1. Postpartum Hemorrhage
Dr.B Khani MD

2. Postpartum Hemorrhage
EBL > 500 cc
10% of deliveries
If within 24 hrs. pp = 1 pp hemorrhage
If 24 hrs. - 6 wks. pp = 2 pp hemorrhage
Causes
uterine atony – genital trauma
retained placenta – placenta accreta
uterine inversion

3. Uterine Atony Most common cause of pp hemorrhage
Contraction of uterus is 1 mechanism for controlling blood loss at delivery
oxytocin and prostaglandins
Risk factors
multiple gestation – chorioamnionitis
macrosomia – precipitous labor
polyhydramnios – tocolytics
high parity – halogenated agents
prolonged labor

4. Uterine Atony: Treatment
uterine massage
oxytocin:
produced by posterior pituitary
causes peripheral vasodilation, reflex tachycardia
administered diluted in IV fluid, not IV push
metabolized/excreted by liver, kidney, oxytocinase
ergot derivatives
prostaglandins
If drugs fail, embolization of arterial supply, ligation, or hysterectomy

5. Uterine Atony: Ergot Derivatives
ergonovine and methylergonovine (methergine)
act via -adrenergic mechanism
adverse effects: nausea/vomiting, vasoconstriction (including coronary), HTN, PAP
relative contraindications: chronic HTN, PIH, PVD, CAD
dose: 0.2 mg IM (not IV), last 2-3 hrs.

6. Uterine Atony: Prostaglandins
 myometrial intracellular free Ca++, enhance action of other oxytocics
Side effects: fever, nausea/vomiting, diarrhea
15-methyl PG F2 (Carboprost, Hemabate)
may cause bronchospasm, altered VQ,  shunt, hypoxemia, HTN
250 g IM or intramyometrially q min, up to max 2 mg.
contraindications: asthma, hypoxemia

7. Genital Trauma
Vaginal: associated with forceps, vacuum, prolonged 2nd stage, multiple gestation, PIH
Rx: I & D and packing
Vulvar: bleeding from branches of pudendal arteries
Retroperitoneal: least common, most dangerous
laceration of branch of hypogastric during C/S (or uterine rupture)
Dx: CT
Rx: expl. lap., ligation of hypogastric, hyst

8. Retained Placenta Obstetric management: manual removal, oxytocin
Anesthetic management:
epidural or spinal anesthesia, if not hypovolemic
or MAC
or GA (ketamine, RSI, intubate, 50% nitrous, fentanyl)
Uterine relaxation may be requested (NTG)

9. Placenta Accreta Definitions: Risk factors:
accreta vera: adherence of placenta to myometrium
increta: invasion of placenta into myometrium
percreta: invasion of placenta to/thru the serosa
Risk factors:
prior uterine trauma + placenta previa

10. Placenta Accreta II Placenta previa + prior C/S v. accreta risk:
Number of prior C/S Incidence of accreta % % % % %
Rx: uterine curettage, oversewing of plac. bed, usually hysterectomy (accreta is most common indication for C-hyst)

11. Uterine Inversion Low mortality Risk factors:
uterine atony
inappropriate fundal pressure
unbilical cord traction
uterine anomaly
Rx: replace the uterus, oxytocin, Hemabate, methergine
may need uterine relaxation transiently
NTG ( g IV) vs. halogenated agent
anecdotal reports of other nitrates, terb, Mg

12. Invasive Treatment Options for Obstetric Hemorrhage
Uterine arteries are branches of internal iliacs (major supply to uterus)
Ovarian arteries also contribute during preg.
Options
angiographic embolization
bil. surgical ligation of uterine, ovarian, internal iliacs (preserves fertility): 42% success
Cesarean or pp hysterectomy
EBL 2500 cc (emergent), 1300 cc (elective)