Professional Documents
Culture Documents
Postpartum Haemorrhage
Introduction Risk Factors Prevention Treatment Pelvic Haematoma Umbrella Pack Uterine Inversion
PPH - Introduction
Acute blood loss most common cause of
hypotension in obstetrics Usually occurs immediately before or after placental delivery Most commonly results when uterus fails to contract - effective haemostasis dependent on contraction of myometrium (compresses severed vessels)
PPH - Introduction
Factors Predisposing to Myometrial Dysfunction
o Uterine Overdistention
o Multiple Pregnancy o Fetal Macrosomia o Hydramnios o Oxytocin-stimulated Labour o Uterine Relaxants o Amnionitis
PPH - Introduction
Abnormal placentation
o Placenta accreta attaches directly into myometrium o Placenta increta - extends deep into myometrium o Placenta percreta - through the uterine serosa & even into the surrounding organs o PPH occurs b/c myometrial tissue present at implantation site insufficient to constrict spiral arteries of the uterus. o Attempting to remove the abnormal placenta frequently results in uncontrolled haemorrhage because of large open sinuses in the myometrium.
PPH Prevention
Active management of 3rd stage of labour & spontaneous
delivery of placenta @ time of C/S Umbilical cord clamping within 30s of delivery, gentle cord traction, followed by IM or IV oxytocin before delivery of placenta Oxytocin s length of 3rd stage of labour (~ 5 min) & low incidence of manual removal (2%) In absence of sig. maternal haemorrhage, additional 30 min of expectant management allow of retained placentas to deliver spontaneously
PPH Tx (Manual)
Manual digital exploration
of uterus to r/o possibility of retained placental fragments
PPH Tx (Manual)
If not detected, manual
massage of uterus should be started
PPH Tx (Pharmacologic)
At the same time, initial Tx of oxytocin 10-20 U/1000 mL
of NS at rates as high as 500 mL in 10 min. If oxytocin fails, synthetic prostaglandin (Prostin, Upjohn) is 2nd line (0.25 mg IM in deltoid q1-2h X 5 doses) Ergovine (0.2 mg IM) used to be 2nd line Misoprostol (1000 g PR) in patients with refractory uterine bleeding shown (OBrien et al.)
PPH Tx (Surgical)
PPH Tx (Surgical)
1st degree involves
fourchet, perineal skin & vaginal mucosal membrane 2nd degree also involves muscles of perineal body; rectal sphincter remains intact
PPH Tx (Surgical)
3rd degree extends
not only through the skin, mucous membrane & perineal body, but includes the anal sphincter
PPH Tx (Surgical)
4th degree
laceration extends through the rectal mucosa
PPH Tx (Surgical)
Cervical laceration NB
to secure base of laceration (often a major source of bleeding); but difficult to suture
PPH Tx (Surgical)
If uterine bleeding not responsive to pharmacologic
methods & no vaginal or cervical lacerations present, surgical exploration may be necessary
PPH Tx (Surgical)
If haemorrhage secondary to atony, vascular ligation
often necessary Hypogastric artery ligation fallen out of favour b/c of prolonged OR time, technical difficulties & inconsistent clinical response If bilateral uterovarian vessel ligation does not stop bleeding, temporary occlusion of infundibulopelvic ligament (digital pressure or clamps) should be attempted ligation indicated if this controls bleeding
PPH Tx (Surgical)
Instead, stepwise progression of uterine vessel ligation
should be performed 1st ligation of ascending branch of uterine arteries (in ~10-15% of atony, unilateral ligation of uterine artery sufficient to control bleeding; bilat will control an additional 75%) If bleeding persists, should attempt to interrupt blood flow between uterus & infundibulopelvic ligament via ligation of anastomosis of ovarian & uterine artery
PPH Tx (Surgical)
PPH Tx (Radiological)
Advantages
d anaesthetic & surgical risks - identification & selective occlusion of specific vessels - avoid hysterectomy Could also use transient transcatheter uterine artery balloon for management of extreme haemorrhage
PPH Tx (Radiological)
Successfully used in postpartum bleeding from atony,
bleeding from pelvic vessel laceration, post c-section haemorrhage & bleeding associated with extrauterine pregnancy Complications - postprocedure fever & pelvic infection (most common) - reflux of embolic material in nontargeted pelvic structures
The End