Hemorrhage Postpartum

Riska Wahyuningtyas,dr,SpOG, M.Ked.Klin

Keseluruhan isi pada dokumen ini merupakan hak cipta dari Asclepio
 Outlines
• Pengertian HPP
• Prediksi HPP
• Etiologi HPP
• Tatalaksana HPP
• Pemasangan Kondom Kateter
• Menghitung Estimasi Perdarahan
• Jenis Uterotonika
HPP
Perdarahan pasca persalinan: Perdarahan
yang terjadi setelah persalinan sebanyak >
500cc untuk persalinan pervaginam dan >
1000cc untuk persalinan perabdominam
Prediksi HPP?
Etiologi
Tatalaksana
Tatalaksana HPP
Tatalaksana HPP
Tatalaksana HPP
B Lynch
Manual Placenta
Kondom Kateter
Pemasangan Kondom Kateter
Pemasangan Kondom Kateter
Estimasi Perdarahan
Uterotonika
 Recalling Session
• Definisi PPH postvaginal delivery vs postcesarean delivery berbeda
• PPH dapat diprediksi pre, intra, postpartum
• Penyebab PPH 4 T à evaluasi simultan
• Tatalaksana kegawatan menentukan outcome pasien
• Selalu bekerja dengan tim
 QnA Trial (1)
1. A 21-year-old G1 now P1 just delivered after a prolonged induction of
labor due to being postdates.
After the placental delivery she continues to bleed excessively. Your initial
intervention to address this bleeding is to activate the normal physiologic
mechanisms. Which of the following is the most important hemostatic
mechanism in combating postpartum hemorrhage?
(A) contraction of interlacing uterine muscle bundles
(B) fibrinolysis inhibition
(C) increased blood-clotting factors in pregnancy
(D) intramyometrial vascular coagulation due to vasoconstriction
(E) markedly decreased blood pressure in the uterine venules
 QnA Trial (2)
2. Which of the following statements most accurately describes
postpartum hemorrhage?
(A) It is prevented primarily by the increased concentration of
clotting factors in maternal blood.
(B) Grand multiparity is a risk factor.
(C) Women with severe pre-eclampsia are more tolerant of heavy
blood loss.
(D) Changes in pulse and blood pressure are good early indicators of
excessive blood loss.
(E) Placenta accreta is the most frequent cause.
 QnA Trial (3)
3. Certain patients are more likely than others to have uterine atony
and hemorrhage after delivery.
Circumstances that predict possible increased bleeding postpartum
include which of the following situations?
(A) prolonged labor
(B) primigravidas
(C) hypertensive disorders
(D) pudendal anesthesia for delivery
(E) obesity
 QnA Trial (4)
A 27-year-old G3P3 has delivered a 9.5lb female after a 21-hour labor in
which contractions were augmented with oxytocin. The placenta delivered
intact. Her perineum has a second-degree laceration.
4. As you begin to repair the perineum, you also have the nurse administer
which of the following?
(A) misoprostol per vagina
(B) misoprostol per rectum
(C) oxytocin orally
(D) prostaglandin F2-alpha IM
(E) oxytocin IV
 QnA Trial (5)
5. After repair of the laceration, the patient continues to bleed heavily.
She has lost 350 cc of blood. At this step you should assess uterine
tone and do which of the following?
(A) inspect the cervix and upper vagina for lacerations
(B) do a manual exploration of the uterus for retained products of
conception
(C) do a bedside ultrasound to evaluate for retained products
(D) place a second large bore IV line
(E) place a foley catheter
 QnA Trial (6)
6. After 45 minutes, the patient has lost 1,400 cc. The uterus is very “boggy”
and does not contract well.
Pulse is 105 bpm, blood pressure is 95/58, and oxygenation is 98%. Studies
show a hemoglobin of 7.2 with a hematocrit of 22%, a platelet count of
95,000. What should be your next step?
(A) recheck of the hematocrit
(B) evaluate for HELLP syndrome
(C) prepare for laproscopy
(D) transfer 2 units packed cells and 2 units fresh frozen plasma
(E) evaluate for von Willebrand’s disease
 QnA Trial (7)
A 36-year-old G7P50015 woman has just delivered a 4,500 g female infant at
39 weeks gestation. She underwent induction of labor with oxytocin for
severe preeclampsia diagnosed with systolic BPs elevated to 160 mm Hg. Her
pregnancy was complicated by uncontrolled gestational diabetes and
resultant polyhydramnios. She was placed on magnesium throughout her
induction for seizure prophylaxis. She had an epidural placed during the first
stage of labor and remained on a normal labor curve throughout. Her second
stage of labor lasted 3 1/2 hours; she was, however, able to deliver vaginally
with preemptive McRoberts maneuvers and steady traction. The third stage
of labor lasted 10 minutes, and the placenta was delivered intact.
Immediately after the third stage, her bleeding was significant with the
expulsion of blood clots and a fundus that was notable for bogginess.
 QnA Trial (8)
7. Which of the following are not risk factors for postpartum hemorrhage (PPH)?
a. Advanced maternal age
b. Grand multiparity
c. Prolonged use of oxytocin during labor
d. Polyhydramnios
e. Prolonged exposure to magnesium during labor
8. Which of the following medications would be contraindicated in the treatment of uterine atony in
this patient?
a. Methylergonovine (Methergine)
b. Carboprost (Hemabate, PGF2 -α)
c. Intramuscular pitocin
d. Misoprostol (PGE1)
e. Calcium gluconate
 QnA Trial (9)
9. Prompt use of a 250-mcg IM injection of carboprost manages to increase
the tone of her uterus and stop the bleeding; however, you continue to
notice a steady stream of blood descending from the vagina. What is the
most appropriate next step in the evaluation of this patient’s bleeding?
a. Perform a bedside ultrasound for retained products of conception
(POCs)
b. Perform a bedside ultrasound to look for blood in the abdomen
significant for uterine rupture
c. Perform a manual exploration of the uterine fundus and exploration for
retained clots or products
d. Examine the perineum and vaginal sulci for tears sustained during
delivery
e. Consult interventional radiology for uterine artery embolization
 QnA Trial (10)
10. The patient was noted to have a third-degree perineal laceration (affected the
external anal sphincter) that was repaired in normal standard fashion. Which of
the following considerations in the treatment and counseling of these patients
are false?
a. You should provide a rectal examination to ensure that the mucosa is intact
b. She should be on regular stool softeners throughout the postpartum period
c. She should be given narcotic medications for pain control on a PRN basis
d. She should be counseled about her risk of anal sphincter defect and
incontinence
e. She should undergo anal endosonography and/or anal manometry in 1 year to
evaluate for sphincter defects
 QnA Trial (11)
11. You are examining the patient’s postpartum hematocrit and note a drop
in her antepartum measurement from 33% to 24%. Her estimated blood
loss from her vaginal delivery and perineal laceration repair was 400 mL.
The nurse reports that the patient has had minimal vaginal bleeding
overnight. What is the next best step in her evaluation/treatment?
a. Reassurance and offer iron supplementation postpartum
b. Offer a blood transfusion for palliation of symptoms of anemia
c. Request a procedure room for dilation and curettage (D&C) of the
uterus
d. Request an abdominal ultrasound for blood in the uterine or
abdominal cavity
e. Examine the site of her laceration repair for hematoma
 QnA Trial (12)
12. In treating uterine atony after delivery, which of the following is
true?
a. Fundal massage should be performed.
b. A 20-unit oxytocin bolus should be administered intravenously.
c. Oxytocin diluted in a crystalloid solution at a concentration of 200
U/min should be administered intravenously.
d. All of above
 QnA Trial (13)
13. Ms. Jones, a 32-year-old G3P2 gravida with chronic hypertension, had a
normal labor that arrested during the second stage at + 1 station. She
complained of mild dyspnea and fatigue. The fetus had a left occiput
anterior presentation and was delivered by forceps. Completion of the
third stage followed quickly, and the fundus was noted to be firm. Brisk
vaginal bleeding was then noted. What is the most likely cause of
bleeding?
a. Uterine atony
b. Uterine rupture
c. Retained placenta
d. Genital tract laceration
 QnA Trial (14)
14. Which of the following is suitable treatment for this
situation?
a. Immediate recognition and calls for assistance improve
outcome
b. If recognized quickly, fundal massage and uterotonic
agents are initiated.
c. The patient is evaluated for regional anesthesia, large-
bore intravenous access is established, and rapid
crystalloid infusion is begun while you wait for blood to
arrive.
d. All of above
 QnA Trial (15)
15. Your patient delivered precipitously and without perineal
laceration. During the first hour postpartum, the vulvar mass
shown here continues to expand, and the patient complains of
significant pain. Evaluation reveals a BP of 90/40 mm Hg, pulse
of 120 bpm, and no fever. Which of the following are reasonable
management approaches to the condition depicted here?
a. Ice packs and observation are planned.
b. This large supralevator hematoma may require angiographic
embolization.
c. This likely connects with the ischioanal fossa, and laparotomy is
planned to exclude or evacuate a large retroperitoneal
hematoma.
d. The point of maximal expansion is incised, clots are evacuated,
bleeding points are ligated, and the evacuated space is
obliterated by sutures.