Download - Postpartum Hemorrhage
![Page 1: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/1.jpg)
Postpartum Hemorrhage
by Shanyar Qadir
Shanyar.com
![Page 2: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/2.jpg)
2 of 26
Blood loss of: > 500 mL during vaginal delivery > 1,000 mL following cesarean delivery
Measurements are subjective and likely inaccurate
Primary (early): within 24 hrs of delivery Secondary (late): from 24 hrs – 12 wks post-
delivery
Definition
![Page 3: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/3.jpg)
3 of 26
Defined clinically as excessive bleeding that makes the patient symptomatic
10% drop in hematocrit Signs/symptoms of blood loss
Objective Criteria
![Page 4: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/4.jpg)
4 of 26
One of the most common obstetrical emergencies
Major cause of maternal morbidity One of the top 3 causes of direct maternal
death in both developing and developed countries
Leading cause of admission to the ICU Incidence
4% after vaginal delivery 6.5% after C/S delivery
Why is it important?
![Page 5: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/5.jpg)
5 of 26
Causes of PPH can be remembered as the 4 ‘Ts’
Tone Uterine atony
Trauma Injury to cervix, vagina, perineum
Tissue Retained placenta &/or membranes
Thrombin Clotting disorders
Etiology
![Page 6: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/6.jpg)
6 of 26
Call for help, ABCs O2 by mask initially 2 x 14-gauge IV lines FBC & clotting studies Test for renal function & liver function tests Cross-match at least 6 units of blood IV fluid resuscitation Notify blood bank & consult hematologist Foley catheter into the bladder & fluid balance chart Blood transfusion asap, O- if not available Central venous pressure & arterial lines May need FFP, platelets & cryoprecipitate (consult hematologist) Eliminate the cause
Initial Management
![Page 7: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/7.jpg)
7 of 26
Most common cause of excessive PPH
Risk Factors: Overworked: Rapid or prolonged labor (most
common) Infected: Chorioamnionitis Relaxed: MgSO4, β-agonists, halothane Overdistended: Multiple pregnancies,
macrosomia, polyhydramnios
Uterine Atony (80%)
![Page 8: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/8.jpg)
8 of 26
Clinical Findings: A soft uterus (feels like dough) palpable above the
umbilicus.
Management: Uterine massage Uterotonics (oxytocin, ergonovine, misoprostol,
carboprost) Surgical: Uterine packing or compression balloon,
B-Lynch suture, sequential arterial ligation, selective arterial embolization, hysterectomy
Uterine Atony (80%)
![Page 9: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/9.jpg)
9 of 26
Bimanual Uterine Massage
![Page 10: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/10.jpg)
10 of 26
CompressionBalloons
![Page 11: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/11.jpg)
11 of 26B-Lynch Suture
![Page 12: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/12.jpg)
12 of 26
Risk Factors: Difficult delivery (shoulder dystocia, macrosomia) Instrumental delivery (forceps, vacuum extractor)
Clinical Findings: Identifiable lacerations (cervix, vagina, perineum)
in the presence of a contracted uterus.
Management: Surgical repair.
Genital Lacerations (15%)
![Page 13: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/13.jpg)
13 of 26
Cervical Laceration Repair
![Page 14: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/14.jpg)
14 of 26
Risk Factors: Accessory placental lobe (most common) Abnormal trophoblastic uterine invasion
Clinical Findings: Missing placental cotyledons in the presence of a
contracted uterus.
Management: Manual removal or uterine curettage under US
guidance.
Retained Placenta (5%)
![Page 15: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/15.jpg)
15 of 26
PlacentaFetal side
![Page 16: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/16.jpg)
16 of 26
PlacentaMaternal side
![Page 17: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/17.jpg)
17 of 26
Succenturiate Placental Lobe
![Page 18: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/18.jpg)
18 of 26
Manual removal of placenta
![Page 19: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/19.jpg)
19 of 26
Uterine curettage
![Page 20: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/20.jpg)
20 of 26
Risk Factors: Abruptio placenta (most common) Severe preeclampsia Amniotic fluid embolism Prolonged retention of a dead fetus
Clinical Findings: Generalized oozing Bleeding from IV sites or lacerations in the presence of a
contracted uterus. Management:
Removal of pregnancy tissues from the uterus Intensive care unit (ICU) support Selective blood-product replacement.
DIC (Rare)
![Page 21: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/21.jpg)
21 of 26
Risk Factors: Fundal placentation Excessive cord traction Previous uterine inversion.
Clinical Findings: Beefy-appearing bleeding mass in the vagina and
failure to palpate the uterus abdominally. Management:
Elevating the vaginal fornices and lifting the uterus back into its normal anatomic position
IV oxytocin.
Inverted Uterus (rare)
![Page 22: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/22.jpg)
22 of 26
Progressive degrees of inversion
![Page 23: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/23.jpg)
23 of 26
Manual replacement of uterine inversion
![Page 24: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/24.jpg)
24 of 26
Clinical Diagnosis Management
Uterus not palpable
Inversion (rare) ↑ fornices, IV oxytocin
Uterus like dough Atony (80%) Uterine massage, oxytocin, ergot, PG F2α
Tears in vagina, cervix
Laceration (15%) Suture & repair
Placenta incomplete
Retained placenta (5%)
Manual removal or curettage
Diffuse oozing DIC (rare) Remove POC, ICU care, blood products
Summary
![Page 25: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/25.jpg)
25 of 26
Thank You!
![Page 26: Postpartum Hemorrhage](https://reader033.vdocuments.us/reader033/viewer/2022061523/554b470bb4c905ff268b50ab/html5/thumbnails/26.jpg)
26 of 26
1. Obstetrics by Ten Teachers, 19e - 20112. Williams Obstetrics, 24e - 20143. A Comprehensive Textbook of Postpartum
Hemorrhage, 2e - 20124. Step Up to Obstetrics & Gynecology – 20145. Obstetrics & Gynecology Lecture Notes – 20136. Postpartum hemorrhage on Wikipedia
(http://en.wikipedia.org/wiki/Postpartum_hemorrhage)
Sources