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Postpartum Hemorrhage Dr. Yasir Katib MB BS, FRCSC.

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Presentation on theme: "Postpartum Hemorrhage Dr. Yasir Katib MB BS, FRCSC."— Presentation transcript:

1 Postpartum Hemorrhage Dr. Yasir Katib MB BS, FRCSC

2 Postpartum Haemorrhage IIIIntroduction RRRRisk Factors PPPPrevention TTTTreatment PPPPelvic Haematoma UUUUmbrella Pack UUUUterine Inversion

3 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)

4 PPH - Introduction  Factors Predisposing to Myometrial Dysfunction o Uterine Overdistention oMultiple Pregnancy oFetal Macrosomia oHydramnios oOxytocin-stimulated Labour oUterine Relaxants oAmnionitis

5 PPH - Introduction  Abnormal placentation oPlacenta accreta – attaches directly into myometrium oPlacenta increta - extends deep into myometrium oPlacenta percreta - through the uterine serosa & even into the surrounding organs oPPH occurs b/c myometrial tissue present at implantation site insufficient to constrict spiral arteries of the uterus. oAttempting to remove the abnormal placenta frequently results in uncontrolled haemorrhage because of large open sinuses in the myometrium.

6 PPH – Risk Factors (Obstetric Haemorrhage >1 L)  Placental abruption  Placenta previa  Multiple pregnancy  Obesity  Retained placenta  Induced labour  Episiotomy  Birth weight > 4 kg

7 PPH – Prevention  Active management of 3 rd stage of labour & spontaneous delivery of 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 3 rd stage of labour (~ 5 min) & low incidence of manual removal (2%)  In absence of sig. maternal haemorrhage, additional 30 min of expectant management allow ½ of retained placentas to deliver spontaneously

8 PPH – Tx (Manual)  Manual digital exploration of uterus to r/o possibility of retained placental fragments

9 PPH – Tx (Manual)  If not detected, manual massage of uterus should be started

10 PPH – Tx (Pharmacologic)  At the same time, initial Tx of oxytocin U/1000 mL of NS at rates as high as 500 mL in 10 min.  If oxytocin fails, synthetic prostaglandin (Prostin, Upjohn) is 2 nd line (0.25 mg IM in deltoid q1-2h X 5 doses)  Ergovine (0.2 mg IM) used to be 2 nd line  Misoprostol (1000  g PR) in patients with refractory uterine bleeding shown (O’Brien et al.)

11 PPH – Tx (Surgical)  Inspection for laceration of maternal tissues could be a likely cause of continued vaginal or cervical bleeding  Repair

12 PPH – Tx (Surgical)  1 st degree – involves fourchet, perineal skin & vaginal mucosal membrane  2 nd degree – also involves muscles of perineal body; rectal sphincter remains intact

13 PPH – Tx (Surgical)  3 rd degree – extends not only through the skin, mucous membrane & perineal body, but includes the anal sphincter

14 PPH – Tx (Surgical)  4 th degree laceration – extends through the rectal mucosa

15 PPH – Tx (Surgical)  Cervical laceration – NB to secure base of laceration (often a major source of bleeding); but difficult to suture

16 PPH – Tx (Surgical)  If uterine bleeding not responsive to pharmacologic methods & no vaginal or cervical lacerations present, surgical exploration may be necessary  Laceration of uterine vessels may be found (i.e. longitudinal lacerations of inner myometrium – thought to be an incomplete form of uterine rupture)

17 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

18 PPH – Tx (Surgical)  Instead, stepwise progression of uterine vessel ligation should be performed  1 st – 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

19 PPH – Tx (Surgical)

20 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

21 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) infection (most common) - reflux of embolic material in nontargeted pelvic structures nontargeted pelvic structures

22 PPH – Pelvic Hematoma  Blood loss not always visible  Occasionally, traumatic laceration of blood vessels can lead to pelvic haematoma formation  3 types oVulvar oVaginal oRetroperitoneal

23 PPH – Pelvic Hematoma  Vulvar oD/t laceration of vessels in superficial fascia of either the ant. or post. pelvic triangle oUsual signs : subacute volume loss & vulvar pain oBlood loss limited by Colle’s fascia & urogenital diaphragm & anal fascia oB/c of fascial boundaries, mass extends to skin & visible haematoma results oTx – volume support & surgical evacuation of blood & clots, pressure bandage, Foley catheter

24 PPH – Pelvic Hematoma

25  Vaginal oFrequently associated with forceps delivery; may be spontaneous oLess common than vulvar oBlood accumulates in plane above level of pelvic diaphragm oUnusual for large amounts of blood to collect oFrequent complaint – severe rectal pressure oExam – large mass protruding into vagina oTx – incision of vagina & evacuation (even if delayed Dx)

26 PPH – Pelvic Hematoma

27  Retroperitoneal oLeast common oMost dangerous to mother oMay not be impressive until sudden onset of hypotension/shock oD/t laceration of one of vessels originating from hypogastric artery oTx : surgical exploration & ligation of hypogastric vessels unilaterally or bilaterally if needed

28 PPH – Uterine Inversion  Characterized by partial delivery of the placenta, followed by rapid onset of shock ( usually before sig. blood loss) in the mother in the 3 rd stage of labour  Can be mistaken for partially separated placenta or aborted myoma  Uncommon but life-threatening event  Incidence : 1/2000 deliveries

29 PPH – Uterine Inversion  Incomplete – if corpus does not pass through cervix  Complete – if corpus passes through the cervix  Prolapsed – if corpus extends through vaginal introitus  Usually occurs in association with a fundally inserted placenta

30 PPH – Uterine Inversion  Tx : fluid therapy & restoration of uterus to N position immediately upon recognition of inversion, without removing the placenta  If initial efforts fail, use of either  -mimetic agents or magnesium sulfate should be tried (esp. if severe maternal hypotension)  Occasionally, impossible to reposition uterus vaginally & laparotomy necessary  Once inversion corrected, oxytocic or prostaglandin agents should be given

31 The End


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