Obstetric Emergency Follow Vaginal or C/S Best definition - Diagnosed Clinically Excessive Bleeding makes patient symptomaticOther def- EBL > 500 ml -NVD EBL > 1000 ml –C/S

Other definitions of PPH

•10% loss of Hb Concentration

•Most likely we underestimate EBL

Uterine atony > 90%( 1/20 deliveries ) Uterine, Cervical or Vaginal

lacerations(1/8 deliveries) Coagulopathy Other-Uterine inversion, Uterine rupture,

poor haemostasis

Grand Multi Uterine abnormality- Fibroids

Phx Prolonged Labour

Multiple pregnancy Precipitate Labour

Polyhydramnios Dysfunctional Labour

Chorioamnionitis Operative Delivery

PET,HELLP,APH,FDIU,AFE Macrosomia

Fundal massage IV access- 16 G Uterotonic drugs- Syntocin 10 to 40 units Ergometrine- 500mcg( C.I -Asthma, HT ) Misoprostel 1000 mcg( 1 RCT and 1 non RCT )

> 1000 ml best Mx in Theatre Notify Obstetric and Anaesthetic

Consultant Notify Blood bank, Haematologist and

Theatre PGF2α (Carboprost) 250mcg every 15

mins max 2 mg Infuse large amount of IV fluids to

prevent Hypotension

T/F Blood products - Pack cells - FFP (All clotting factors) - Cryoprecipitate( Fibrinogen.factor

V,VIII, XIII and VWF) - Platelets( 1 unit=50 ml, 6 units

increase by 30,000)

•EUA -Check Vagina, Cervix,Uterus

Uterine packs used variable success

Foley Catheter- # 24 30 ml balloon to 60ml

leave for 12-24 hours

Sengstaken- Blackemore tube

• Involve Gyne Oncologist if possible • Best Vertical midline incision • Uterine vessel ligation ± Utero Ovarian • Hypogastric artery ligation • B-Lynch suture (compress the uterus) ( simple to learn,safe, fertility preserves)

• Recombinant facer VIIa ( Novo seven)

(Obs & Gyne 2003 case report) - Effective when conventional

methods fail - Bypassing inhibitors to factor

VIII and IXDose 60mcg/Kg to 100 mcg/Kg

Precautions before closing the abdomen

•Haemostasis

•Inspect bladder and Ureters

2°PPH24 Hours to 6 weeks

Incidence 0.5 to 2%

Pathogenesis – Uterine atony 2º to retained products or infection

But exact cause unknown

Treatment

•No RCT•Uterotonics•Antibiotics•If retained products D&C

132 Consecutive women 75 D&C Tx Successful 90% 57 Med Tx Successful 72%

Complication of Surgery Perforation 3% Uterine adhesionsUS does not distinguish which patient need surgery or medical Tx