• Every attendant at birth needs to have the
knowledge, skills, and critical judgement
needed to carry out AMSTL
The components of ATML
(1) Giving uterotonic (uterus-contracting) drug
within one minute of birth of the newborn.
(2) Clamping and cutting the umbilical cord soon
after birth.
(3) Applying controlled cord tension (also referred
to as controlled cord traction) to the umbilical
cord while applying simultaneous counter-
pressure to the uterus through the abdomen; and
(4) Immediately massaging the funds of the uterus
through the woman’s abdomen until the uterus is
contracted
A. 3 IU oxytocin IV push immediately after delivery
IMPORTANT!
– Large dose > 5 IU of bolus oxytocin can cause
hypotension
B. 10 - 20 IU oxytocin in 1000 ml of isotonic
saline solution .
C. IM syntometrine ( ergometrine 0.5 mg +
syntocinon 5 units )
D. IV 0.25 mg or 0.5 mg ergometrine after the
delivery
– Problems
• cervical constriction & entrapment of the
placenta
• contraindicated in hypertensive patients
After delivery of the fetus gentle traction is
applied on umblical cord (Brandt’s Andrew
manoever) until placental separation occurs
• Inspect the placenta & membranes for
completeness carefully
• Following delivery
– check frequently the status of the uterus &
presence of vaginal bleeding.
– Check V/S frequently especially in the 1st two
hours after delivery.
Mx of bleeding before delivery of
the placenta
Bleeding in the third stage could be due to
• Retained placenta as a result of
– Constriction of the cervix or
– Morbidly adherent placenta
– Uterine atony
Or
• Laceration of the genital tract
• After taking all the necessary precautions
• IV line , blood grouping & cross match , Iv infusion containing
oxytocin & alarming the OR team
– Do controlled cord traction
– If the manoever is successful bimanual compression
of the uterus till adequate contraction is achieved (
10 - 20 IU oxytocin in 1000 ml of saline solution)
• If the traction fails do pelvic exam to exclude
cervical constriction or abnormal adherence
• If there is entrapment due to cervical
constriction , relax the uterus
• eg. General anesthesia
• In few cases the placenta is firmly attached to
the uterus & it is impossible to find an adequqte
plane of cleavage (placenta accreta) in that
case do hysterectomy
Mx of bleeding after delivery of
the placenta
• Bleeding is again usually due to atony or
lacerations
• The 1st step is to check whether the
uterus is well contracted or not
• Do bimanual uterine compression
( Hamilton’s manoeuver ) to stop or
decrease the bleeding
• In the mean time begin with IV infusion of
oxytocin ( 20 IU in 1000 ml N/S or RL & give
ergometrine IV or IM)
• If blood loss continues start with another IV
line resucitation including blood transfusion
• explore the uterine cavity to remove retained
clot or fragments of placenta or do gauze or
post partum curettage
• If bleeding continues take the patient to OR &
prepare for immediate laparotomy
• Bimanual compression of the uterus is
continued in the mean time till incision is
started
Compression of Abdominal
Aorta
• Apply downward pressure with
closed fist over abdominal aorta
through abdominal wall (just
above umbilicus slightly to
patient’s left)
• With other hand, palpate
femoral pulse to check adequacy
of compression
– Pulse palpable = inadequate
– Pulse not palpable =
adequate
• Maintain compression until
bleeding is controlled
• Bilateral uterine artery ligation is simple & effective
to control most cases of PPH & preserves the
patient’s reproductive capacity
• Bilateral intrnal iliac ( hypogastric ) artery ligation can
be done if there is broad ligament or lateral pelvic
hematoma
• Hysterectomy is the definitive & last method of
controlling PPH
Abnormally adherent placenta
• Rarely the placenta is unusually adherent to the
implantation site
• The physiological cleavage line is lacking due to
scanty or absent decidua
• one or more cotyledons can firmly attach to the
defective decidua or even myometrium
Classification
• Placenta accreta(80%)
– placental villi are attached with the myometrium
• Placenta increta(15%)
– chorionic villi invade the myometrium
• Placenta percreta(5%)
– the villi penetrate the myometrium & reach the
serosal layer
• Incidence :unknown ( 1:2500 - 1 : 7000 )
• Etiology
– common in conditions where defective decidual
formation is more likely
• The abnormal adherence may involve
– all cotyledons - total placenta accreta
– a few or several cotyledons - partial placenta accreta
– a single cotyledon- focal placenta accreta
Predisposing factors
• placenta previa
• previous curettage
• previous CS
• previous severe infection
• grand multiparity
Clinical presentation & diagnosis
• Antepartum
– rarely acute abdomen can occur due to uterine perforation
– US diagnosis is possible antepartum ( expert !! )
`loss of normal luscency`
• Delivery - presentations during delivery depends on
the
. site of implantation
. depth of myometrial invasion
. number of cotyledons involved
• Focal p. accreta
– severe bleeding usually occurs or rarely
asymptomatic resulting in the formation of
placental polyps
• Partial p. accreta
– hemorrhage is profuse due to partial separation
• Total p. accreta
– little or usually no bleeding
– unsuccessful attempt in doing traction may result
in uterine inversion
Mx
Therapeutic possibilities
• Conservative(uterine preservation) versus
definitive(hysterectomy) management
Conservative management is a valid option if
preservation of fertility is important.
1. Leaving the placenta in place (totally or in
fragments);
2. Localized resection and repair;
3. Oversewing a defect, especially if percreta is
identified; and
4. Blunt dissection/curettage.
Inversion of the uterus
• uncommon but life threatening
– the fundus of the uterus descends through the
uterine body & cervix in to the vagina &
sometimes protrudes through the vulva
– Incidence:one in 2500 deliveries
• Inversion may be classified as follows:
1. Incomplete: corpus does not protrude through
cervix;
2. Complete: corpus protrudes through the cervix;
3. Prolapse: corpus extends to/through introitus;
4. Acute: occurs without cervical contraction;
5. Chronic: 04 weeks time differential between
inversion and cervical contraction
Etiology
• complete uterine inversion is almost always caused
by strong traction on the umblical cord of a placenta
attached to the fundus
• Contributing factors:
tough cord
relaxed uterus
fundal pressure(Crede’s maneuver)
morbidly adherent placenta
Diagnosis
• acute complete inversion resulting from cord traction
is simple to diagnose
• suspect incomplete inversion in a patient having
deep shock with out obvious vaginal bleeding
(neuroegenic !!! )
• if iv infusion fails to increase blood pressure suspect
inversion
• dimpling or absence of palpable uterus on abdominal
exam
Management
• delay in treatment is fatal!
• Steps
– call assistance including anesthesist
– freshly inverted uterus with separated placenta
can easily be repositioned immediately
– secure 2 IV lines. Give crystalloids or blood to
reverse hypovolemia
• if placenta is still attached to the uterus , it is not
removed unless
. Iv secured
. blood prepared
. anesthesia ( halothane ) is administered
. Oxtocic drugs
• removing the placenta with out the above
preconditions increase the risk of PPH
• less blood loss if placenta removed after
replacement
• oxytocin is not given until after the uterus is restored
to its normal configuration
• stop relaxants & begin with oxytocin infusion to
affect uterine contraction while maintaining the
uterus in normal position
• after uterus is well contracted , continue to monitor
the uterus transvaginally for evidence of subsequent
inversion ( rare )
• surgical intervention is indicated if vaginal
replacement fails
Secondary PPH
• the most common cause of late PPH is poor
epithelization of or poor involution of the
placental site
• Other causes include
-retained pieces of placenta
-infection ( endometritis )
-chorio-carcinoma ( recurrent vaginal bleeding
after the 4th week post partum suggestive )
Management
• uterotonics ( ergometrine 0.5 mg IM )
• antibiotics if there is evidence of infection
• curettage is only needed if bleeding persists or there
is evidence of tissue in sonography or suspected
chorio-carcinoma
N. B curettage can be complicated by severe bleeding
& as long as possible avoid it
Thanx

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postpartum hemorrhage

  • 2. Objective • Describe the significance of postpartum hemorrhage • Discuss the causes of postpartum hemorrhage • Discuss the prevention of postpartum hemorrhage • Describe the management of postpartum hemorrhage • Describe uterine inversion & its management
  • 3. Introduction WARNING: Rapid action in response to PPH is critical! More than half of all maternal deaths occur within 24 hours of childbirth, mostly due to excessive bleeding. Uterine atony is the major factor of postpartum hemorrhage (PPH) which causes more than one- quarter of all maternal deaths worldwide
  • 4. Classification of PPH • Primary (early) PPH –Third stage hemmorhage (before placental delivery ) –True PPH (after placental delivery) • Secondary ( late ) PPH
  • 5. PRIMARY ( EARLY ) PPH • Problems associated with the definition of PPH – Estimation of blood loss is very difficult & inaccurate – Definitions are not universally accepted – Even less amount of bleeding can lead to complications • eg. anemia , pre-eclampsia
  • 6. Currently accepted definitions of primary PPH • Blood loss per vaginum in excess of 500 ml after vaginal delivery or > 1000 ml after CS in the 1st 24 hours • A HCT change of 10 % from the previous level • Bleeding resulting in derrangement of the vital signs & a need for RBC transfusion
  • 7. Secondary ( late ) PPH • Is defined as bleeding occuring between 24 hours and 6 weeks after delivery
  • 8. Primary PPH • The two most common causes of primary PPH are –uterine hemorrhage –lacerations of the genital tract • 4T`s : Tone, Tissue, Trauma, Thrombin
  • 9. Predisposing factors & causes of primary PPH I. Bleeding from placental implantation site i. Uterine atony • overdistended uterus - (hydramnios , multifetal pregnancy ,fetal macrosomia ) • prolonged labor • precipitate labor • previous PPH due to atony !!! • high parity
  • 10. • General anesthesia E.g. Halothane • chorioamnionitis • Oxytocin induction or augumentation • Uterine hypoxia eg. hypotension • Mismanagement of the third stage • Operative vaginal or abdominal deliveries
  • 11. ii. Retained placental tissue • succenturate lobe • pieces of cotyledon • abnormally adherent placenta (accreta ,increta & percreta)
  • 12. II. Trauma to the genital tract • Large episiotomy • Lacerations of the perineum , vagina & cervix • Uterine tupture III. Uterine inversion IV. Coagulation abnormalitities – Hypofibrinogenemia – Thrombocytopenia – DIC
  • 13. Diagnosis & clinical findings • The diagnosis is usually simple unless there is unrecognized intrauterine or intravaginal blood collection or uterine rupture (intraperitoneal bleeding )
  • 14. Management of PPH • Prevention is the most important aspect of management – Prevent Prolonged Labor – Active Management of the Third Stage of Labor – Avoid perineal/vaginal trauma – Monitor closely
  • 15. ICM/FIGO Joint Statement on Active Management of the Third Stage of Labor (AMTSL) • AMSTL has been proven to reduce the incidence of postpartum hemorrhage, reduce the quantity of blood loss and reduce the use of transfusion • AMSTL should be offered to all women who are giving birth • Every attendant at birth needs to have the knowledge, skills, and critical judgement needed to carry out AMSTL
  • 16. The components of ATML (1) Giving uterotonic (uterus-contracting) drug within one minute of birth of the newborn. (2) Clamping and cutting the umbilical cord soon after birth. (3) Applying controlled cord tension (also referred to as controlled cord traction) to the umbilical cord while applying simultaneous counter- pressure to the uterus through the abdomen; and (4) Immediately massaging the funds of the uterus through the woman’s abdomen until the uterus is contracted
  • 17. A. 3 IU oxytocin IV push immediately after delivery IMPORTANT! – Large dose > 5 IU of bolus oxytocin can cause hypotension B. 10 - 20 IU oxytocin in 1000 ml of isotonic saline solution . C. IM syntometrine ( ergometrine 0.5 mg + syntocinon 5 units )
  • 18. D. IV 0.25 mg or 0.5 mg ergometrine after the delivery – Problems • cervical constriction & entrapment of the placenta • contraindicated in hypertensive patients After delivery of the fetus gentle traction is applied on umblical cord (Brandt’s Andrew manoever) until placental separation occurs
  • 19. • Inspect the placenta & membranes for completeness carefully • Following delivery – check frequently the status of the uterus & presence of vaginal bleeding. – Check V/S frequently especially in the 1st two hours after delivery.
  • 20. Mx of bleeding before delivery of the placenta Bleeding in the third stage could be due to • Retained placenta as a result of – Constriction of the cervix or – Morbidly adherent placenta – Uterine atony Or • Laceration of the genital tract
  • 21. • After taking all the necessary precautions • IV line , blood grouping & cross match , Iv infusion containing oxytocin & alarming the OR team – Do controlled cord traction – If the manoever is successful bimanual compression of the uterus till adequate contraction is achieved ( 10 - 20 IU oxytocin in 1000 ml of saline solution)
  • 22. • If the traction fails do pelvic exam to exclude cervical constriction or abnormal adherence • If there is entrapment due to cervical constriction , relax the uterus • eg. General anesthesia • In few cases the placenta is firmly attached to the uterus & it is impossible to find an adequqte plane of cleavage (placenta accreta) in that case do hysterectomy
  • 23. Mx of bleeding after delivery of the placenta • Bleeding is again usually due to atony or lacerations • The 1st step is to check whether the uterus is well contracted or not • Do bimanual uterine compression ( Hamilton’s manoeuver ) to stop or decrease the bleeding
  • 24. • In the mean time begin with IV infusion of oxytocin ( 20 IU in 1000 ml N/S or RL & give ergometrine IV or IM) • If blood loss continues start with another IV line resucitation including blood transfusion • explore the uterine cavity to remove retained clot or fragments of placenta or do gauze or post partum curettage • If bleeding continues take the patient to OR & prepare for immediate laparotomy • Bimanual compression of the uterus is continued in the mean time till incision is started
  • 25. Compression of Abdominal Aorta • Apply downward pressure with closed fist over abdominal aorta through abdominal wall (just above umbilicus slightly to patient’s left) • With other hand, palpate femoral pulse to check adequacy of compression – Pulse palpable = inadequate – Pulse not palpable = adequate • Maintain compression until bleeding is controlled
  • 26. • Bilateral uterine artery ligation is simple & effective to control most cases of PPH & preserves the patient’s reproductive capacity • Bilateral intrnal iliac ( hypogastric ) artery ligation can be done if there is broad ligament or lateral pelvic hematoma • Hysterectomy is the definitive & last method of controlling PPH
  • 27. Abnormally adherent placenta • Rarely the placenta is unusually adherent to the implantation site • The physiological cleavage line is lacking due to scanty or absent decidua • one or more cotyledons can firmly attach to the defective decidua or even myometrium
  • 28. Classification • Placenta accreta(80%) – placental villi are attached with the myometrium • Placenta increta(15%) – chorionic villi invade the myometrium • Placenta percreta(5%) – the villi penetrate the myometrium & reach the serosal layer
  • 29. • Incidence :unknown ( 1:2500 - 1 : 7000 ) • Etiology – common in conditions where defective decidual formation is more likely • The abnormal adherence may involve – all cotyledons - total placenta accreta – a few or several cotyledons - partial placenta accreta – a single cotyledon- focal placenta accreta
  • 30. Predisposing factors • placenta previa • previous curettage • previous CS • previous severe infection • grand multiparity
  • 31. Clinical presentation & diagnosis • Antepartum – rarely acute abdomen can occur due to uterine perforation – US diagnosis is possible antepartum ( expert !! ) `loss of normal luscency` • Delivery - presentations during delivery depends on the . site of implantation . depth of myometrial invasion . number of cotyledons involved
  • 32. • Focal p. accreta – severe bleeding usually occurs or rarely asymptomatic resulting in the formation of placental polyps • Partial p. accreta – hemorrhage is profuse due to partial separation • Total p. accreta – little or usually no bleeding – unsuccessful attempt in doing traction may result in uterine inversion
  • 33. Mx Therapeutic possibilities • Conservative(uterine preservation) versus definitive(hysterectomy) management Conservative management is a valid option if preservation of fertility is important. 1. Leaving the placenta in place (totally or in fragments); 2. Localized resection and repair; 3. Oversewing a defect, especially if percreta is identified; and 4. Blunt dissection/curettage.
  • 34. Inversion of the uterus • uncommon but life threatening – the fundus of the uterus descends through the uterine body & cervix in to the vagina & sometimes protrudes through the vulva – Incidence:one in 2500 deliveries • Inversion may be classified as follows: 1. Incomplete: corpus does not protrude through cervix; 2. Complete: corpus protrudes through the cervix; 3. Prolapse: corpus extends to/through introitus; 4. Acute: occurs without cervical contraction; 5. Chronic: 04 weeks time differential between inversion and cervical contraction
  • 35. Etiology • complete uterine inversion is almost always caused by strong traction on the umblical cord of a placenta attached to the fundus • Contributing factors: tough cord relaxed uterus fundal pressure(Crede’s maneuver) morbidly adherent placenta
  • 36. Diagnosis • acute complete inversion resulting from cord traction is simple to diagnose • suspect incomplete inversion in a patient having deep shock with out obvious vaginal bleeding (neuroegenic !!! ) • if iv infusion fails to increase blood pressure suspect inversion • dimpling or absence of palpable uterus on abdominal exam
  • 37. Management • delay in treatment is fatal! • Steps – call assistance including anesthesist – freshly inverted uterus with separated placenta can easily be repositioned immediately – secure 2 IV lines. Give crystalloids or blood to reverse hypovolemia
  • 38. • if placenta is still attached to the uterus , it is not removed unless . Iv secured . blood prepared . anesthesia ( halothane ) is administered . Oxtocic drugs • removing the placenta with out the above preconditions increase the risk of PPH • less blood loss if placenta removed after replacement
  • 39. • oxytocin is not given until after the uterus is restored to its normal configuration • stop relaxants & begin with oxytocin infusion to affect uterine contraction while maintaining the uterus in normal position • after uterus is well contracted , continue to monitor the uterus transvaginally for evidence of subsequent inversion ( rare ) • surgical intervention is indicated if vaginal replacement fails
  • 40. Secondary PPH • the most common cause of late PPH is poor epithelization of or poor involution of the placental site • Other causes include -retained pieces of placenta -infection ( endometritis ) -chorio-carcinoma ( recurrent vaginal bleeding after the 4th week post partum suggestive )
  • 41. Management • uterotonics ( ergometrine 0.5 mg IM ) • antibiotics if there is evidence of infection • curettage is only needed if bleeding persists or there is evidence of tissue in sonography or suspected chorio-carcinoma N. B curettage can be complicated by severe bleeding & as long as possible avoid it
  • 42. Thanx