Post partum hemorrhage

RK

Introduction
PPH is a common complication of childbirth and a leading cause of maternal morbidity and mortality Although maternal mortality rates have declined greatly in the developed country, PPH remains a leading cause of maternal mortality elsewhere. Thus, clinicians should identify risk factors before and during labour, in order to optimize care for high risk women

Definition
Excessive blood loss from the genital tract after delivery Its a third stage complication Estimated blood loss of 500ml or more in vaginal delivery And blood loss of 1000ml or more in caesarean section

Types
Primary: PPH occuring in 24 hours of delivery Secondary: PPH occuring between 24 hours to 6 weeks after delivery

Causes
Atonic or hypotonic uterus(90%): Caused by failure of the uterus to contract after delivery Due to overdistended uterus(twins or polyhydramnions), prolonged labor, infection, retained tissue and etc

 Genital tract trauma(7%): Tears, Large episiotomy, lacerations of cervix, and Ruptured uterus

 Coagulation disorders Placental abruption Sepsis Prolong retention of dead fetus Pt who is on heparin lead to excessive bleeding Massive transfusion Amniotic fluid embolism Inherited or acquired coagulation defects

 Abnormal placental site: Placenta previa Placenta accreta Placenta percreta

 Rare cause: Uterine rupture Uterine inversion

Risk factors

Antenatal risk factors for PPH

Previous PPH Previous retained placenta Maternal Hb <8.5g/dl at onset of labour High BMI Para 4/> Antapertum hemorrhage Overdistention of uterus(twins/polyhydramnions) Uterine abnormalities Low lying placenta Maternal age, >35 years

***Presence of this risk factors in the pregnant lady suggest that she should deliver in an obs unit with blood transfusion and surgical management of PPH facilities

Intrapartum risk factors of PPH

Induction of labour Prolonged 1st/2nd/3rd stage of labour Use of oxytocin Caesarean section

Investigation
FBC RFT Clotting Studies Vital sign: Temp, Pulse, BP Pulse oximetry Urine output

Initial assessment
Identify estimated blood loss

Visual blood loss estimation (not accurate) Blood collection drapes/ weighing swab (accurate)

Management
a) Resuscitation b) Monitoring c) Treatment

a)resuscitation
Seek assistance- ACTIVE RED ALERT Set up 2 IV lines(Branula size 14-16 gauge) Do blood investigation(Hb level, Platelet, bleeding time, clotting time, PT, aPTT, BUSE) Group & crossmatch 4 units of blood Stabilise patient while waiting for the blood result with Hartmann solution/Colloid Transfuse blood when available as soon as possible Resuscitation trolley at bedside Inform M.O and specialist oncall

b) monitoring
Colour, pulse, BP,resp rate Monitor urine output CVP line if required

c) treatment
Give IV ergometrine 0.5 mg Start IV syntocinon infusion 40 units in 500ml normal saline at 100ml/hour If placenta not delivered, massage uterus gently to stimulate a contraction and deliver the placenta If placenta delivered, check placenta If incomplete, explore uterus under sedation/GA If complete, check for cervical laceration or other genital tract trauma

 If traumatic lesions or retained placenta have been excluded, give IM carboprost(Haemabate) 250mcg. This dose can be repeated after 15 minutes up to 3 doses. If bleeding still persist, prepare patient for surgical intervention Consider surgical measures early when conservative management fails

BIMANUAL UTERINE COMPRESSION

SURGICAL
Uterine balloon tamponade Uterine compression sutures Uterine artery ligation Internal artery ligation Uterine artery embolisation Hysterectomy

Complication
Severe PPH related to massive blood loss with hypovolemic shock: resp(ARDS), renal(Acute tubular necrosis) Hypopituitarism following severe PPH(sheehan syndrome) due to severe ischemia of hypertrophied pituitary Surgical intervention complication: uterine perforation, uterine synechiae(Asherman syndrome), urinary tract injury, genitourinary fistula, sepsis, and etc

 Thank you