11.Postpartum+Hemorrhage

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11.Postpartum+Hemorrhage

  1. 1. Postpartum Hemorrhage
  2. 2. Definition <ul><li>Defined as blood loss in excess of 500 mL at the time of vaginal delivery or more than 1000 mL following cesarean delivery. </li></ul><ul><li>A loss of these amounts within 24 hours of delivery. </li></ul><ul><li>Occurs in 4% of deliveries. </li></ul>
  3. 3. Etiology <ul><li>Uterine atony ( tone ) </li></ul><ul><li>genital tract trauma </li></ul><ul><li>Retained placental tissue </li></ul><ul><li>Coagulation disorders( thrombosis ) </li></ul>
  4. 4. Uterine atony <ul><ul><li>Uterus fails to contract to control bleeding at placental site </li></ul></ul><ul><ul><li>Predisposing Causes </li></ul></ul><ul><ul><ul><li>Excessive Uterine distension </li></ul></ul></ul><ul><ul><ul><ul><li>Twin Gestation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fetal Macrosomia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Polyhydramnios </li></ul></ul></ul></ul><ul><ul><ul><li>Multiparity </li></ul></ul></ul><ul><ul><ul><ul><li>Fibrosis in uterine muscle </li></ul></ul></ul></ul>
  5. 5. Uterine atony <ul><ul><ul><li>Prolonged labor </li></ul></ul></ul><ul><ul><ul><li>Labor augmented with oxytocin </li></ul></ul></ul><ul><ul><ul><li>General Anesthesia </li></ul></ul></ul><ul><ul><ul><li>Magnesium sulfate infusion </li></ul></ul></ul><ul><ul><ul><li>chorioamnionitis </li></ul></ul></ul>
  6. 6. genital tract trauma <ul><li>Perineal body laceration </li></ul><ul><li>Periurethral area laceration </li></ul><ul><li>Vaginal sidewall laceration </li></ul><ul><li>Cervical laceration </li></ul><ul><li>Uterine rupture </li></ul><ul><li>Incision extention during cs </li></ul><ul><li>Uterine inversion </li></ul>
  7. 7. Retained placental tissue <ul><li>Retained placenta </li></ul><ul><li>placenta accreta. </li></ul><ul><li>placenta percreta </li></ul><ul><li>Low placental implantation </li></ul>
  8. 8. Coagulation disorders <ul><li>Thrombotic thrombocytopenia purpura </li></ul><ul><li>Amniotic fluid embolus </li></ul><ul><li>idiopathic thrombocytopenic purpura </li></ul><ul><li>Von Willebrand’s disease </li></ul><ul><li>Inability to form a stable blood clot in the placental site,and susceptible to immediate hemorrhage </li></ul>
  9. 9. Obstetric shock <ul><li>Defination: hypotension without significant external bleeding may occasionally develop in an obstetric patient. </li></ul><ul><li>Causes: </li></ul><ul><ul><ul><ul><li>concealed hemorrhage :an improperly sutured episiotomy can lead to a soft tissue hematoma. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>uterine inversion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>amniotic fluid embolism </li></ul></ul></ul></ul>
  10. 10. Differential Diagnosis <ul><li>The fundus of the uterus: uterine atony, uterine inversion </li></ul><ul><li>Inspection of the vagina and cervix: Lacerations </li></ul><ul><li>Manual exploration of the uterine cavity: retained placental tissue; uterine wall lacerations,or partial uterine inversion </li></ul><ul><li>If no cause found for bleeding : coagulopathy </li></ul>
  11. 11. Management
  12. 12. General Treatment <ul><li>Screened for anemia and special type of blood held in the lab </li></ul><ul><li>Intravenous infusion </li></ul><ul><li>Monitoring patient’s vital signs </li></ul><ul><li>Resuscitation with normal saline </li></ul>
  13. 13. Uterine Atony <ul><li>A rapid continuous intravenous infusion of dilute oxytocin(40 to 80 U in 1L of normal saline) </li></ul><ul><li>Ergonovine maleate or methylergonovine, 0.2mg,im </li></ul><ul><li>Analogues of prostaglandin F2a, im </li></ul><ul><li>Bimanual compression and massage of the uterine corpus </li></ul><ul><li>Packing the uterine cavity </li></ul><ul><li>Place an angiocatheter into the uterine arteries for injection of thrombogenic materials. </li></ul><ul><li>Operative intervention: supracervical abdominal hysterectomy; ligation of the uterine arteries. </li></ul>
  14. 14. Genital Tract Trauma <ul><li>Repair of vaginal lacerations : </li></ul><ul><li>the first suture must be placed well above the apex of the laceration </li></ul><ul><li>without dead space </li></ul><ul><li>Cervical lacerations need not be sutured unless they are actively bleeding </li></ul><ul><li>Large expanding hematomas require surgical evacuation of clots and a search for bleeding vessels that can be ligated. </li></ul><ul><li>A laparotomy and bilateral hypogastric artery ligation may be necessary. </li></ul><ul><li>A uterine rupture: subtotal or total abdominal hysterectomy. </li></ul><ul><li>Uterine Inversion: replaced </li></ul>
  15. 15. Retained Placental Tissue <ul><li>Manual removal of the placenta </li></ul><ul><li>A large curette </li></ul><ul><li>Hysterectomy: extensive placenta accreta. </li></ul>
  16. 16. Coagulopathy <ul><li>Infusion of blood products </li></ul><ul><li>Thrombocytopenia: platelet concentrate infusions </li></ul><ul><li>Von Willebrand’s disease: factor VIII concentrate or cryoprecipitate </li></ul><ul><li>Hemoglobin level <100 g/L: Blood transfusion </li></ul>

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