34- Post Partum Haemorrjhage

POST PARTUM POST PARTUM HAEMORRHAGE HAEMORRHAGE

DEFINITIONDEFINITION

PPH is defined asPPH is defined as a blood a blood loss in excess of 500 c.c. loss in excess of 500 c.c. after vaginal delivery, after vaginal delivery, and more than 1000 c.c. and more than 1000 c.c. following C.Sfollowing C.S

TYPES OF PPHTYPES OF PPH

Primary PPH: Primary PPH: Immediate bleeding, or Immediate bleeding, or within first 24 hours, after delivery. It is the within first 24 hours, after delivery. It is the most important variety as it is associated most important variety as it is associated with acute blood loss that may be life with acute blood loss that may be life threatening.threatening.

Secondary PPH:Secondary PPH: Bleeding which is Bleeding which is delayed > 24 hours, and till the end of delayed > 24 hours, and till the end of puerperium. It is uncommon, the bleeding puerperium. It is uncommon, the bleeding tends to be mild and chronic, and may tends to be mild and chronic, and may even present as a gynaecological problem.even present as a gynaecological problem.

PRIMARY POST PARTUM PRIMARY POST PARTUM HAEMORRHAGEHAEMORRHAGE

INCIDENCE: INCIDENCE: The incidence of PPH The incidence of PPH varies from 0.5 - 4 % depending on varies from 0.5 - 4 % depending on the proper management of labour.the proper management of labour.

AETIOLOGY:AETIOLOGY:1.1. Placental site haemorrhage (atonic Placental site haemorrhage (atonic

PPH) PPH) 2.2. Traumatic laceration of the genital Traumatic laceration of the genital

tract (traumatic PPH).tract (traumatic PPH).3.3. Disseminated Intravascular Disseminated Intravascular

Coagulation (DIC)Coagulation (DIC)

PLACENTAL SITE HAEMORRHAGE (Atonic PPH)PLACENTAL SITE HAEMORRHAGE (Atonic PPH)

1.1. Over distension of the uterus (e.g. over sized baby, Over distension of the uterus (e.g. over sized baby, polyhydramnios and twins). polyhydramnios and twins).

2.2. Prolonged labour (maternal exhaustion and Prolonged labour (maternal exhaustion and dehydration)dehydration)

3.3. Antepartum haemorrhage (placenta praevia and Antepartum haemorrhage (placenta praevia and accidental haemorrhage). accidental haemorrhage).

4.4. Grand multiparity (lax and weak uterine muscles). Grand multiparity (lax and weak uterine muscles). 5.5. Precipitate labour (rapid delivery gives no time for Precipitate labour (rapid delivery gives no time for

efficient uterine retraction).efficient uterine retraction).6.6. Nervous shock & full bladder lead to reflex atony of Nervous shock & full bladder lead to reflex atony of

the uterus.the uterus.7.7. Retained separated placenta (partial or complete). Retained separated placenta (partial or complete).

In these cases the myometrium cannot contract and In these cases the myometrium cannot contract and retract sufficiently due to presence of retained retract sufficiently due to presence of retained placental tissue placental tissue

LACERATIONS OF THE GENITAL LACERATIONS OF THE GENITAL TRACTTRACT (Traumatic PPH)(Traumatic PPH)

1.1. Perineal, vaginal, or cervical Perineal, vaginal, or cervical lacerationslacerations

2.2. Rupture of the uterus Rupture of the uterus

DISSEMINATED INTRAVASCULAR DISSEMINATED INTRAVASCULAR COAGULOPATHY (DIC)COAGULOPATHY (DIC)

1.1. Abruptio placentaAbruptio placenta

2.2. Retained IUFDRetained IUFD

3.3. Amniotic fluid embolism Amniotic fluid embolism (AFE).(AFE).

CLINICAL PICTURECLINICAL PICTURE History: History: Ask for the presence of a Ask for the presence of a

risk factorrisk factor– Atonic PPH: over distended uterus, Atonic PPH: over distended uterus,

multifetal pregnancy, polyhydramnios, multifetal pregnancy, polyhydramnios, etc.etc.

– Traumatic PPH: traumatic or Traumatic PPH: traumatic or instrumental delivery. instrumental delivery.

General Examination: General Examination: Check for Check for signs of hypovolaemic shocksigns of hypovolaemic shock

Pallor, rapid weak pulse, low B.P., Pallor, rapid weak pulse, low B.P., subnormal temperature, and oliguria.subnormal temperature, and oliguria.

CLINICAL PICTURECLINICAL PICTURE Abdominal Examination: Abdominal Examination: To check To check

the size and consistency of the the size and consistency of the uterus.uterus.– Atonic PPH is usually revealed, but may Atonic PPH is usually revealed, but may

be partially or entirely concealed.be partially or entirely concealed.– In atonic PPH, palpation of the uterus In atonic PPH, palpation of the uterus

reveals a soft consistency. The fundal reveals a soft consistency. The fundal level may be higher than expected if level may be higher than expected if bleeding is partially concealed.bleeding is partially concealed.

– In traumatic PPH, the uterus is firm, and In traumatic PPH, the uterus is firm, and vaginal bleeding continues in spite of a vaginal bleeding continues in spite of a well contracted uterus. The cause of well contracted uterus. The cause of traumatic PPH should be confirmed by traumatic PPH should be confirmed by PV examination.PV examination.

CLINICAL PICTURECLINICAL PICTUREVaginal Examination: Vaginal Examination:

Preferably done under Preferably done under anaesthesiaanaesthesia–To detcetd bleeding from a To detcetd bleeding from a perineal, vaginal, or cervical perineal, vaginal, or cervical laceration.laceration.

–To explore digitally the uterine To explore digitally the uterine cavity for retained parts, and cavity for retained parts, and for exclusion of uterine for exclusion of uterine rupture. rupture.

COMPLICATIONS OF PPHCOMPLICATIONS OF PPH

1.1. Maternal mortality (PPH represents about Maternal mortality (PPH represents about 34% of MMR in egypt).34% of MMR in egypt).

2.2. Haemorrhagic shock (due to exessive rapid Haemorrhagic shock (due to exessive rapid blood loss, and possible DIC) blood loss, and possible DIC)

3.3. Acute renal failure (2ry to hypovolaemic Acute renal failure (2ry to hypovolaemic shock).shock).

4.4. Puerperal sepsis (2ry to low immunity and Puerperal sepsis (2ry to low immunity and possible manipulations and retained possible manipulations and retained products)products)

5.5. Sheehan's syndrome (hypopituitrism leading Sheehan's syndrome (hypopituitrism leading to 2ry amenorrhea due to hypovolaemic to 2ry amenorrhea due to hypovolaemic shock) shock)

MANAGEMENT OF PPH MANAGEMENT OF PPH

Prevention:Prevention:1.1. Proper antenatal care (ANC):Proper antenatal care (ANC):

Previous history of PPHPrevious history of PPH Grand multiparity (uterine muscle atony)Grand multiparity (uterine muscle atony) Hydramnios, twins, oversized fetus (over Hydramnios, twins, oversized fetus (over

distension of uterine muscle).distension of uterine muscle). Placenta praevia and abruptio placenta Placenta praevia and abruptio placenta

(causes of APH).(causes of APH). Correction of anaemia during pregnnacyCorrection of anaemia during pregnnacy


Prevention:Prevention:2.2. Proper management of the 1st and 2nd Proper management of the 1st and 2nd

stages of labour:stages of labour: Avoid difficult and prolonged labour.Avoid difficult and prolonged labour. Avoid difficult and unnecessary Avoid difficult and unnecessary

instrumental delivery, especially if instrumental delivery, especially if conditions are not suitable for safe conditions are not suitable for safe applicationsapplications


PreventionPrevention::3.3. Proper management of the 3rd stage of Proper management of the 3rd stage of

labour:labour: Active management of the 3rd stage; reduces the Active management of the 3rd stage; reduces the

occurrence of PPH by nearly 50%.occurrence of PPH by nearly 50%. Wait for signs of separation before delivery of the Wait for signs of separation before delivery of the

placenta. Attempts to express the placenta before placenta. Attempts to express the placenta before its separation are dangerous.its separation are dangerous.

Routine use of ecbolics after delivery, especially in Routine use of ecbolics after delivery, especially in high risk cases.high risk cases.

Intermittent uterine massage every 15 minutes, Intermittent uterine massage every 15 minutes, and continuous observation for the pulse, and continuous observation for the pulse, temperature, B.P., and vaginal bleeding, throughout temperature, B.P., and vaginal bleeding, throughout the first two hours after deliverythe first two hours after delivery


TreatmentTreatment::1.1. AntishockAntishock measures measures and blood and blood

transfusion, whenever necessary.transfusion, whenever necessary.

2.2. Gentle uterine massage:Gentle uterine massage: done by done by placing the thumb abdominally on the placing the thumb abdominally on the uterine fundus and the four fingers of uterine fundus and the four fingers of the same hand behind to stimulate the the same hand behind to stimulate the uterus to contractuterus to contract


TreatmentTreatment::3.3. EcbolicsEcbolics: must be given with uterine : must be given with uterine

massage. These include: massage. These include: Oxytocin given as an I.V. drip (syntocinon); to Oxytocin given as an I.V. drip (syntocinon); to

increase the frequency and strength of uterine increase the frequency and strength of uterine contraction. (It should never be given as direct I.V. contraction. (It should never be given as direct I.V. bolus, as it may cause serious hypotension and bolus, as it may cause serious hypotension and arrythmias.arrythmias.

Methyl ergometrin (methergin); 0.2–0.5 mg, I.M. or Methyl ergometrin (methergin); 0.2–0.5 mg, I.M. or I.V., causes tetanic uterine contractions.I.V., causes tetanic uterine contractions.

Mesoprostol (synthetic prostaglandin); given by Mesoprostol (synthetic prostaglandin); given by rectal route, in a dose of 800 – 1000 ugrectal route, in a dose of 800 – 1000 ug


TreatmentTreatment::4.4. If bleeding persists the following steps If bleeding persists the following steps

are activatedare activated:: If the placenta was retained; it should be delivered If the placenta was retained; it should be delivered

immediately by controlled cord traction or manual immediately by controlled cord traction or manual removal.removal.

If the placenta was already delivered, then perform If the placenta was already delivered, then perform a vaginal exploration under anaesthesia to reveal:a vaginal exploration under anaesthesia to reveal:

Undiagnosed retained placenta fragments which Undiagnosed retained placenta fragments which should be removed, orshould be removed, or

Vaginal or cervical lacerations that should be Vaginal or cervical lacerations that should be sutured and repaired. sutured and repaired.

Bimanual compression of the uterus may be life Bimanual compression of the uterus may be life saving until a laparotomy is performed saving until a laparotomy is performed

Bimanual Compression


TreatmentTreatment::5.5. If bleeding persists a Laparotomy If bleeding persists a Laparotomy

is mandatory:is mandatory: Subtotal hysterectomySubtotal hysterectomy: is the standard : is the standard

procedure if bleeding is uncontrollable.procedure if bleeding is uncontrollable. Internal iliac artery ligationInternal iliac artery ligation: may be : may be

attempted if the patient's general condition attempted if the patient's general condition allows in an attempt to preserve the allows in an attempt to preserve the uterus, if the patient is young and desirous uterus, if the patient is young and desirous of further fertility. If this procedure fails to of further fertility. If this procedure fails to control the bleeding, hysterectomy is control the bleeding, hysterectomy is performed without hesitationperformed without hesitation

SECONDARY POST PARTUM SECONDARY POST PARTUM HAEMORRHAGEHAEMORRHAGE

Definition:Definition: Bleeding Bleeding which is delayed > 24 which is delayed > 24 hours, and till the end of hours, and till the end of puerperium puerperium

CausesCauses

1.1. Retained placental fragments; diagnosed Retained placental fragments; diagnosed by U.S., and treated by ecbolics and/or by U.S., and treated by ecbolics and/or D&C.D&C.

2.2. Separation of an infected slough from a Separation of an infected slough from a laceration in the lower genital tract; give laceration in the lower genital tract; give antibiotics.antibiotics.

3.3. Sloughing of an infected submucous Sloughing of an infected submucous fibroid polyp.fibroid polyp.

4.4. Undiagnosed chronic uterine inversion.Undiagnosed chronic uterine inversion.

5.5. Rarely choriocarcinoma.Rarely choriocarcinoma.

TreatmentTreatment

Treatment is that of the Treatment is that of the cause.cause.

KEY POINTS IN PPHKEY POINTS IN PPH PPH is an important mostly preventable cause of PPH is an important mostly preventable cause of

maternal mortalitymaternal mortality Uterine atony is the commonest cause for Uterine atony is the commonest cause for

PPH .Genital tract lacerations or DIC are other PPH .Genital tract lacerations or DIC are other possible causes. possible causes.

Abdominal palpation of the uterus can differentiate Abdominal palpation of the uterus can differentiate atonic from traumatic PPH.atonic from traumatic PPH.

Proper management of the third stage of labour is Proper management of the third stage of labour is very important in prevention of PPH.very important in prevention of PPH.

First aid treatment of 1ry PPH is massage and First aid treatment of 1ry PPH is massage and ecbolics, with exclusion of retained placental ecbolics, with exclusion of retained placental fragments. If bleeding is severe and uncontrollable, fragments. If bleeding is severe and uncontrollable, subtotal hysterectomy may be life saving. subtotal hysterectomy may be life saving.

PPH cannot always be prevented for it occasionally PPH cannot always be prevented for it occasionally occurs when conditions are in all respect normal.occurs when conditions are in all respect normal.

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34- Post Partum Haemorrjhage