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Postpartum Hemorrhage due to uterine atony

Postpartum Hemorrhage due to uterine atony

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Published by: mie_anum on Apr 27, 2010
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PPH is one of the most leading causes of maternal mortality after delivery of baby. PRIMARY PPH: 
the loss of 500cc or more of blood during the first 24 hours after the delivery of the baby.

Can be divided into 4 main causes :
1. T 2. T 3. T 4. T TONE (Uterine Atony) TRAUMA (Genital trauma & lacerations) TISSUE (Retained placenta) THROMBOSIS (Bleeding disorders)

Tone: Uterine Atony
90% of cases: Etiology 1. Over distended uterus Polyhydramnios Multiple gestation Macrosomia 2. Uterine exhaustion Prolonged labor Rapid labor High parity 3. Intra amniotic infection Chorioamnitis Fever Prolonged ROM 4. functional/anatomic distortion of uterus Fibroid uterus Placenta previa Uterine anomalies

Objective Study


To identify the best treatment for primary postpartum hemorrhage due to uterine atony To observe management of primary postpartum hemorrhage due to uterine atony at HRPZII

History taking Physical examination Investigation

Patient s Profile
Name : Madam S Age : 38 Race : Malay RN : 557715 Parity : Para 6, postnatal of unplanned pregnancy Delivery : 21/03/10 at 0915H with EBL 400cc DOA : 20/03/10 Chief Complaint : Presented with show, leaking with ¼ pad soaked with irregular contraction pain L.M.P : 25/06/09 (sure of date, regular menstrual period) E.D.D : 02/04/10 (confirmed by scan at 18 weeks)

History of Present Illness
unplanned pregnancy. First scan was done at 17 weeks and expected date of delivery was 02 April 2010. A referred case from KK Lundang Paku Patient presented with show, leaking with ¼ pad soaked, and irregular contraction pain, fetal movement was good. During that time, patient was watching television and suddenly felt water gushing out from vagina with irregular contraction pain. This patient was known case of anemia in pregnancy but patient denied any vaginal bleeding during pregnancy.

On admission: admission: 
Patient had intermittent pain contraction  Show  leaking liquor  FM good  No s&s of UTI  NO s&s of anemia

Labor Summary
Patient was being admitted to ward 25 on 20/03/10 at 20/03/ 1942H 1942H with c/o of show, leaking with ¼ pad soaked with irregular contraction pain Os opening was 6cm at 0230H and was being sent to 0230H LR. LR. ARM was done 2nd stage of delivery start at 0350H 0350H Child had been born at 0915H, 3.4kg, Length 51cm,, no 0915H, 51cm, fetal anomely Complete placenta expelled at 0925H, weight at 0.7kg 0925H, EBL was 400cc 400cc

3rd stage : Placenta completely delivered Noted blood oozing post placenta delivery. delivery. Noted also that the uterus doesn t contracted well. well. IM pitocin had been given 10iU at both 10iU leg. leg. Uterine massage was then being done, followed by IV pitocin 40iU in 1pint NS. 40iU NS. Blood taken for FBC

Antenatal History
Booking was done 17 weeks of gestation, her body weight was 45kg and height was 144cm, BMI was 21.7. her blood pressure was 120/70 mmHg. On systemic examination all system was found to be normal and uterine size was corresponded to the date. hemoglobin level was 10.6 and her blood and rhesus group is B positive. The serology test for syphilis (Venereal Disease Research Laboratory) and HIV rapid test was non reactive. Anti tetanus toxoid (ATT) injection was completed at 10 February 2010. She also had rubella vaccination which is taken in 1987.

MOGTT at 24 weeks, result was normal Her first ultrasound examination was done during her booking; the result showed the fetus growth and progress was good. She was not having any vaginal bleeding and discharge during pregnancy.

Obstetric History
No Year Period of Gestation Full term Place of Delivery HRPZII Mode of Delivery SVD Weight Status 1 1995 3.1 Alive and Well



Full term




Alive and Well



Full term




Alive and Well



Full term




Alive and Well



Full term




Alive and Well



Full term




Alive and Well

Gynecology History
Since menarche at 16 yrs old, her menses had been regular of 28 - 30 days cycle with normal flow for 6-7 days with only slight 6dysmenorrhoea not requiring any medication Not on any contraceptives done Pap Smear at 1998

Past Medical/ Surgical History
No significant past medical history and she did not underwent any surgeries.

Medicine/Allergies History
Not on any medication No history of allergic to seafood or medication

Family History
Her father was passed away with natural death, her mother still alive but has hypertension and gout. No history of malignancy in the family, no history of hereditary illness and all the siblings are healthy.

Social History
She is a housewife but before this work as operator in factory near their house husband work in construction site she denied smoking and alcohol intake but her husband was occasional smoker all the children are healthy.

Systemic Review
Central Nervous System no headache, no seizure, no abnormal movements, no paraesthesiae Ear, Nose and Throat Gastrointestinal System no ear and nasal discharge no vomiting, no hematemesis, no abdominal pain, no diarrhoea, no constipation, no per rectal bleed Cardiovascular System no chest pain, no palpitation, no orthopnea, no ankle swelling Genitourinary System no dysuria, no hematuria, no incontinence, no loin pain, no frequency or urgency Respiratory System Musculoskeletal System no shortness of breath, no cough, no wheezing no joint, muscle and bone pain, no limitation to joint movement Haematological and lymphatic system no rash, no bruising, no lymphadenopathy, no spleen and liver enlargement

Physical Examination

General examination
Medium built women, alert, conscious, not pale Patient not in pain and comfortable BP: 143/70, PR: 112, T: 37°c 37° Currently :
PV Bleeding 2 pad soaked No s&s of anemia No short of breath No calf tenderness Patient was stable BF established

Systemic Examination
All the system were found to be normal, the thyroid was not palpable no murmur and any additional sound detected. Both lungs are clear, there is present of normal vesicular breath sound, no rhonchi, no crepitation and no added sound detected.

Abdominal examination
INSPECTION: No lesions, no scars or dilated vein noted No distended abdomen Linea nigra, striae gravidarum, striae albican Blood clot evacuated from vagina PALPATION: Soft and non-tender nonUterine contract at 22 weeks, soft
AUSCULTATION: Bowel sound present No other altered bowel sound


FBC 20/0310&21/03/10
Lab view White blood cell Red blood cell RBC distribution width Hemoglobin Hematocrit Mean cell hemoglobin Mean cell volume Mean cell hemoglobin concentration Platelet Neutrophil Lymphocyte Monocyte Eosinophil Basophil 245 72.6 19.4 0.74 0.6 0.0 198 78.5 12.5 0.88 0.1 0.1 150-400 ×10 /L 15040.0-75.0 40.00.00-50 0.000.00-0.80 0.000.00-0.50 0.000.00-0.20 0.00Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal 8.9 4.08 15.4 11.2 35.1 27.5 86.6 31.9 Value 11.0 3.31 14.8 9.4 28.1 28.4 84.9 33.5 Normal range 4.0-11.0 ×10 /L 4.04.5-6.5 ×10 /L 4.511.3-14.9 % 11.312-14g/dL 1239-52 % 3926-32 pg 2677-91 fl 7731-40pg/cell 31Normal Normal Normal Normal Normal Normal Normal Normal State Normal Low Normal Low Low Normal Normal Normal

PT/APTT Test Prothrombin Time Test Prothrombin Time Control INR APTT APTT Control Ratio Result 13.8 13.5 1.03 29.0 38.3 0.76 24.6-37.5 24.6Normal Range 10.7-13.8 10.7-

Patient s Progression 21/03/10 11:20am estimated blood lost is 850cc. on examination patient alert, conscious and mild pale, blood pressure was taken 145/81 mmHg, pulse rate is 112 bpm. On palpation abdomen is soft and uterus contracted well 20 weeks, the pad still staining with blood. Impression: primary postpartum hemorrhage due uterine atony

21/03/10 9:00pm Currently completed transfusion 20PC and 2Ü FFP, the pad still ¼ staining with blood within 2 hours. No anemic symptoms, the plan were allow orally, vital sign monitoring ½ hourly until patient stable, IV Lasix 20mg STAT, strict I/O chart. 21/03/10 12:00 midnights Currently patient alert, conscious and not pale, no anemic symptoms, no excessive bleeding, breastfeeding established and taken orally well. Blood pressure was 118/78 and pulse rate is 98, on palpation, abdomen is soft, non tender and no calf tenderness.

Management Plan 1. Encourage orally and high iron diet 2. Strict pad chart and to inform if per vaginal bleeding 3. Encourage ambulation 4. Encourage breastfeeding 5. off CBD

Madam S, 38 years old malay, housewife, Para 6, post SVD with skin nick repaired

1.Postnatal with primary PPH due to 1.Postnatal uterine atony, EBL 1050cc

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