1. Postpartum Hemorrhage Zeng Wangjiang Zeng Wangjiang Department of OBGY Department of OBGY Tongji Hospital Tongji Hospital

7. 12 autopsy of maternal death

8. Maternal mortality PPH usually ranks in the top 3 causes of maternal mortality, along with embolism and hypertension. 7-10 / 100,000 live births in the United States. 8% of these deaths caused by PPH ; (Berg, 1996). 1000 / 100,000 live births (Nigeria); 25% of maternal deaths are due to PPH,(WHO) more than 100,000 maternal deaths per year ( WHO, Abouzahr, 1998).

9. Definition A blood loss of more than 500ml after the baby delivery in the first 24h postpartum—a primary or acute postpartum hemorrhage Excessive blood loss after the first 24h— secondary or late postpartum hemorrhage

10. Problem Estimates of blood loss at delivery are subjective and generally inaccurate ; 10% fall in hematocrit value to define PPH, (Cunningham, 2001); Any amount of blood loss that threatens the hemodynamic stability of the woman;

11. Etiology Uterine atony; Placental factors; Genital tract trauma; Coagulopathy;

12. Uterine atony Overdistension of the uterus; caused by multifetal gestation; Polyhydramnios; fetal abnormality ( severe hydrocephalus); uterine structural abnormality; failure to deliver the placenta

13. Uterine atony fatigue due to prolonged labor or rapid forceful labor; inhibition of contractions by drugs : anesthetic agents, magnesium sulfate, beta- sympathomimetics, and nifedipine. bacterial toxins (eg, chorioamnionitis, endomyometritis, septicemia), hypoxia due to hypoperfusion (abruptio placenta), hypothermia due to massive resuscitation or prolonged uterine exteriorization.

14. Placenta factors Retained placenta : placenta accreta : partial accreta, complete accreta : placenta increta; Placenta percreta; Placenta : succenturiate;

15. Genital trauma (uterine rupture) previous cesarean delivery scars. fibroidectomy; uteroplasty for congenital abnormality; cornual or cervical ectopic resection; uterus curettage, biopsy, hysteroscopy, laparoscopy, or IUD;

16. Genital trauma (uterine rupture) following very prolonged or vigorous labor; relative or absolute cephalopelvic disproportion the uterus has been stimulated with oxytocin or prostaglandins. extrauterine or intrauterine manipulation of the fetus. attempts to remove a retained placenta manually or with instrumentation.

17. Genital trauma (cervical laceration) forceps delivery; Assisted vaginal delivery (forceps or vacuum) ; spontaneously. manual exploration or instrumentation of the uterus;

18. Genital trauma Vaginal sidewall laceration; operative vaginal delivery; occur spontaneously ( fetal hand presents with the head); manipulations to resolve shoulder dystocia. Lacerations often occur in the region overlying the ischial spines; Episiotomy;

19. Genital trauma Bleeding from trauma may be concealed ; Vaginal hematoma; retroperitoneum, Hematoma of broad ligament lower genital tract hematoma; abdominal cavity hematoma.

20. coagulopathy disorders of the coagulation system and platelets do not usually result in excessive bleeding ( immediately); the efficiency of uterine contraction and retraction for preventing hemorrhage (Baskett, 1999). Fibrin deposition and clots supplying vessels play a significant role in the hours and days following delivery; abnormalities in these areas can lead to late PPH

21. Coagulopathy idiopathic thrombocytopenic purpura (ITP); HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count); placenta abruption; DIC; amniotic fluid embolism ; Sepsis; functional abnormalities of platelets.

22. Clinical findings in obstetric hemorrhage ( adapted from Int J Gyn/obs 1997) Blood volume lose Blood pressure (systolic) Symptoms and signs Degree of shock 500~1000(10 ~15%) normalPalpitations, tachycardia, dizziness compensated 1000~1500(1 5~25%) Slight fall (80~100m m Hg) Weakness,tach ycardia, sweating mild 1500~2000(2 5~35%) Moderate fall(70~80m m Hg) Restlessness, pallor, oliguria moderate 2000~3000 (35~50%) Marked fall (50~70 mm Hg) Collapse, air hunger, anuria severe

23. Diagnosis and treatment (uterine atony) Prolonged labor; Assessment of uterine tone and size ; The presence of a boggy uterus with either heavy vaginal bleeding or increasing uterine size; Bleeding : interval, dark color, clots; Placenta delivery delay;

24. Uterine atony placing a hand on the uterine fundus and massaging the uterus; therapeutic oxytocin. 20 U iv drop; 10 U intramyometrially; Emptying the bladder; Sterile technique is used.

25. Bimanual massage

26. Uterine atony Ergonovine : 0.2~0.4 mg, im or intramyometrially ; The maximum total dose is 1.2 mg; Hypertension is a relative contraindication. 15-methyl prostaglandin F2-alpha (carboprost): 0.5~1 mg im, not to exceed 2 mg Misoprostol: 200 ug, 卡前列甲酯 : 1 mg; Asthma is a relative contraindication.

27. Placenta factors examine the placenta for completeness. Bleeding before or after placenta delivery; Bleeding : dark or bright color, clots placenta accreta : perform manual removal; curettage Placenta increta : suture or hysterectomy; Placenta percreta: hysterectomy;

28. Manual removal method

29. Genital trauma Bleeding occurs after baby delivery; Bright red; clots; Persistent; Vaginal hematoma; Cervical laceration; stitch begins above the apex of the tear.

30. Cervical laceration

31. caution hematomas in the lower genital tract ; broad ligament and retroperitoneal hematomas ; intense pain and localized, tender swelling; Broad ligament hematomas may be palpated as masses adjacent to the uterus; Disproportion (blood lose and shock symptom );

32. coagulopathy A review of the history; ongoing bleeding or oozing from puncture sites, mucous surfaces, or wounds; Test PT and APTT, platelet; D-dimers fibrinogen level;

33. treatment Infuse fresh frozen plasma (FFP): normalize the coagulation test findings; 1 U of FFP for every 5 U of PRBCs; Keep the platelet >50 X 10 9 /L ; 1u increase 10 X 10 9 /L ; Cryoprecipitate :provides VIII, XIII, von Willebrand factor, The use of heparin and antifibrinolytic therapy is not recommended. ;

34. Emergency treatment Vaginal packing: paravaginal hematoma; Uterine packing: Packing may also be used as a temporizing measure before arterial embolization ; uterine tamponade with balloon devices ( isolated report ); Remove the pack in 24-36 hours.

35. Uterine packing

36. Surgical therapy Uterine artery ligation: provide approximately 90% of uterine blood flow; 95% ~100% success rate; The ovarian artery ligation; Internal iliac artery ligation : Hysterectomy is required if internal iliac artery ligation is unsuccessful ; Selective arterial embolization

37. Management of obstetric hemorrhage Once the diagnosis is made, immediately notify appropriate staff members; The magnitude and underlying cause of the bleeding to some degree record : blood transfusion and blood products is likely to be critical.

38. Fluid resuscitation loss of 1 L of blood requires replacement with 4-5 L of crystalloid; colloid solutions : albumin, dextran (no more than 1500ml);

39. Blood transfusion Whole blood is no longer available ; PRBCs are initially used; uncrossmatched O-type Rh-negative PRBCs ;

40. Step1 (WHO) Administer oxygen by mask. Place 2 large-bore intravenous lines. Take blood for crossmatch of 6 U PRBCs, coagulation screen, urea level, creatinine value, and electrolyte status. Begin immediate rapid fluid replacement with NS or Ringer lactate solution. Transfuse with PRBCs as available and appropriate

41. Step 2 Monitor pulse, blood pressure, blood gas status, and acid-base status, and consider monitoring central venous pressure. Measure urine output using an indwelling catheter. Order regular CBC counts and coagulation tests to guide blood component therapy

42. Step 3 Order coagulation screen ( activated partial thromboplastin time) if fibrinogen, thrombin time, and D- dimer results are abnormal. Give FFP if coagulation test results are abnormal and sites are oozing. Give cryoprecipitate if abnormal coagulation test results are not corrected with FFP and bleeding continues. Give platelet concentrates if the platelet count is less than 50 X 10 9 /L and bleeding continues. Use cryoprecipitate and platelet concentrates before surgical intervention.

43. Step 4 If antepartum, deliver the fetus and placenta. If postpartum, use oxytocin, prostaglandin, or ergonovine. Explore and empty the uterine cavity, and consider uterine packing. Examine the cervix and vagina, ligate any bleeding vessels, and repair trauma. Ligate the uterine blood supply (ie, uterine, ovarian, and/or internal iliac arteries). Consider arterial embolization. Consider hysterectomy.

44. Thank you