4Maternal mortality Hemorrhage Infection Hypertension Thromboembolism The single mostImportant cause ofMaternal deathEvery year, women die because of postpartum hemorrhage – one every 4 minutes
5Definition Estimated blood loss with vaginal delivery: > 500cc Estimated blood loss with C/S: > 1000cc1ry : within 24h after delivery2ndry : after 24h up to weeks
6Avoid underestimating significant bleeding Don’t underestimate EBLDon’t disregard slow but unrelenting trickleIf signs of shock* without high EBL, must consider hidden bleeding (internal injury, hidden hematoma)Requires urgent treatment
7A 60 kg pregnant has 6L of blood volume at 30 weeks
8EpidemiologyIncidence : 4 % 88 % of deaths are seen in the first 4 hrs Abdominal or pelvic bleeding can be hidden
9Early postpartum hemorrhage causes Uterine atonyGenital tract traumaRetained placental tissueLow placental implantation due to relative musculature in the LUS so insufficient control of bleedingUterine inversionCoagulation disordersAbruptio placentaeAmniotic fluid embolismRetained dead fetusInherited coagulopathy
15Bimanual Uterine ExamConfirms diagnosis of uterine atony: the fundus is soft “ boggy “ , poorly contracting
16Initial Assessment (orders) Remember ABCsCheck the vitals and correct the shock stateStart a large-bore IVObtain CBCPlatelet count , PT , PTTBlood crossmatch (keep 4 units of packed RBCs in hand )IV infusion of norm.saline or ringer lactate (it’s best to avoid glucose containing fluids)3ml of crystalloid / ml of EBL
17Initial Assessment (orders).cont. Insert urethral catheter to monitor urine outputBlood and blood product transfusion may be required ifblood loss is continuing,if the blood volume lost is over 30%,or if the patient’s clinical status reflects developing shock despite aggressive resuscitation
18ManagementBimanual Uterine massage is often adequate for stimulating uterine involution. medications
19Oxytocin ( pitocin )promotes rhythmic contractions of the upper uterine segmentGive IM or IU, no rapid IV infusion (Can cause BP)10 – 40 U in 1 L NS at 250cc/h. / IVCan get Antidiuretic effect in very high doses
20Methylergonovine Methergine 0.2 mg IM only Max. of 3 doses contracts both upper and lower uterine segments tetanicallycauses vasoconstriction and hypertensioncontraindicated in hypertensionside effects: HTN, nausea, vomitting
21Prostaglandins F2 Hemabate 0.25mg intramyometrial q 15min Rapid response 3-10 minutesMax. 8 dosesAvoid in asthmatic patients.This is 80% to 90% effective in stopping PPH in cases that are refractory to oxytocin and ergometrine
22misoprostolCytotec Recent data indicates that it can be used as 1st line 800 – 1000 mcg rectally
23Other measures Uterine packing or tamponade When uterotonic agents failUseful in cases of placenta praevia or accretaEither gauze or Foley, Sangestaikin blakemore tubeRecent reports of large series have confirmed the high success rates of balloon devicesUterine artery embolization by placing angiocatheter and injecting thrombogenic material
25Exploratory laparotomy : B-lynch technique : effective in uterine atonyBilateral uterine artery ligationHypogastric artery ligationSuprecervical or TAH is the definitive treatment for intractable PPH
312-Tissue: Retained placenta Prolong 3rd stage of delivery( > 30 minutes) seen in ~ 6% of deliveries.Prior retained placenta.Prior manual removal of placentaPrior C/S, curettage p-pregnancy, uterine infection, and increased parity.Prior C/S scar & previa (25%)Most patients have no risk factors.
32US evaluation of retained tissue should be performed before uterine instrumentation
33Brandt-Andrews maneuver To determine if the placenta has separated Firm traction is applied to the umbilical cord with one hand while the other applies suprapubic counterpressure
34Abnormal adherent placenta Caused by missing or defective decidual layer .Placenta Accreta:Placenta adherent to myometrium.Placenta Increta:myometrial invasion.Placenta Percreta:penetration of myometrium to orbeyond serosa.
35Placenta Accreta: Most common type. With incidence of % if previous C/S or previaThe incidence increase as the no. of previous C/S increasedPrior uterine surgery and placenta praevia in the current pregnancy r 2 important RF –US and color dopplerTAH is the definitive treatment
36Placenta accreta and uterine atony are the 2 commonest causes of postpartum hysterectomy
37Removal of Abnormal Placenta Oxytocin 10U in 20cc of NS placed in clamped umbilical vein.If this fails, get OB assistance.Check Hct, type & cross 2-4 u.Two large bore IVs.Anesthesia support.
38Removal of Abnormal Placenta Relax uterus with halothane general anesthetic and subcutaneous terbutaline.Bleeding will increase dramatically.With fingertips, identify cleavage plane between placenta and uterus.Keep placenta intact.Remove all of the placenta.
41Removal of Abnormal Placenta If successful, reverse uterine atony with oxytocin, Methergine, Hemabate.Consider surgical set-up prior to separation.If manual removal not successful, large blunt curettage or suction catheter, with high risk of perforation, so to be done on US guidanceConsider prophylactic antibiotics.
43Trauma (3rd “T”)(cervical, vaginal and preineal laceration) Suspected if bleeding persists and uterine fundus is contracting. Episiotomy Hematoma Uterine inversion Uterine ruptureIn C/S LT laterl extension of the incision can damage ascending branches of the uterine a while inferior extension damages the cervical branches.
45Repair of cervical laceration At the two lateral angles while dilating the first stage. Repair lacerations quickly. Place initial suture above the apex of laceration to control retracted arteries.
46Vulvar Hematomasmore likely w/ operative vaginal deliveries and episiotomiesexcessive unilateral swelling and painHematomas less than 3cm in diameter can be observed expectantly.If larger or expanding , incision and evacuation of clot is necessary.Irrigate and ligate bleeding vessels.With diffuse oozing, perform layered closure to eliminate dead space.Broad spectrum antibiotics should be given
47Limited from spread by fascia lata Central tendon of the perineum prevents it from crossing the midline
49Retroperitoneal heamtoma more likely after C/S delivery – symptom may be shock, excess flank pain.
50Uterine Inversion Rare: ~1/2500 deliveries Turning inside out of the uterusC/F:Acute abdominal painBlue-gray mass protruding from vagina.Suspect if shock disproportionate to blood loss
51Causes include: Uterine atony. Excessive traction on cord while exerting fundal pressure before complete placental separationManual removal of the placentaAbnormal placentationUterine anomalies
52Hypotension worsened by vaso-vagal reaction. Avoid excessive cord traction, and always guard the uterus when applying tractionHypotension worsened by vaso-vagal reaction.Consider atropine 0.5mg IV if bradycardia is severe.
56If replacement is unsuccessful : Uterine relaxant agents like NG IV ( 100 ug ) , Terbutaline, MgSO4
57Uterine Rupture Complete separation of the uterine wall Incidence is 0.5 %Prior scar in 40 %
58Risk factors include: Prior C/S Prior uterine surgery, myomectomy Classical : 4-7 %Lower transverse < 1 %Prior uterine surgery, myomectomyHyperstimulation with OxytocinTrauma.Breech version and extractionAbruptio placentaUterine manipulation during labor”Forceps delivery, intra –uterine pressure cathinsertion”Parity > 4.spontaneous
59Uterine Rupture Suspect if: Rx : sudden change in FHR tracing Fetal parts easily palpated abdominallyFetal bradycardia in 50 – 70 % of casesvaginal bleedingabdominal tendernessmaternal tachycardiasigns of shock are out of proportion to visible blood lossR/O abruptio placentaRx :ABCs.IV fluids.Immediate laparotomy and deliver the infant and repair the scar
61Thrombosis (4th “T”) Coagulopathies are rare. Pre-existing conditions (congenital)ITP, von WillebrandsObstetric-relatedHypertensive disorders, HELLPAbruptionFetal demiseSepisDrugs (e.g. aspirin)Suspect if oozing from puncture sites noted.Work up with platelets, PT, PTT, fibrinogen level, fibrin split products, and possibly antithrombin III.
62Maintain: Fibrinogen > 100mg/dl with FFP Platelets > 50,000 with packed plateletsHematocrit > 30% with PRBCs
63AFE 1/20.000 pregnancies Causes 10 % of maternal deaths in US Mortality rate is 80 %S & S :HypoxiaHypotension and shockAltered mental statusDICBronchospasmClinical diagnosisLabs : ABG, electrolytes, CBC and coagulation profileDefinitive diagnosis is demonstrating the fetal squamous cells and lanugo in the pulmonary vascular space
64Rx :ABCIntubationIV access with volume support, inotropic agents and pressorsPRBC and FFP as coagulopathy risk is 50 % in the first 2 hrs.
65Management of excessive bleeding once vitally stable Regardless of the cause, replacing RBC mass is mandatory2 iron tablets ( each 300 mg )PPH in subsequent pregnancies occurs in 10 %
67Late postpartum hemorrhage It complicates 1 % of pregnanciesLate hemorrhage is more likely due to:Subinvolution of the uterus.Endometritis.Uterine fibroidRetained placental fragment.Coagulopathy and blood dyscariasisVWD is present in % of adults with menorrhagia as pregnancy elevates factor 8 level, and drops postpartumplyTreatment : ( depend on the cause )Uterotonic agentsAntibioticsCurrettage
69Prevention Active Management of 3rd stage of labour Oxytocic is givenCord is clampedPlacenta delivered by controlled cord traction (CCT) with counter-traction on the fundusFundal massageevidence supports use of oxytocin after delivery of anterior shoulder, or more commonly in the U.S after the delivery of the placentaStrong research support for use of post partum administration of pitocin