1. Postpartum Hemorrhage
Mrs. Mahdia
4/13/2017
Mrs. Mahdia Kony

2. Definition
Total blood loss >500 ml at vaginal delivery and >1000 ml at cesarean delivery suffers from the limitations of clinical estimation of blood loss during delivery.
Average blood loss following vaginal delivery, cesarean section, and cesarean hysterectomy was estimated by Pritchard et al .to be approximately 500, 1000, and 1500 ml, respectively.
4/13/2017
Mrs. Mahdia Kony

3. Types 4/13/2017 Mrs. Mahdia Kony
Early or primary PPH: within 24 hours of delivery
Late or secondary PPH: if they occur 24 hours after delivery
4/13/2017
Mrs. Mahdia Kony

4. Retained placental fragments
Atony (90% of pts)
Genital tract trauma
Coagulopathy
Retained placental fragments
Uterine inversion
Uterine rupture
Causes of primary PPH
4/13/2017
Mrs. Mahdia Kony

5. Subinvolution of the placental bed Retained placental fragments
Coagulopathy
Endomyometritis
Subinvolution of the placental bed
Retained placental fragments
Late PPH
4/13/2017
Mrs. Mahdia Kony

6. Prevention Avoid genital tract trauma.
Prophylactically use oxytocic agents at the onset of the third stage of labor.
Actively manage the third stage of labor (with controlled cord traction after signs of placental separation have occurred
4/13/2017
Mrs. Mahdia Kony

7. Uterine Atony “4 T's”: Causes of
Tone
Thrombosis
Tissue
Truma
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Mrs. Mahdia Kony

8. Diagnosis of Uterine Atony
Presence of a soft uterus on abdominal examination
Vaginal bleeding.
4/13/2017
Mrs. Mahdia Kony

9. Risk factors
uterine over distention: polyhydramnios, multiple gestation, fetal macrosomia
2. rapid or prolonged labor
3. oxytocin use
4. high parity
5. Chorioamnionitis
6. myometrial relaxing agents (magnesium sulfate, anesthetic agents
7. Nitroglycerine
4/13/2017
Mrs. Mahdia Kony

10. Prevention of uterine atony
Active management of 3rd stage of labor
(1) uterotonic administration (oxytocin) immediately upon delivery of the baby
(2) Early cord clamping and cutting
(3) gentle cord traction with uterine countertraction when the uterus is well contracted
4/13/2017
Mrs. Mahdia Kony

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Mrs. Mahdia Kony

12. Treatment
Massage
Bimanual uterine massage and compression between a hand on the abdomen and a hand in the vagina.
4/13/2017
Mrs. Mahdia Kony

13. Medications
Oxytocin intravenously (10 to 40 U per liter up to 500 ml in 10 minutes), intramuscularly, or intramyometrially (10 U).
There are no contraindications to the use of oxytocin.
Side effects: nausea, vomiting, and water intoxication secondary to its antidiuretic effect are rare.
4/13/2017
Mrs. Mahdia Kony

14. Medications
Methylergonovine ( Methergine) intramuscularly, intravenously, or intramyometrially (0.2 mg every 2 to 4 hours).
Methylergonovine is contraindicated in patients with hypertension.
Side effects of hypertension, seizures, nausea, vomiting ,and palpitation.
4/13/2017
Mrs. Mahdia Kony

15. Supportive Measures
adequate fluid resuscitation via two large-bore IVs
replacement of blood products as needed,
anesthesia consultation in the event emergent laparotomy is necessary.
4/13/2017
Mrs. Mahdia Kony

16. Genital Tract Trauma
Genital tract trauma constitutes approximately 7% of postpartum hemorrhages
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Mrs. Mahdia Kony

17. Clinical manifestations
Hemorrhage
Bright red bld.
Lacerations or hematoma
unexplained tachycardia
Hypotension
Anemia
shock
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Mrs. Mahdia Kony

18. Risk Factors abnormal presentation operative delivery Episiotomy
precipitous delivery
obstructed labor
fetal macrosomia
multiple gestation
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Mrs. Mahdia Kony

19. Bleeding from an episiotomy or perineal laceration is usually obvious and prompt ligature will control the bleeding
Persistent bleeding with a contracted uterus especially after oxytocin has been administered is strongly suggestive of genital tract lesion.
Exploration is best done under general anaesthesia or continued epidural anaesthesia.
4/13/2017
Mrs. Mahdia Kony

20. Significant bleeding in the absence of cervical, vaginal or perineal tears is suggestive of uterine rupture even if there is response to oxytocics.
Digital exploration of uterus in cases of previous c/s and difficult or complicated deliveries.
4/13/2017
Mrs. Mahdia Kony

21. Treatment
Full-thickness mucosal repair, beginning above the apex because bleeding vessels tend to retract.
Continuous interlocking absorbable suture is generally used.
When suturing in the proximity of the urethra, insertion of a catheter is advisable to avoid injury of this structure.
blood transfusion
antibiotics to prevent secondary infection.
4/13/2017
Mrs. Mahdia Kony

22. Retained Placental Tissue
Clinical Manifestations:
bleeding persists in the absence of apparent lacerations or atony.
The expelled placenta should be carefully inspected for completeness following each delivery.
4/13/2017
Mrs. Mahdia Kony

23. Early cord traction attempts
Risk Factors
Early cord traction attempts
placenta accreta, increta, and percreta, and succenturiate lobe.
Placenta accreta occurs in 1 in approximately 2,500 to 7,000 deliveries and consists of a relatively superficial attachment of the placenta to the myometrium. More invasive attachment (placenta increta or percreta) is less common.
4/13/2017
Mrs. Mahdia Kony

24. Predisposing factors previous postpartum curettage cesarean delivery
Hysterotomy
placenta previa
high parity.
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Mrs. Mahdia Kony

25. Treatment manual intrauterine exploration or curettage.
Care must be taken to avoid uterine perforation, placenta accreta, increta, or percreta should be suspected.
Treatment usually requires hysterectomy for these abnormal placentations.
conservative surgical management (with manual removal and packing) can be attempted.
Maternal morbidity and mortality are high if surgical therapy is necessary.
4/13/2017
Mrs. Mahdia Kony

26. THROMBOSIS- COAGULOPATHY
Hereditary coagulopathies: Haemophila A
Acquired during pregnancy:
Thrombocytopenia
HELLP syndrome
DIC (eclampsia, intrauterine foetal death, septicaemia, placenta abruptio, amniotic fluid embolism).
Anti coagulant therapy: Valve replacement, patients on absolute bed rest.
4/13/2017
Mrs. Mahdia Kony

27. Uterine Inversion Clinical Manifestations:
abdominal examination reveals the uterine fundus to be inverted or missing.
Vaginal inspection and examination confirm the diagnosis.
4/13/2017
Mrs. Mahdia Kony

28. Levels of inversion
level I: The fundus may be inverted above the cervix,
level II: below the cervix but within the vagina
level III: outside the vagina
level IV: the uterus and vagina may both be found outside the vulva.
4/13/2017
Mrs. Mahdia Kony

29. Risk Factors fetal macrosomia fundal placentation use of oxytocin
uterine anomalies
placenta accreta.
Fifty percent of reported cases occur spontaneously in primiparous patients.
4/13/2017
Mrs. Mahdia Kony

30. Treatment manual replacement
intravascular volume replacement. If the placenta has not been removed: replace the uterus by applying pressure to the inverted fundus without removing the placenta and increasing natural oxytocin.
If manual replacement succeeds, the placenta can be manually removed
uterine contraction assured by massage and oxytocin infusion. If manual replacement fails,
When all above measures fail, laparotomy is indicated to correct the inversion
4/13/2017
Mrs. Mahdia Kony

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Mrs. Mahdia Kony

32. Uterine Rupture Clinical Manifestations Tachycardia Shock
fetal distress
disappearance of presenting part from the pelvis
variable amount of pain and vaginal bleeding.
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Mrs. Mahdia Kony

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Mrs. Mahdia Kony

34. Classifications of uterine rupture
Complete rupture involves rupture of visceral peritoneum and results in intraperitoneal bleeding.
Incomplete rupture occurs when the visceral peritoneum remains intact over ruptured myometrium.
4/13/2017
Mrs. Mahdia Kony

35. Risk Factors obstructed labor multiple gestation abnormal fetal lie
high parity.
use of oxytocin
Prostaglandins
spontaneous uterine hyperstimulation
internal podalic version
breech extraction.
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Mrs. Mahdia Kony

36. Treatment intravascular volume and blood replacement
immediate laparotomy.
With spontaneous rupture, 85% of patients require hysterectomy, whereas 65% of ruptured scars can be repaired
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Mrs. Mahdia Kony

37. Late Postpartum Hemorrhage
Late postpartum hemorrhage is defined as any sudden loss of any amount of fresh blood occurring after the first 24 hours of delivery and within 6 weeks postnatally.
4/13/2017
Mrs. Mahdia Kony

38. Subinvolution of the placental bed
Diagnosis
Retained placental tissue
Subinvolution of the placental bed
Endometritis
4/13/2017
Mrs. Mahdia Kony

39. Treatment Uterotonics curettage antibiotics.
If the bleeding is not severe, antibiotics make a good first choice, and if bleeding persists, curettage should be implemented.
4/13/2017
Mrs. Mahdia Kony

40. Puerperal Infections
Puerperal febrile morbidity: a temperature of (38°C), the temperature to occur in any two of the first 10 days post partum, exclusive of the first 24 hr, and to be taken by mouth by a standard technique at least four times daily.
The overall rate of postpartum infection is estimated to be 1% to 8%.
4/13/2017
Mrs. Mahdia Kony

41. Puerperal Infections
Transient, low-grade fever is common in the postpartum period and will resolve spontaneously in the majority of patients who delivered vaginally.
In patients who undergo cesarean delivery, only 30% of fevers will resolve spontaneously, reflecting the greater risk for development of infection after surgery (26).
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Mrs. Mahdia Kony

42. Risk factors PROM Anemia Hemorrhage Episiotomy and CS Placenta retain
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Mrs. Mahdia Kony

43. History and Physical Physical examination focusing on: Lungs Breast
uterine fundus
abdomen for incision infections
Perineum
lower extremities
4/13/2017
Mrs. Mahdia Kony

44. Laboratory Tests Complete blood count with differential.
Urinalysis with culture.
Blood cultures may be considered.
Sputum for Gram's stain and culture if respiratory infection is suspected
4/13/2017
Mrs. Mahdia Kony

45. Treatment Nutrition: anemia prevention Antimicrobial treatment
broad-spectrum, high dose, long time
Drainage
Treatment of thrombophlebitis
4/13/2017
Mrs. Mahdia Kony

46. Complications of PPH Immediate complications: Anaemia.
HypovolemicShock.
Acute renal failure.
Acute Liver failure (hepato-renal syndrome)
Acute pulmonary oedema, consumption coagulopathy, transfusion reactions, (iatrogenic).
4/13/2017
Mrs. Mahdia Kony

47. Long term complications: Infections: puerperal infections
Sheehan’s syndrome (necrosis of anterior pituitary).
Chronic anaemia.
Chronic renal failure.
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Mrs. Mahdia Kony

48. tubal obstruction secondary to infections, post hysterectomy.
Infertility:
Asherman’s syndrome; a condition characterized by the presence of adhesions and/or fibrosis within the uterine cavity due to scars
Sheehan syndrome
tubal obstruction secondary to infections, post hysterectomy.
4/13/2017
Mrs. Mahdia Kony