PPH & COAGULATION DISORDERS

SALWA NEYAZIASSISTANT PROF.& CONSULTANT OBSTETRICIAN GYNECOLOGEST

PEDIATRIC & ADOLESCENT GYNECOLOGEST

Postpartum Hemorrhage

DefinitionLoss of 500 ml or more of blood following

vaginal delivery. (Hg. may occur before, during or after delivery of the placenta )

Or 1000 ml of blood loss for cesarean sectionEarly PPH Blood lost during the first 24 hrs

after deliveryLate PPH Blood lost between 24hr—6weeks

after delivery

Postpartum Hemorrhage

Incidence 5-8% It is the most common cause of excessive

blood loss in pregnancy Hemorrhage (including APH, PPH, abortion

& ectopic) is the leading obstetric cause of maternal mortality in Saudi Arabia & underdeveloped countries

It is the third leading cause of MM in USA

Morbidity & Mortality

Women compromised by anemia or intercurrent illness are at increased risk of complications

Anemia Morbidity related to blood

transfusion hepatitis, HIV, transfusion rection

Morbidity related to hypovolemic shock

Renal failure (acute tubular necrosis)

Morbidity & Mortality

Shehan’s syndrome postpartum hypotension partial or complete necrosis of the anterior pituitary panhypopituitrism

-Characterized by failure to lactate, amenorrhea, hypothyroidism, adrenal insufficiency & breast size & loss of pubic & axillary hair.

-Incidence 1:10000 deliveries

Sterility resulting from Hysterectomy performed to control severe Hg

Etiology of PPH

1-Uterine atony With separation of the placenta many uterine

blood vessels are severed abruptly the bleeding that results is controlled by contraction & retraction of the myometrium to compress the blood vessels

Uterine atony results when there is failure of the myometrium to contract

It accounts for 50% of the cases of PPH

1-Uterine Atony

Predisposing causes: Uterine over distension twins,

polyhydramnious or large infant

Grandmultiparity

Prolonged labor

Dysfunctional labor

Oxytocin induction or augmentation of labor

Contd/Uterine Atony Predisposing Causes

Instrumental deliveries Uterine infections General anesthesia with halogenated

compounds Previous HG or blood transfusion Uterine lieomyoma Intrauterine manipulation Abruptio placenta with couvelaire

uterus

Etiology of PPH2-Obstetric lacerations 20%of PPH

It may involve the vagina, vulva, cervix or uterus

Predisposing causes : Precipitate delivery, operative delivery & large infant

Hematomas laceration of blood vessels underneath vaginal or vulvar epithelium

Etiology of PPH contd/Obstetric lacerations

Excessive bleeding from the episiotomy if it involves varicosities or arteries, if the episiotomy is large, early episiotomy or delayed repair

Rupture uterus risk factors: CS or uterine surgery, IOL with PG or oxytocin, grandmultiparity & malpresentation

Etiology of PPH

3-Retained placental tissue

5-10% of PPH

Predisposing causes: placenta accreta, mismanegement of the 3rd stage of labor, succenturiate placenta

U/S or sonohysterography are helpful in the DX of pt. with retained placental tissue

Etiology of PPH

4-Low laying placenta as the lower segment is less contractile

excessive bleeding from the placental site after delivery

5-Inversion of the uterus Due to strong traction on an umbilical cord

attached to a fundal placenta 1:2000-6000 deliveries Immediate replacement is mandatory to

prevent life threatening Hg

Etiology of PPH

6-Coagulation defects-Consumptive coagulopathy due to

abruptio placenta, retained dead fetus, amniotic fluid embolism, severe PET, septicemia or abortion

-Medical causes of coagulation defects Von Willbrand’s disease, ITP, leukemia, dilutional coagulopathy (when >8 U of blood transfused)

MANAGEMENT

1-Predelivery preparation-Type & screen blood for all Pt in labor-High risk Pt Cross matching Large bore IV catheter Severely anemic Pt transfused

2-Management at delivery

Oxytocin IM or IV with the delivery of the anterior shoulder blood loss at delivery & PPH by 40%

Uterine massage after delivery of the fetus

Delivery of the placenta by controlled cord traction

Inspection of the placenta for completeness

3-Management in the immediate post partum period

Manual removal of the placenta MRP

-Timing of MRP immediately if there is HG Wait for 30 if there is no Hg

-Usually performed under GA

-Prophylactic antibiotics given

Contd/Management in the immediate post partum period

Repair of lacerations-Episiotomy should be repaired immediately

-The vagina & cx should be inspected & any lacerations repaired

-Lacerations extending into the broad ligament require laparotomy

-Large hematomas require operative management

4-Evaluation of persistent bleeding

1-Manually compress the uterus2-Obtain blood for X-matching if not

done3-Start IV fluids or blood replacement4-Insert a 2nd IV catheter5-Cathterize the bladder6-Start IV oxytocin7-Inspect the cx & vagina

4-Evaluation of persistent bleeding

8-Manually explore the uterine cavity in vaginal delivery following CS, when

intrauterine manipulation has been performed, when abnormal uterine contour has been noted or preterm delivery

Ensure that there are no retained placental tissue & that the uterus is intact

Look for possible structural abnormalities of the uterus

5-Measures to control bleeding1-Bimanual compression & massage of the

uterus

2-Curettage When manual exploration fails to remove fragments of adherent placenta

It may result in perforation or asherman’s syndrome

3-Utrotonic agents-Oxytocin 20-40 U/L IV infusion 10-15ml/min-Methylergonovine 0.2 mg IM (contraindicated

in hypertensive Pt)-PGF2α intramyometrial injection or IM-Misoprostol rectally

5-Measures to control bleeding

4-Radiographic embolization of uterine arteries or internal iliac

5-Operative managementa-Pressure occlusion of the aorta to provide time

to identify the source of bleedingB-Uterine artery ligationC-Internal iliac ligationD-B-lynch sutureE-Hysterectomy

6-uterine packing

Consumptive coagulopathy DICPregnancy induces hypercoagulbility factor I(fibrinogen), VII, VIII, IX, X Plasminogen but plasmin activity

Causes of Obstetric coagulopathy:

A-Activation of the extrinsic coagulation pathway through the release of thromboplastin from tissue destruction

1-Abruptio placenta (the most common cause )2-Intrauterine fetal death (IUFD) & delayed

delivery occurs if the dead fetus is retained for >1 month (25%)

Rare before that

Causes of Obstetric coagulopathy:

B-Direct activation of factor X by proteases as present in mucin. Amniotic fluid contains abundant mucin from fetal cells rapid DIC with amniotic fluid embolism

C-Septicemia release of bacterial endotoxins disruption of vascular endothelium tissue factor is released activation of the extrinsic coagulation pathway

D-Abortion results in coagulopathy when there is prolonged retention of a dead fetus, septic abortion

E-HELLP syndrome Deposition of fibrin in endothelial cells of blood vessels (consumptive coagulopathy) microangiopathic hemolysis

Clinical evidence of defective hemostasis

Exessive bleeding at the site of modest trauma Characterizes defective hemostasis eg.

Bleeding from venipuncture sites, nicks from shaving, trauma from insertion of a catheter, spontaneous bleeding from nose or gums, continuous oozing from cut surfaces during surgery, petechiae.

Lab. evidence of defective hemostasis

1-Hypofibrinogenemia <100 mg/dl

2-Fibrinogen degradation products

3-Thromboctopenia

4-Prolonged PT & PTT

Amniotic fluid embolism

Abrupt onset of hypotension, hypoxia, and cosumptive coagulopathy

one of these manifestation may dominate

1:20000 deliveries

Amniotic fluid embolism

Clinical presentation

In the late stages of labor or immediately postpartum

Gasping for air, seizures, cardiorespiratory arrest, DIC, Hg, & death (60-90%)

Fetal survival ~70%

No data that any type of intervention improves the prognosis

Treatment of coagulopathy

1-Fresh frozen plasma2-PLatlets transfusion3-Cryoprecipitate4-PRBC 5-Heparin for IUFD Should not be used in cases of abruptio

placenta, septicemia6-Antibiotics for Pt with septicemia or

septic abortion