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Postpartum hemorrhage

Prepared by:

Dr. Gehanath Baral


MBBS,DGO,MD
Senior Consultant Gynecologist & Obstetrician: Government of Nepal
Visiting Professor: CTGU
24th April, 2007

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Definition
• Postpartum hemorrhage is excessive bleeding following
the birth of a baby.

• The average amount of blood loss after the birth of a


single baby in vaginal delivery is about 500 ml and for a
cesarean birth is approximately 1,000 ml.

• Any amount of bleeding from or into the genital tract


following birth of the baby upto the end of puerperium
which adversely affect the general condition of the
patient.
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Types
1. Primary:
– 3rd stage: Before placental delivery
– True PPH: From placental delivery upto 24
hours

2. Secondary: After 24 hours upto 6 weeks


of delivery.

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Causes of 10 PPH

1. Uterine inertia

2. Genital tract trauma

3. Bleeding disorder

4. Other:

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Other causes:
1. Placental abruption
2. Placenta previa
3. Overdistended uterus
4. Multiple pregnancy
5. Pregnancy-induced hypertension (PIH)
6. Having many previous births
7. Prolonged labor
8. Infection
9. Obesity
10. Medications to induce labor
11. Medications to stop contractions (for preterm labor)
12. Use of forceps or vacuum-assisted delivery
13. General anesthesia
14. Tear of cx,vagina,uterine vessels
15. Parametrial hematoma
16. Morbid adhesion of placenta
17. Uterus rupture

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Uterine inertia
1. Overdistention of uterus:
1. Multiple pregnancy
2. Polyhydramnios
3. Big baby
4. Big placenta
2. Delayed/imperfect retraction:
1. Precipitate labor
2. Grandemulti
3. Fibroid
4. Prolonged labor
5. Refractoriness after Induction/Augmentation
3. Retained placenta/membrane

4. Anesthesia, Malnutrition , Anemia

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Uterine inertia

Placental delivery

Uterine contractions Uterine contractions


present absent

Compression of Blood vessels


bleeding vessels bleed freely

No PPH Uterine atony PPH

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Prognosis
1. Shock

2. Sepsis

3. Lactation failure

4. DVT/Pulmonary embolism

5. Sheehan’s syndrome

6. Death (if not treated)


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C/F:
• Uncontrolled bleeding
• Decreased blood pressure
• Increased heart rate
• Decrease in the red blood cell count
(hematocrit)
• Swelling and pain in tissues in the vaginal
and perineal area

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Symptoms
Related to blood loss with postpartum hemorrhage

Blood
pressure, Signs and
Blood loss, percent (mL) mm Hg symptoms
10 to 15 (500 to 1000) Normal Palpitations,
dizziness,
tachycardia
15 to 25 (1000 to 1500) Slightly low Weakness,
sweating,
tachycardia
25 to 35 (1500 to 2000) 70 to 80 Restlessness,
pallor, oliguria
35 to 45 (2000 to 3000) 50 to 70 Collapse, air
hunger, anuria

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Diagnosis of vaginal bleeding after childbirth
Presenting Symptom and Symptoms and Signs Probable
Other Symptoms and Signs Sometimes Present Diagnosis
Typically Present
• Immediate PPHa • Shock Atonic uterus
• Uterus soft and not
contracted
• Immediate PPHa • Complete placenta Tears of
• Uterus contracted cervix, vagina
or perineum
• Placenta not delivered • Immediate PPHa Retained
within 30 minutes after • Uterus contracted placenta
delivery
• Portion of maternal • Immediate PPHa Retained
surface of placenta missing • Uterus contracted placental
or torn membranes with fragments
vessels

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Presenting Symptom and Symptoms and Signs Probable
Other Symptoms and Signs Sometimes Present Diagnosis
Typically Present
• Uterine fundus not felt on • Inverted uterus apparent Inverted uterus
abdominal palpation at vulva
• Slight or intense pain • Immediate PPHb
• Bleeding occurs more than • Bleeding is variable Delayed PPH
24 hours after delivery (light or heavy,
• Uterus softer and larger continuous or irregular)
than expected for elapsed and foul-smelling
time since delivery • Anaemia
• Immediate PPHa (bleeding • Shock Ruptured
is intra-abdominal and/or • Tender abdomen uterus
vaginal) • Rapid maternal pulse
• Severe abdominal pain
(may decrease after rupture)

a Bleeding may be light if a clot blocks the cervix or if the woman is lying on
her back.
b There may be no bleeding with complete inversion.

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MANAGEMENT of ATONIC UTERUS

An atonic uterus fails to contract after delivery.


Continue to massage the uterus.
Use oxytocic drugs which can be given together or
sequentially

Oxytocin Ergometrine/ 15-methyl


Methyl-ergometrine Prostaglandin
F2α
Dose and IV: Infuse 20 IM or IV (slowly): 0.2 IM: 0.25 mg
route units in 1 L IV mg
fluids at 60 drops
per minute
IM: 10 units

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Use of oxytocic drugs
Oxytocin Ergometrine/ Methyl- 15-methyl
ergometrine Prostagland
in F2α
Dose and IV: Infuse 20 units in 1 IM or IV (slowly): 0.2 IM: 0.25 mg
route L IV fluids at 60 drops mg
per minute
IM: 10 units
Continuing IV: Infuse 20 units in 1 Repeat 0.2 mg IM after 0.25 mg
dose L IV fluids at 40 drops 15 minutes every 15
per minute If required, give 0.2 mg minutes
IM or IV (slowly) every
4 hours
Maximum Not more than 3 L of IV 5 doses (Total 1.0 mg) 8 doses
dose fluids containing (Total 2 mg)
oxytocin
Precautions/ Do not give as an IV Pre-eclampsia, Asthma
Contrain- bolus hypertension, heart
dications disease
Prostaglandins should not be given intravenously.
They may be fatal.
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How is postpartum hemorrhage
diagnosed?

1. Complete medical history (symptoms)


2. Physical examination (signs)
3. Laboratory tests:

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Physical examination
– Temperature - elevated temperature may indicate
endometritis (infection of the lining of the uterus)
which may cause secondarypostpartum hemorrhage
– Blood pressure and Pulse rate to help determine
presence of shock
– Feel abdomen to determine how much the uterus has
contracted down into the pelvis and establish if the
uterus is tender
– Vaginal examination to determine if opening of the
cervix is open or closed and to determine if vaginal
discharge is offensive
– Examine the genital area to look for any lacerations,
tears or episiotomy wounds which may contribute to
postpartum hemorrhage
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• Blood test
– Full blood count
– Coagulation profile including INR, PT, APTT
– More sophisticated bleeding disorder tests depending on
suspicion e.g. Hemophilia screening, von Willebrand's disease,
platelet function studies, platelet antibodies
• Swab of vaginal discharge - for microscopy and culture

• Radiological investigations
– Pelvic ultrasound scan to exclude retained products and clots in
the uterus

• Estimation of blood loss (this may be done by counting the number


of saturated pads, or by weighing of packs and sponges used to
absorb blood; 1 milliliter of blood weighs approximately one gram)

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Treatment of postpartum
hemorrhage
• The aim of t/t is to find and stop the cause of the bleeding as quickly
as possible.
• Treatment for postpartum hemorrhage may include:
1. Medication (to stimulate uterine contractions)
2. Manual massage of the uterus (to stimulate contractions)
3. Removal of placental pieces that remain in the uterus
4. Examination of the uterus and other pelvic tissues
5. Packing the uterus with sponges and sterile materials (to compress
the bleeding area in the uterus)
6. Tying-off of bleeding blood vessels
7. Laparotomy - surgery to open the abdomen to find the cause of the
bleeding.
8. Ligation of vessels supplying the uterus
9. Hysterectomy - surgical removal of the uterus; in most cases, this is
a last resort.

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Uterine vascular supply

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Collateral Circulation
The circulation after ligature of the hypogastric artery is carried on
by the anastomoses of:
1. The uterine and ovarian arteries
2. The vesical arteries of the two sides
3. The hemorrhoidal branches of the hypogastric with those from the
inferior mesenteric
4. The obturator artery, by means of its pubic branch, with the vessel
of the opposite side, and with the inferior epigastric and medial
femoral circumflex
5. The circumflex and perforating branches of the profunda femoris
with the inferior gluteal
6. The superior gluteal with the posterior branches of the lateral sacral
arteries
7. Tthe iliolumbar with the last lumbar
8. The lateral sacral with the middle sacral
9. The iliac circumflex with the iliolumbar and superior gluteal

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Supportive treatment
• Antibiotics

• Intravenous (IV) fluids, blood, and blood


products

• Oxygen by mask

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Secondary PPH
• Bleeding usually on second week of delivery
• Cause:
1. Retained bits of placenta and membrane
2. Sloughing out of cervicovaginal laceration
3. Endometritis and subinvolution of placental site
4. 20 hemorrhage from uterine scar
5. Withdrawal bleeding estrogen given for lactation
supression
• D/D: Cx carcinoma, Placental polyp, Infected
fibroid polyp, Uterine inversion

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Treatment of 20 PPH
1. I/V fluid/Blood

2. Oxytocics

3. Antibiotics

4. Exploration/ Histopathological exam

5. Hemostatic suture

6. Laparotomy
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Morbidly adherent placenta

1. Placenta accreta - The placenta is abnormally


attached to the inside of the uterus.

2. Placenta increta - The placental tissues invade


the muscle of the uterus.

3. Placenta percreta - The placental tissues go all


the way into the uterine muscle and may break
through (rupture).

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Morbidly adherent placenta

Accreta/Increta:
1. Removal as much as can be
2. Oxytocics
3. Intrauterine plugging
4. Placental bed suture
Percreta:
1. Cut cord near to the placenta
2. Start antibiotics and methotrexate
3. Hysterectomy
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Oxytocics

• Ergonovine/ Methylergonovine/
Methergine

• Oxytocin/Pitocin/Syntocinon/Xitocyn

• Prostaglandins

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Active management of the third stage of
labor
• Objective: interventions designed to speed the delivery of the
placenta by increasing uterine contractions and to prevent PPH by
averting uterine atony.
• The usual components are:
– (1) giving a uterotonic (uterus-contracting) drug within one
minute of birth of the newborn;
– (2) clamping and cutting the umbilical cord soon after birth;
– (3) applying controlled cord tension (also referred to as
controlled cord traction) to the umbilical cord while applying
simultaneous counter-pressure to the uterus through the
abdomen.
– After delivery of the placenta, massaging the fundus of the
uterus through the abdomen also can help the uterus contract to
minimize further bleeding.

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Expectant management of the third stage of
labor
• Synonyms:
– conservative management
– physiological management

• Waiting for signs that the placenta is separating


from the uterine wall (for example, observing a
gush of blood)

• Allowing it to deliver spontaneously.

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Manual Removal of Placenta
1. Sedation

2. Hand introduced along the cord inside and feel placental margin

3. Keep uterus steady and guide the vaginal finger by abdominal hand

4. Insinuate fingers in between the uterine wall and placenta and separate
placenta

5. Remove placenta with traction on the cord and explore the uterine cavity

6. Give oxytocics and gental massage to uterus

7. Inspect other injury or bleeding from uterus,cervix and vagina

8. Inspect completeness of placenta and membrane

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Complication/Difficulty of MRP

Complication: Difficulty:

• Bleeding and shock from 1. Morbidly adherent


incomplete removal placenta

• Injury to uterus 2. Ring contraction or hour


glass contraction of
• Inversion of uterus uterus

• Introduction of infection
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