Post partum hemorrhage

Lunthaporn Puttanavinajarn,MD

Definition
Loss of 500 ml of blood or more after completion of 3th stage of labor

Incidence
17% of maternal mortality is due to hemorrhage incidence of around 5% Atony and retained placenta 80% lacerations 20%

Calculation of maternal blood volume (TBV)

Non pregnancy TBV TBV= [ height(inches)x50]+[weight(pounds)x25]
2

Pregnancy TBV add 50% to non pregnancy(~ 30%-60%) Pregnancy TBV in serious hemorrhage Acute return to non pregnancy TBV

Post partum hemorrhage

Early PPH: occurs within 24 hours after delivery Late PPH : occurs 24 hours to 6 weeks after delivery (more likely due to infection and retained placental tissue)

Predisposing factors and causes

Bleeding from placenta implantation site - uterine atony
General anesthetics : halogenated hydrocarbons Poorly perfused myometrium : hypotension Overdistended uterus : large fetus, twins, hydramnios Prolonged labor Very rapid labor High parity Following augmented labor Uterine atony in previous pregnancy Chorioamnionitis

Predisposing factors and causes

Bleeding from placenta implantation site - retained placenta tissue
Abnormally adherent : accreta, increta,percreta Avulsed cotyledon, succenturiate lobe

Trauma to Genital Tract - Large episiotomy - Laceration of perineum, vagina, or cervix - Ruptured uterus Coagulation defects

The causes of postpartum hemorrhage can be thought of as the four Ts

Tone: Uterine atony Tissue: Products of conception, placenta Trauma: Planned --- Cesarean section , episiotomy
Unplanned -- Vaginal/cervical tear, surgical trauma

Thrombin: Congenital--- Von Willebrand's disease

Acquired --- DIC, dilutional coagulopathy

Management
assess condition of mother and provide oxygen, and perform gentle massage of the uterine fundus and monitor the patient for delivery of the placenta or excessive bleeding If continues hemorrhaging initiate resuscitative efforts (infusion of crystalloid solution, cardiac, blood pressure, pulse, pulse oximetry monitoring, 100% oxygen ) laboratory tests, determination of the cause of bleeding Type and cross match packed red blood cells for transfusion

Management
Assess the uterus with bimanual examination Contracted uterus initiate a prompt search for lacerations, retained parts Oxytocin initiated to stimulate and maintain uterine contraction and control hemorrhage If uterine inversion gently push the uterus back into position. Fortunately, the cervix does not contract around the inverted uterus Check the placenta for evidence of missing placental tissue cervix and vagina must be thoroughly inspected for any trauma

Uterine atony
Failure of the uterus to contract following delivery High parity increase risk for uterine atony Incidence PPH : Low parity 0.3 % Para 4 or greater 1.9%

Medications for Uterine Atony

1. Oxytocin promotes rhythmic contractions 2. Methergine 3. Hemabate
4. Misoprostol (Cytotec)

Oxytocin
Add 20 U of oxytocin to 1 L of crystalloid Administer fluid at rate high enough to control uterine atony If 20 units are added to 1 L, infuse at rate of 200-600 mL/h intrinsic antidiuretic effect cause water intoxication

Methergine
Causes tetanic uterine contraction May trap placenta Can cause Hypertension, especially IV 0.2mg (1 amp) IM,IV Contraindicated in hypertensive patients and those with pre-eclampsia.

Prostaglandin F2 -alpha
Hemabate 0.25 mg IM q 15min (max X8) Controls hemorrhage in 86% when used alone, and 95% in combination with above. Contraindicated in active systemic diseases. Can cause nausea/vomiting/diarrhea, BP

Misoprostol (Cytotec)
Synthetic prostaglandin E 1 analog 1000 mcg PR for 1 dose Increases toxicity of oxytocic agents Can cause diarrhea, fever

Bleeding unresponsive to medication

Use bimanual uterine compression : massage of the posterior aspect of the uterus with abdominal hand and massage through the vagina of the anterior uterine aspect with the other

Unresponsive Uterine Bleeding

Tamponade techniques
gauze balloons , condom/glove Laparotomy conservative
Vessel ligation ( uterine , ovarian , hypogastric ) Uterine -- Vertical full thickness sutures - Compression Suture (B-Lynch) 1997 - Modified B-Lynch (Hayman ) 2002 - Horizontal full thickness sutures - Square Suture 2000 - figure of eight - Combination of sutures hysterectomy procedure of last resort, and a few patients really need to save their lives

Embolization : effective methods for controlling intractable

hemorrhage

Third-stage bleeding
Attempt to remove the placenta by usual methods. Excess traction on cord may cause cord tear or uterine inversion. If placenta retained for >30 minutes manual removal (may be caused by abnormal placental implantation)

Prolonged Third-stage bleeding

Prolonged placenta separation >30min Median third-stage duration ~ 6 mins > 30 mins :increased measures of hemorrhage (currettage or transfusion)

Technique of Manual Removal

Adequate analgesia or anesthesia Aseptic technique Grasping fundus through abdominal wall with one hand Other hand, introduced into the vagina and passes into the uterus along umbilical cord Located placenta margin, ulnar border of the hand insinuated between placenta and uterine wall

Retained placental fragment

Remaining piece of placenta : common cause of bleeding Cause : Succenturiate placenta, Abnormal placenta adherence(accreta, increta, percreta) Inspection of placenta after delivery must be routine

Abnormal implantation
Caused by missing or defective decidua Placenta Accreta: Placenta adherent to myometrium. Placenta Increta: myometrial invasion. Placenta Percreta: penetration of myometrium to or beyond serosa. These only bleed when manual removal attempted.

Lacerations of the genital tract

Causes: Instrumented delivery (forceps) manipulative delivery (breech extraction ,precipitous labor, macrosomia) Types: perineum laceration vaginal laceration cervical laceration

perineum and vaginal laceration

The first degree tear: involves only skin and a minor part of the perineal body the second degree tear: involves the perineal body and vagina the third degree tear: involves the anal sphincter and anal canal

management
Vaginal examination soon after delivery repair: cervical laceration >2cm in length and be actively bleeding laceration of vaginal and perineum

Uterine Inversion
Rare: ~1/2000 deliveries. Causes include: Excessive traction on cord. Fundal pressure. Uterine atony.

Uterine Inversion
Blue-gray mass protruding from vagina Hypotension worsened by vaso-vagal reaction. Consider atropine 0.5mg IV if bradycardia is severe High morbidity and some mortality seen: get help and act rapidly

Uterine Inversion
Push center of uterus with three fingers into abdominal cavity Need to replace the uterus before cervical contraction ring develops Otherwise, will need to use MgSO4, tocolytics, anesthesia, and treatment of massive hemorrhage When completed, treat uterine atony

Uterine Rupture
Rare: 0.04% of deliveries Risk factors include: - Prior C/S - Prior uterine surgery - Hyperstimulation with oxytocin - Trauma - Parity > 4

Uterine Rupture
Risk factors include: - Placental abruption - Forceps delivery (especially mid forceps) - Breech version or extraction.

Uterine Rupture before delivery

Vaginal bleeding. Abdominal tenderness. Maternal tachycardia. Abnormal fetal heart rate tracing. Cessation of uterine contractions.

Uterine Rupture after delivery

May be found on routine exam Hypotension more than expected with apparent blood loss Increased abdominal girth

Uterine Rupture
Sometimes found incidentally(During routine exam of uterus) - Small dehiscence, less than 2cm - Not bleeding - Not painful Can be followed expectantly

Uterine Rupture
When recognized, get help ABCs IV fluids Surgical correction

Conclusion

Prevention
ANC Labor room

Thank you For Your attention