1. Obstetric Haemorrhage Obstetric Emergencies Empangeni Hospital 28th July 2000

2. Obstetric Haemorrhage Causes of ANTEPARTUM haemorrhage Abruptio Placentae Placenta praevia Local causes Unknown origin

3. ABRUPTIO PLACENTAE Underlying pathology Hypertensive Disease Multiple pregnancy Trauma Anaemia Polyhydramnios

4. PLACENTA PRAEVIA Predisposing factors Previous Caesarean Section Most have no known cause – presumed late implantation

5. Local & Unknown Causes of APH Rupture of uterus Carcinoma of cervix Trauma Cervical polyp Bilharzia of cervix ? Edge bleed ? Haemorrhoids

6. Obstetric Haemorrhage Induction of labour with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar, in comparison with the rate in spontaneously labouring women.

7. Abruptio Placentae Features Pain and tenderness Often I.U.F.D “Hypotension on hypertension” Clotting defects Renal impairment

8. Antepartum Haemorrhage Exclude abruption, uterine rupture, placenta praevia with labour Is she stable? - ?BP, pulse Check Abdomen - previous C/S scar, fundal height and uterine tenderness Check FH Vaginal examination and ARM

9. Abruptio placentae

10. Abruptio Placentae Resuscitate - FDP, whole blood Monitor BP and urine output Give oxytocin infusion or prostaglandin if necessary to induce contractions Avoid Caesarean Section unless salvageable baby, or no progress Watch out for PPH

11. Placenta Praevia Diagnose by Ultrasound Resuscitate, monitor BP and amount of bleeding Persistent bleeding requires delivery whatever the gestation  34 weeks - buy time for steroids prevent contractions with indocid

12. Placenta Praevia Transfer anterior placenta praevia Elective caesarean if  37 weeks Never cut through the placenta Lower segment may need to be packed

13. Post Partum Haemorrhage Predisposing factors Antepartum haemorrhage Multiple pregnancy Prolonged labour Caesarean Section

14. Post Partum Haemorrhage Causes *Uterine atony *Obstetric trauma

15. Post Partum Haemorrhage Atonic uterus (soft uterus) *Compression - bimanual is best *Oxytocin - 10 units IV *Syntometrine 1 amp IM *PgF2α 5mg in 500 ml IV *Misoprostol (PgE1) 1mg (5 tabs) rectally Trauma (hard uterus) * Vaginal tears are most common * Cervical tears rare unless instrumental * Remember the ruptured uterus * Uterine inversion

16. Post Partum Haemorrhage Other causes Instrumental Delivery After Caesarean Section Infection - 2° PPH Retained placental fragments

17. Post Partum Haemorrhage Rub up a contraction Get help Insert two large bore IV lines - Haes-Steril Give an oxytocic Explore digitally for fragments and tears Explore with speculum for tears - especially cervix Evacuate under GA

18. Rupture of Uterus Two types True rupture Dehiscence of scar

19. Rupture of Uterus True Rupture Contractions stop Continuous pain Tender abdomen Fundus ill-defined PV Bleeding Fetal heart dips or absent fetal heart Scar Dehiscence Dehiscence may be silent – no bleeding Fetal distress Haematuria Vague uterine outline Failed induction

20. Rupture of Uterus High Index of suspicion in grande multips and in scarred uteri All cases of Ante and Intra partum haemorrhage must exclude rupture Laparotomy if suspected Repair or Hysterectomy?

21. Surgical Management Direct suture Stepwise devascularisation Internal iliac artery ligation Hysterectomy B-Lynch, “foley tourniquet”, packing

22. Stepwise Devascularisation