Management of Pph

7/31/2019 Management of Pph

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Topic : POST PARTUM HAEMORRHAGE

Presenter: Dr. Mutabazi K. Sharif

Date: 29th September 2011.


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PRESENTATION OUTLINE Definition

Classification

Aetiology

Clinical Presentation

Management

Prevention


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DEFINITION Bleeding from the female genital tract of >500mls

after vaginal delivery or >1000mls after caesariansection or any amount of blood that results inhemodynamic instability.

NB. Its usually difficult to estimate the amount ofblood loss so your clinical acumen suffices.


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CLASSIFICATION Primary/Immediate PPH.

This occurs with in the first 24 hours after the first 24

hours. Secondary /Delayed PPH.

This occurs 24 hours after delivery up to six weekspostpartum.


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The situation in Uganda For every100,000 new mothers, 435 diewhile giving

birth(UDHS 2006).

Only41% of deliveries are attended by a skilled birth

attendant. Emergency obstetric care (Emoc) coverage is only at

23.9%(MoH Emoc Needs Assessment Survey 2004)

Comprehensive obstetric care only at 8.1%.

According to UNDP , Uganda's progress towardsachieving MDG no.5 (reduce maternal mortality bythree quartersby 2015)is uncertain.

About 80% maternal death are due to PPH


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AETIOLOGY/CAUSES(4-Ts) Tone .

Causes of Uterine atony.

Retained products(placental cotelydons,clots)Polyhydromnios

Grand multiparity

Multiple pregnancy

Macrosomia /big baby

Poor management of 3rd stage of labour.


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PPH CAUSES contd Trauma

Perineal tears

EpisiotomyRuptured uterus

Cervical tears


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CAUSES contdTissue Thrombin

Retained placental tissueand clots

Disseminated intravascularcoagulopathy

Congenital bleedingdisorders

Thrombocytopenia(lowplatelets)


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RISK FACTORSAntepartum Intra/Post Partum

Antepartum haemorrhage

IUFD

Preclampsia-Eclampsia

Chorioamnionitis

Grand multiparity

Multiple pregnancy Previous h/o PPH

Coagulation defects

Anaemia

Prolonged labour

Augmentation of labour Poor mgt 3rd stage.

Vacuum extraction

Internal podalic version

Some general anaestheticse.g. halothane


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CLINICAL FEATURES Is this PPH?

Consider risk factors

Estimate the amount of blood loss(soakedgauze/cotton, blood collected in Kidney dish orBuckets). This is often misleading, use your clinicaljudgment.

General Examination(? Pallor, Cold extremities)CVS, B/P(Syst0.9 urgentresuscitation required).


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CLINICAL FEATURES Depends on the cause.

Atonic uterus.

The uterus is soft and not contracted.Tears .

The placenta is complete and uterus is well contracted.

Tissue/ Retained placenta/placental products.

Placenta not delivered with in 30 min or placenta isincomplete.


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CLINICAL FEATURES Inverted Uterus

Uterine fundus not felt on abdominal palpation

It may be apparent on vaginal examination. Ruptured uterus

Bleeding could be vaginal or abdominal(abd distention,shifting dullness, tenderness+/- fluid thrill).

Delayed PPH.

Bleeding is variable, uterine subinvolution.


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CLINICAL FEATURES P/A IS the uterus well contracted?

V/E. ? Pereneal tears, Cervical tears

EUA. CNS, is she confused? , do GCS.

In case you are in doubt call a colleague.


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Work up/ investigations HaemotologyHb, Blood grouping and cross match. CBC

The hemoglobin and hematocrit are helpful in estimating bloodlosses. However, in a patient with acute hemorrhage, severalhours may pass before these levels change to reflect the blood lossand platelet count.

If the white blood cell count is elevated, suspect endometritis ortoxic shock syndrome.

- Look for thrombocytopenia Coagulation studies e.g. PT, aPTT LFTs(remember HELLP syndrome) ImagingAbdominal U/scan


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Management of PPH.

CALL FOR HELP, it is never managed alone, minutes lost in delays mayresult in death

Do a primary survey(ABC)

Perform theA irway assessment evaluating it for patency. AssessB reathing adequacy and provide supplementation with 100% oxygen asneeded.Assess the C irculatory status (including peripheral pulses, heart rate, bloodpressure, and a perineal examination). Support circulation to vital organs byputting the patient into the Trendelenburg position, placing at least 2 large-bore IVs, starting a rapid crystalloid infusions(normal saline/RL)through both IVs, and establishing continuousvital sign monitoring toguide continued management. Never give dextrose.Laboratory studies: Obtain samples for laboratory testing. Consider HB,

Grouping and cross match & blood cultures if the patient is febrile or thevaginal blood/discharge is malodorous, as endometritis may be acomplicating factor.


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Management contd. Secondary survey.

Perform a focused physical exam.

Examine the CVS, ABDOMINEN, Perineal exam r/otears, RS , Skin and CNS.

Midwives should be able to examine the cervix forcervical tears


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Management contd Interventions.

Address the 4Ts plus 1. Start with Tone since it is the

most common cause of PPH. NB. WHO recommendsempirical treatment of uterine atony in early PPH.

Uterine massage and expulsion of any retainedproducts.

Pass a urethral catheter.Administer uterotonics.


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ManagementDrug Oxytocin Ergometrine 15-methylProstaglandinF2a

Dose and Route IV 20 IU/1L

NS/RL 60drops/min

IM (IV SLOWLY)

0.2Mg

0.25mg

Continuing dose IV 20IU/1LNSorRL 40

Drops/min

Repeat 0.2mgafter 15 minutes

0.25mg every 15minutes

Maximum dose Not more than 3Lcontainingoxytocin

5 doses(1mg) 8 doses(2mg)


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Management contd Oxytocin is preferred to ergometrine or prostaglandin. If

oxytocin is not available use ergometrine as second line.Ergometrine is contraindicated in pregnancy.

Misoprostol may be used as third line in case the aboveare not available as 800mcg per rectum

Trauma.

Repair lacerations (perineal or cervical).

Tissue .

If retained placental is suspected manual removal should bedone.


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Management contd. Traction(uterine inversion).

Manual replacement should be attempted

Thrombosis . Review the patients CBC and clottingstudies. Transfuse with fresh blood if FFP orPlatellets are not available.


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Management contd Patient continues tobleed despite the above, Think

about placenta accreta,increta or percreta orruptured uterus.

Do bimanual compression/aorticcompression/condom tamponade as you prepare fortheatre/Referral. Packing the uterus is notrecommended by WHO but can be done if expertise

for condom tamponade is not available as definitivemeasures are being worked on.

In theatre you can do uterine artery ligation or B-lynch suture or Hysterectomy.


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Summary of Management. Remember HAEMOSTASIS

H askfor help

Aassess vital parameters , blood loss and resuscitate.

Eestablish aetiology plus Ensure availability of blood Mmassage the uterus

Ooxytocin infusion

S shift to theatre and exclude Trauma(cervical tears

and ruptured uterus),Tissue(adherrent placenta) Ttamponade, balloon/condom or uterine packing NB

the latter is not recommended by WHO but can beused when expertise for condom tamponade is notavailable.


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Summary of ManagementAapplyuterine compression suture e.g. B-Lynch

Ssystematic pelvic devasicularisation (e.g. Uterineartery ligation).

Iinterventional radiology. Uterine arteryembolisation.

Ssubtotal/Total hysterectomy


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Prevention of PPH Active management of 3rd stage of labour Skilled birth attendant.

Encourage ANC Anemia must always be corrected during pregnancy. Mothers with a previous h/o of PPH,multiparous women,

those with multiple pregnancy should deliver at hospitals. Monitor of 4th stage and pueperium. Perform a quick intervention as soon as PPH is

diagnosed. Prevent infection with use of prophylactic ABCs Ensure timely referral/consultations.

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Management of Pph