Obsterics & Gynecology Hospital of Fudan University Weirong Gu
Blood loss in excess of 500 ml following birth within the first 24 hours of delivery◦ Serious intrapartum complication◦ The most significant cause of maternal death worldwide,
mortality : 140 000 per year (1 maternal death every 4 minutes)◦ Incidence: 4–6% of pregnancies◦ Actual incidence: more high because of inaccurate, significant
underreporting
Primary PPH◦ Occurring within the first 24 hours of delivery◦ 4–6% of pregnancies◦ Caused by uterine atony in 80% or more of cases
Secondary PPH◦ Occurring between 24 hours and 6–12 weeks postpartum◦ 1% of pregnancies
4 “ T ”◦Tone: uterine atony◦Tissue: retained placenta◦Trauma: vaginal, cervical, or uterine injury◦Thrombin: coagulopathy (pre-existing or acquired)
——SOGC guideline (number 235, October 2009): Active Management of the Third Stage of Labor: Prevention and Treatment of Postpartum Hemorrhage
The most common and important cause of PPH
The primary protective mechanism for immediate hemostasis after delivery:◦ Myometrial contraction causing occlusion of uterine blood
vessels ——living ligatures of the uterus◦ Blood flow from the vascular space to the uterine cavity via
the myometrium is impeded
Etiologic category and process Clinical risk factors
Overdistension of uterus Polyhydramnios, Multiple gestation, Macrosomia
Uterine muscle exhaustion Rapid labor, Prolonged labor, High parity, Oxytocin use
Intra-amniotic infection Fever, Prolonged rupture of membranes
Functional/anatomic distortion of uterus
Fibroids, Placenta previa, Uterine anomalies
Uterine-relaxing medications Halogenated anesthetics, Nitroglycerin
Bladder distension
Placenta abruptionPlacenta abruption
胎儿胎儿子宫内膜子宫内膜
胎盘胎盘脐带脐带
宫颈宫颈
出血出血
Placenta previaPlacenta previa
Twin pregnancyTwin pregnancy
胎儿胎儿胎儿胎儿
胎盘胎盘
宫颈宫颈
脐带脐带脐带脐带
阴道阴道
fibroidfibroid
肌壁间肌肌壁间肌瘤瘤 浆膜下肌浆膜下肌瘤瘤内膜下肌内膜下肌瘤瘤带蒂带蒂浆膜下肌浆膜下肌瘤瘤
带蒂带蒂内膜下肌内膜下肌瘤瘤
Uterine anomalies
Etiologic category and process
Clinical risk factors
Avulsed lobule, Succenturiate lobe
Incomplete placenta at delivery
Abnormally adhered: Accreta, Increta, Percreta
Placenta previa with or without previous uterine surgery,
Prior myomectomy,Prior cesarean delivery,Asherman’s syndrome,Submucous leiomyomata,Maternal age older than 35 years
Succenturiate lobe
Placenta villi attach Placenta villi invade Placenta villi penetrate to the myometrium into the myometrium through the myometrium
Accreta Increta Percreta
Etioiogic category and process Clinical risk factors
Lacerations of the cervix, vaginal, or perineum
Precipitous deliveryOperative delivery
Puerperal Hematomas Nulliparity, episiotomy, and forceps delivery
Laceration of cervix
I II
III
Lacerations of perineum
Etioiogic category and process Clinical risk factors
Pre-existing states Primary thrombocytopeniaAplastic anemia
Acquired in pregnancy HELLP syndrome Abruption placenta Prolonged intrauterine fetal demise Sepsis
Amniotic fluid embolism Significant hemorrhage
Elevated blood pressureAntepartum hemorrhageFetal demiseFeverSudden collapse
Vaginal bleeding◦ Bleeding with characteristic soft, poorly contracted (“boggy”) uterus on
bimanual pelvic examination ——uterine atony◦ Bleeding while the uterus is firmly contracted —— retained placenta ——genital tract laceration ◦ Bleeding without clot ——coagulopathy◦ Pelvic or rectal pressure and pain ——genital tract hematomas
Hypovolemic shockIrritable,pallor and clamminess of skin, tachycardia,
narrow pulse pressure
——mild degree of shock
Weight method :◦ Blood loss(ml) =( dressing wet weight after birth - dressing dry
weight before birth ) /1.05(specific gravity of blood) Volume method:
◦ Collect blood using a container Area method :
◦ 10cm*10cm gause soak blood = 10ml blood
Shock index =heart rate/systolic pressure ( mmHg ) ( normal <0.5 ) shock index estimate loss of blood ( ml ) loss of blood volume 0.6~0.9 <500~750 <20% =1.0 1000~1500 20~30% =1.5 1500~2500 30~50% ≥2.0 2500~3500 ≥50~70%
The initial goal◦ Identifying and treating the cause of blood loss◦ Instituting resuscitative measures to maintain hemodynamic
stability and oxygen perfusion of the tissues
Call for help Resuscitation
◦ Assess the “ABC”◦ Monitor BP, P, R◦ Empty bladder, monitor urine output ◦ IV line◦ Crystalloid, isotonic fluid replacement◦ Oxygen by mask
Laboratory tests◦ Complete blood count◦ Coagulation screen◦ Blood grouping and cross ——SOGC 2009
Uterine massage◦ Diminish bleeding, expel blood and clots, and allow time for
other measures to be implemented
Uterotonic drugs◦ Ongoing blood loss in the setting of decreased uterine tone
requires the administration of additional uterotonics as the first-line treatment for hemorrhage
Drug Dose/Route Frequency Comment
Oxytocin IV: 10–40 units in 1 liter normal saline
or lactated Ringer’s solution
IM: 10 units
Continuous Avoid undiluted rapid IV infusion, which causes hypotension
Carbetocin IV/IM:100 μg
Ergometrine IM: 0.2 mg Every 2–4 h Avoid if patient is hypertensive
Drug Dose/Route Frequency Comment
15-methyl PGF2α
(Hemabate)
IM: 0.25 mg Every 15–90 min, 8 doses maximum
Avoid in asthmatic patients
Diarrhea, fever, tachycardia can occur
Dinoprostone(PGE2)
Suppository: vaginal or rectal 20 mg
Every 2 h Avoid if patient is hypotensive. Fever is common.
Misoprostol(PGE1)
800–1,000 mcg rectally
Uterine tamponade Exploratory laparotomy Uterine artery embolization
Indication : uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after vaginal delivery
Technique Comment
—Packing —4-inch gauze; can soak with 5,000 units of thrombin in 5 mL of sterile saline
—Foley catheter —Insert one or more bulbs; instill 60–80 mL of saline
—Sengstaken–Blakemore tube
—SOS Bakri tamponade balloon —Insert balloon; instill 300–500 mL of saline
Packing Bakri Balloon tamponade
Indication : When uterotonic agents with or without tamponade measures fail to control bleeding in a patient who has given birth vaginally
Techniques◦ Compression sutures◦ Artery ligation ◦ Hysterectomy
B-Lynch technique◦ First reported by B-lynch in 1993 ◦ Compress the uterine corpus and decrease bleeding◦ Rare Complication : uterine ischemic necrosis with
peritonitis
Modified B-Lynch ◦ e.g. Hemostatic multiple square suturing ◦For postpartum hemorrhage caused by uterine atony,
placenta previa, or placenta accreta◦Eliminateing space in the uterine cavity by suturing both
anterior and posterior uterine walls
Bilateral uterine arteries ligation
Bilateral internal iliac arteries ligation
Bilateral ovarian arteries ligation
Uterine arteries ligation
Internal iliac arteries ligation
Diminish the pulse pressure of blood flowing to the uterus
The timing of this intervention is important: it must be done without delay, before excessive blood loss has occurred
Surgical skill is required to avoid failure and complications such as damage to other vascular structures and the ureters
Indication: massive hemorrhage has not responded to previous interventions
Notice: If hysterectomy is performed for uterine atony, there should be documentation of other therapy attempts
overy
bladder
uterus
vagina
cervix
cavitycavity
salpinx
endometriummyometrium
subtotal
total
Hysterectomy
Indication: stable vital signs , persistent bleeding, especially if the rate of loss is not excessive
Used for bleeding that continues after hysterectomy Used as an alternative to hysterectomy to preserve
fertility
Radiographic identification of bleeding vessels Embolization with gelfoam, coils, or glue, or balloon
occlusion
H.A.E.M.O.S.T.A.S.I.S. H: Ask for help A: Assess (vital parameters, blood loss) and resuscitate E: Establish etiology and check medication supply (oxytosin, ergometrine) and availability of blood M: Massage uterus O: Oxytocin infusion, prostaglandins (intravenous, rectal, intramuscular, intra- myometrial)
S: Shift to operating room, exclude retained products and trauma, bimanual compression T: Tamponade balloon, uterine packing A: Apply compression sutures S: Systematic pelvic devascularization (uterine, ovarian, internal iliac) I: Intervention radiologist, uterine artery embolization if appropriate S: Subtotal or total abdominal hysterectomy
——ICM/FIGO guideline 2006: Postpartum hemorrhage today: initiative 2004—2006
Diagnosis: detection of an echogenic mass in the uterus by ultrasonography
Directed therapy ◦ Whole placenta in uterus : manual removal ◦ Incomplete separation ( avulsed lobule, succenturiate lobe )
: gentle curettage ◦ Placenta accreta
curettage wedge resection medical management hysterectomy
Lacerations of perineum, vagina, or cervix
Genital tract hematomas
Identification and proper repair of lacerations ◦ Transfer to a well-equipped operating room ◦ Proper patient positioning◦ Adequate operative assistance◦ Good lighting◦ Appropriate instrumentation (eg, Simpson or Heaney
retractors)◦ Adequate anesthesia
May not be recognized until hours after the delivery Sometimes occur in the absence of vaginal or
perineal lacerations The main symptoms are pelvic or rectal pressure and
pain
Directed therapy ◦ Draining the blood within the hematoma (sometimes placing
a drain in situ)◦ Suturing the incision◦ Packing the vagina◦ Interventional radiology
Directed therapy◦ Appropriate testing◦ Blood products infused as indicated◦ Simultaneous surgery if the coagulopathy caused or
perpetuated by the hemorrhage
Baseline studies◦ Complete blood count with platelets◦ Prothrombin time◦ Activated partial thromboplastin time◦ Fibrinogen◦ A type and cross order
Be ordered when excessive blood loss is suspected and should be repeated periodically as clinical circumstances warrant
Response to hemorrhage before laboratory results are known
A simple measure of fibrinogen◦ A volume of 5 mL of the patient’s blood is placed into a
clean, red-topped tube and observed frequently. Normally, blood will clot within 8–10 minutes and will remain intact
◦ If the fibrinogen concentration is low, generally less than 150 mg/dL, the blood in the tube will not clot, if it does, it will undergo partial or complete dissolution in 30–60 minutes
AMTSL (active management of the third stage of labor)◦ Routine use of uterotonics◦ Early cord clamping, controlled cord traction◦ Appropriate uterine massage after delivery of the placenta
Subinvolution of placental site Retained products of conception Infection Inherited coagulation defects
The extent of bleeding usually is less than that seen with primary postpartum hemorrhage
Ultrasound evaluation can help identify intrauterine tissue or subinvolution of the placental site
Treatment may include uterotonic agents, antibiotics, and curettage
Management may vary greatly among patients, depending on etiology and available treatment options, and often a multidisciplinary approach is required
Balancing the use of conservative management techniques with the need to control the bleeding and achieve hemostasis
Uterotonic agents should be the first-line treatment for postpartum hemorrhage due to uterine atony
When uterotonics fail following vaginal delivery, exploratory laparotomy is the next step
Williams Obstetrics, 23rd Edition ACOG Practice Bulletin No. 76. 2006. Postpartum
hemorrhage ICM/FIGO guideline 2006: Postpartum hemorrhage today:
initiative 2004—2006 SOGC guideline (number 235, October 2009): Active
Management of the Third Stage of Labor: Prevention and Treatment of Postpartum Hemorrhage
RCOG Green-top Guideline No. 52 May 2009:Prevention and management of postpartum haemorrhage
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