Postpartum Hemorrhage HEE HEE That’s the only fake blood I could manage!!! Too messy. Jessi Goldstein MD MCH Fellow September 7,

Objectives We will discuss: Prevention of PPH. Causes of PPH. Initial and secondary interventions in PPH in both vaginal and Cesarean delivery. Causes and treatment of secondary PPH. 2

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Advanced Techniques for PPH Initial Interventions should include fundal massage, IV access, lab tests and uterotonic drugs and fluid resuscitation. Secondary interventions for vaginal delivery include checking for lacerations, removing retained products (sweeping, suction curettage), uterine tamponade (ballons, packing), arterial embolization, and laparotomy and ultimate hysterectomy if needed. 23

Advanced Techniques for PPH Initial Interventions for C/S should include fundal massage, IV access, lab tests and uterotonic drugs and fluid resuscitation. Controlling incisional bleeding with suture ligation Intraoperative interventions for Cesarean delivery include uterine and ovarian artery ligation (O’Leary stitch), Uterine compression sutures (The most popular technique is the B- Lynch suture), balloon tamponade, and hysterectomy as last resort. Uterine artery embolization and Bakri balloon management can be considered postoperatively as well. 24

©2011 UpToDate® Anterior uterine wall with B-Lynch suture in place and an enlarged drawing (box) of lower uterine segment with B-Lynch suture in place 25

Sutures are placed to ligate the ascending uterine artery and the anastomotic branch of the ovarian artery. Uterine vessel ligation is known as the O’leary stitch. ( Taken from Up to date) 26

Uterine Artery Embolization: Right uterine angiogram reveals occlusion of the right uterine artery (arrow) after superselective uterine artery embolization. The procedure successfully stopped the bleeding ( Taken from Up to date). 27

Bakri Balloon is a tamponade technique that can be used for PPH. 28

Secondary PPH Defined as excessive bleeding 24 hrs to 12 weeks postpartum. Incidence is about 1 percent of women. Theory is that thought to be atony or subinvolution of placental site from retained products or infection. 29

Management of Secondary PPH Evaluate for underlying disorders (coagulopathies). For atony give uterotonics. If large amount of bleeding, fever uterine tenderness, or foul smelling discharge treat for endometritis. Consider suction currettage. 30

Case 1 A 22y/o G1P0 was delivered by vaccum assisted vaginal delivery approximately 2 hours ago. She was induced for mild preeclampsia at 37 weeks and required pitocin augmentation for several hours prior to needing an operative vaginal delivery for fetal distress. She had a second degree laceration that was repaired, but she has soaked a whole pad in the last 15 minutes and the nurse would like you to evaluate her. 31

Case 2 A 22 yo G4P3 approximately 4 days s/p delivery presents at OB triage and mentions to you that she feels lightheaded and has been having bleeding at about a pad an hour for the last 2 days. 32

Thank you!!! Questions? 33