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    11.Postpartum+Hemorrhage 11.Postpartum+Hemorrhage Presentation Transcript

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