Pph1 [autosaved]

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Pph1 [autosaved]

  1. 1. ABSTRACT • The third stage of the labour usually eclipsed by the excitement of the birth of a baby and of all the stages of labour it is the most crucial one for the mother. Various complications may occur unexpectedly or if accurate preventive measures not taken such as postpartum haemorrhage, retention of placenta, shock, uterine inversion etc. Here the light is mainly focused on the postpartum haemorrhage. Its etiology, types, clinical effects, diagnoses, preventive measures are the main part of discussion. The most important part that is the management which play a major role in protecting the life of the patient is also elaborated here according to the respecting etiology. As the clinical examination, ultrasound scanning were carried out in each case and there are various methods used to treat postpartum haemorrhage but homoeopathy can also be an effective method for prophylaxis of disturbance of uterine contractile function in delivery and at the postnatal stage for pregnant women at higher risk of complications. Here some homoeopathic therapeutics also mentioned which play a good role in the management of postpartum haemorrhage.
  2. 2. POSTPARTUM HAEMORRHAGE (PPH) PRESENTED BY: KANCHAN SINGH
  3. 3. CONTENTS DEFINITION PRIMARY POSTPARTUM SECONDARY POSTPARTUM HAEMORRHAGE HAEMORRHAGE •CAUSES •CAUSES •DIAGNOSIS & CLINICAL •DIAGNOSIS EFFECTS •PREVENTION •MANAGEMENT •MANAGEMENT
  4. 4. •Amount of blood loss in excess of 500ml following birth of the baby. •Clinical definition: any amount of bleeding from or into the genital tract following birth of the baby up to the end of the puerperium which adversely affects the general condition of the patient evidenced by rise in pulse rate & falling blood pressure is called postpartum haemorrhage. •Depending upon the amount of blood loss it can be minor(<1l), major(>1l) or severe (>2l). •The incidence is about 4-6% of all deliveries DEFINITION
  5. 5. PRIMARY PPH Haemorrhage occurs within 24 hrs following the birth of baby Third Stage Haemorrhage: bleeding occurs before the expulsion of placenta. True Postpartum Haemorrhage: Bleeding occurs subsequent to expulsion of placenta SECONDARY PPH Haemorrhage occurs beyond 24 hrs and within puerperium also called delayed or late puerperal haemorrhage
  6. 6. ETIOLOGY OF POSTPARTUM HAEMORRHAGE 4 Ts Tone Uterine atony 95% Tissue Retained tissue/clots Trauma Lacerations, rupture, inversion Thrombin Coagulopathy
  7. 7. ATONIC UTERUS Normal postpartum condition with contracted uterus preventing haemorrhage Uterine atony allows haemorrhage to flow into the uterus •It is the commonest cause of postpartum haemorrhage. •With the separation of placenta, the uterine sinuses which are torn, cannot be compressed effectively due to imperfect contraction and retraction of the uterine musculature & the bleeding continues.
  8. 8. PREDISPOSING FACTORS- INTRAPARTUM PROLONGED AND RAPID LABOUR OPERATIVE DELIVERY INTERNAL PODALIC VERSION CHORIOMNIONITIS SHOULDER DYSTOCIA COAGULOPATHY INDUCTION OR AUGMENTATION
  9. 9. PREDISPOSING FACTORS- ANTEPARTUM •ABRUPTIO PLACENTA/ PLACENTA PREVIA •FETAL DEMISE •BLEEDING DISORDER •GESTATIONAL HYPERTENTION •OVER DISTENDED UTERUS
  10. 10. POSTPARTUM CAUSES •Lacerations or episiotomy •Retained placental / placental abnormalities •Uterine rupture / inversion •Coagulopathy
  11. 11. LACERATIONS OR EPISIOTOMY •Trauma involves usually the cervix, vagina, perineum, paraurethral region and rarely the rupture of the uterus occurs. •Blood loss from the episiotomy wound is most often underestimated.
  12. 12. RETAINED PLACENTA / PLACENTAL ABNORMALITIES PLACENTA ACCRETA PLACENTA PRAEVIA ABRUPTIO PLACENTA BATTELDORE PLACENTA VASA PREVIA SUCCENTURIATE PLACENTA CIRCUMVALLATE PLACENTA RETAINED PLACENTA- When it is not expelled out even 30 minutes after the birth of the baby
  13. 13. INVERSION OF THE UTERUS It is an extremely rare but a life threatening complication in third stage in which uterus is turned inside out partially or completely ETIOLOGY •Pulling the cord while uterus is atonic esp. when combined with fundal pressure. •Fundal pressure while uterus is relaxed-faulty technique in manual removal. DANGERS •Shock •Haemorrhage •Pulmonary embolism •If left uncared for, it may lead to-infection, uterine slough & a chronic one UTERINE RUPTURE •It is potentially catastrophic event during childbirth by which the integrity of myometrial wall is breached •Life threatning event for mother + baby
  14. 14. DIAGNOSIS OF UTERINE INVERSION SIGNS SYMPTOMS •Acute lower abdominal pain with bearing down sensation •Bimanual examination not only confirm the diagnosis but also the degree COMPLETE INVERTED UTERUS •Sonography can confirm the diagnosis when clinical examination is not clear •In complete variety, a pear shaped mass protrudes outside the vulva with the broad end pointing downwards and looking reddish purple in colour
  15. 15. MANAGEMENT - UTERINE INVERSION 1)To replace that first part which is inverted last with the placenta attach to the uterus by steady firm pressure exerted by fingers. 2) To apply counter support by the other hand placed on the abdomen. 3) After replacement, the hand should remain inside the uterus until the uterus becomes contracted by parenteral oxytocin or PGF2α 4) The placenta is to be removed manually only after the uterus become contracted Usual treatment of shock including blood transfusion should be arranged simultaneously
  16. 16. COAGULOPATHY •Blood coagulation disorders are less common causes of postpartum haemorrhage. •The blood coagulopathy may be due to diminished procoagulants or increased fibrinolytic activity. •The conditions where such disorders may occur are abruption placentae, jaundice in pregnancy, thrombocytopenic purpura etc. •Speciifc therapy following coagulation screen includingrecombinant activated factor VII may be given.
  17. 17. DIAGNOSIS AND CLINICAL EFFECTS PELVIC HEMATOMA POSTERIOR ASPECT OF UTERUS SHOWING LEFT BROAD LIGAMENT HEMATOMA VAGINAL BLEEDING •In the majority, the vaginal bleeding is visible outside, as a slow trickle. •Rarely, the bleeding is totally concealed either as vulvo-vaginal or broad ligament hematoma. CLINICAL EFFECTS :- • Alteration of pulse, blood pressure & pulse pressure . •On occasion, blood loss is so rapid & brisk that death may occur with in a few minutes. -State of uterus as felt per abdomen, gives a reliable clue as regards the cause of bleeding. •In traumatic haemorrhage, the uterus is found well contracted. •In atonic haemorrhage, the uterus is found flabby and becomes hard on massaging
  18. 18. PROGNOSIS Postpartum haemorrhage is one of the life threatening emergencies. It is one of the major cause of maternal deaths both in developing & developed countries. CONTRIBUTING FACTORS •Prevalence of malnutrition & anaemia. •Inadequate antenatal & intranatal care. •Lack of blood transfusion facilities. •Substandard care. THERE IS ALSO INCREASED MORBIDITY THESE INCLUDE: •Shock •Transfusion reaction •Puerperal sepsis •Failing lactation •Pulmonary embolism •Thrombosis & thrombophlebitis LATE SEQUALE INCLUDES: •Sheehan's syndrome( selective hypopituitarism) •Rarely diabetess incipidus.
  19. 19. PREVENTION-ANTENATAL •Improvement of the health status of the women & to keep the haemoglobin level normal (>10g/dl). •High risk patients who are likely to develop PPH ( such as twins, hydramnios etc.) are to be screened & delivered in a well equipped hospital •Blood grouping should be done for all women so that no time is wasted during pregnancy. •Placental localization must be done in all women with previous caesarean delivery by USG or MRI to detect placenta accrete or percreta •Women with morbid adherent placenta are at high risk of PPH. Such a case should be delivered by senior obstetrician.
  20. 20. PREVENTION- INTRANATAL •Active management of the third stage, for all women in labour should be routine as it reduces PPH by 60%. •Cases with induced or augmented labour by oxytocin, the infusion should be continued for at least 1 hour after the delivery. •Women delivered by caesarean section, Oxytocin 5IU slow IV is to be given to reduce blood loss •Exploration of the utero-vaginal canal for evidence of trauma following difficult labour or instrumental delivery. •Expert obstetric anaesthesist is needed when the delivery is conducted under general anaesthesia •During caesarean section spontaneous separation & delivery of the placenta reduces blood loss (30%). •Examination of the placenta & the membranes should be a routine so as to detect at the earliest any missing part.
  21. 21. MANAGEMENT OF THIRD STAGE BLEEDING •Control the fundus, massage & make it hard •Inj. Methergin 0.2mg IV •To start normal saline drip with oxytocin & arrange for blood transfusion •Catheterise the bladder Placenta separated Not separated Express the placenta out by controlled cord traction Manual removal under GA Traumatic haemorrhage should be tackled by sutures
  22. 22. TRUE POSTPARTUM HAEMORRHAGE (It is bleeding occurs subsequent to expulsion of placenta) MANAGEMENT OF TRUE POSTPARTUM HAEMORRHAGE:- Principles: Simultaneous approach -Communication -Resuscitation -Monitoring and -Arrest of bleeding It is essential in all cases of major PPH (blood loss >1000ml or clinical shock). Management Immediate measures are to be taken by the attending House officer(Doctor/Midwife) -Call for extra help-involve the obstetric registrar on call. -Put in two large bore (14 gauge) IV cannulas. -Keep the patient flat and warm. -Send blood for group, cross matching, diagnostic tests and ask for 2 units (at least) of blood.
  23. 23. -Infuse rapidly 2 litres of normal saline (crystalloids) or plasma substitutes like haemaccel(colloids), an urea linked gelatin, to re-expand the vascular bed. It does not interfere with cross matching. -Give oxygen by mask 10-15L/min. -Start 20 units of oxytocin in 1L of normal saline IV at the rate of 60 drops per minute. Transfuse blood as soon as possible. -One midwife /Rotating Houseman should be assigned to monitor the following:- 1.Pulse 2.Blood pressure 3.Respiratory rate and oxymeter 4.Type and amount of fluids the patient has received 5.Urine output(continuous catheterisation) 6.Drugs-type, dose and time 7.Central venous pressure(when sited).
  24. 24. ACTUAL MANAGEMENT The first step is to control the fundus and to note the feel of the uterus. ATONIC UTERUS Step 1 : a) Massage the uterus to make it hard and express the blood clot. b) Methegrin 0.2mg is given intravenously. c) Inj oxytocin drip is started (10 units in 500ml of normal saline) at the rate of 40-60 drops per minute. d) Foley catheter to keep bladder empty and to monitor urine output. e) To examine the expelled placenta and membranes , for evidence of missing cotyledon or piece of membranes . If the uterus fails to contract, proceed to the next step. Step 2 : The uterus is to be explored under general anaesthesia. MASSAGE THE FUNDUS
  25. 25. Step 3 : Uterine massage and bimanual compression. Step 4 : UTERINE TAMPONADE 1.Tight intrauterine packing Intrauterine packing is useful in case of uncontrolled postpartum haemorrhage where other methods have failed and the patient is being prepared for transport to a tertiary care centre. 2.Balloon tamponade: Bakri balloon Balloon tamponade Sangstaken-blakemore tube
  26. 26. Step 5 : Surgical methods to control PPH a) Ligations of uterine arteries- the ascending branch of the uterine artery is ligated at the lateral border between upper and lower uterine segment.
  27. 27. b) Ligation of the ovarian and uterine artery anastomosis- if bleeding continues, it is done just below the ovarian ligament c) Ligation of anterior division of internal iliac artery- Reduces the distal blood flow
  28. 28. d) B-Lynch compression suture and multiple square sutures-
  29. 29. e) Angiographic arterial embolisation (bleeding vessel) under fluoroscopy can be done using gel foam. Outcome following unilateral uterine artery embolisation -Success rate is more than 90% and it avoids hysterectomy.
  30. 30. STEP 6: Hysterectomy It is done in cases where uterus fails to contracts and bleeding continues in spite of the above measure
  31. 31. Hemorrhage occurs beyond 24 hours and within puerperium, called delayed or late puerperal hemorrhage. SECONDARY POSTPARTUM HAEMORRHAGE
  32. 32. •Infection and separation of slough Over a deep cervico-vaginal laceration CAUSES •Retained bits of cotyledons and membranes
  33. 33. •Endometriosis and subinvolution of the placental site •Secondary hemorrhage from caesarean section Wound usually occur between 10-14 days
  34. 34. •ULTRASONOGRAPHY is useful in detecting the bits of placenta inside the uterine cavity •INTERNAL EXAMINATION shows subinvolution of the uterus •INTERNAl EXAMINATION shows massive bleeding •INTERNAL EXAMINATION shows evidence of sepsis DIAGNOSIS White fluid show presence of pus
  35. 35. SUPPORTIVE THEREPY CONSERVATIVE ACTIVE TREATMENT -BLOOD TRANSFUSI- ON -METHERGIN 0.2 mg INTRAMUSCULARLY -ANTIBIOTIC AS A ROUTINE IF SLIGHT BLEEDING, NO APPARENT CAUSE CAREFFULL WATCH FOR A PERIOD OF 24 hrs. -GENERAL ANAESTHESIA -AT TIMES REQUIRE LAPAROTOMY MANAGEMENT
  36. 36. MANAGEMENT – ABC’s ENSURE THAT YOU ARE ALWAYS AHEAD WITH YOUR RESUSCITATION!!! •Consider need for Foley catheter, CVP, arterial line, etc. •Consider need for more expert help FOLEY CATHETER CVP
  37. 37. MANAGEMENT OF PPH DIRECTED THERAPY “TONE” •Massage •Compress •Drugs “TISSUE” •Manual removal •Curettage “TRAUMA” •Correct inversion •Repair laceration •Identity rupture “THROMBIN” •Reverse •Anticoagulation •Replace factors MANUAL FUNDAL MASSAGE REMOVAL OF PLACENTA CORRECTION OF UTERINE INVERSION
  38. 38. THERAPEUTICS IN HOMOEOPATHY • HAMAMELIS VIRGINIANA- Profuse discharges, which stimulates a haemorrhage, and form a drain upon system as severe as loss of blood. Bad effects from loss of blood. Uterine haemorrhages active or passive. • IPECACUANHA- Haemorrhages active or passive, bright red, from the uterus; profuse, clotted; heavy, oppressed breathing during; stitches from navel to uterus. • ERIGERON CANADENSE- Haemorrhages from the uterus with dysuria; bright red flow; pregnant women with a “week uterus”. • SABINA- Retained placenta from atony of uterus; intense after, pains. Inflammation of ovaries or uterus after abortion or premature labour. Haemorrhage from the uterus. Promotes expulsion of moles or foreign bodies from uterus. • SECALE CORNUTUM- Women's of very lax muscular fibre; everything seems loose and open; no action; vessels flabby; passive haemorrhages. Discharge of sanious liquid blood with a strong tendency to putrescence. After-pains: too long; too painful; hour glass contraction. • CANTHARIS VESICATORIA- Retained placenta,with dysuria. Expels moles, dead fetuses, membranes etc. Constant discharge from uterus. Pain in os coccyx, lancinating and tearing. • CARBO VEGETABILIS- Haemorrhages from any mucous outlet; in systems broken down, debilitated; blood oozes from weakened tissues; vital force exhausted. In the last stages of disease, with copious cold sweat,cold breath, cold tongue, voice lost, this remedy may save a life. • CAULOPHYLLUM THALICTROIDES- Haemorrhage, after hasty labour; want of tonicity in the womb; passive, after abortion. • USTILAGO MAYDIS- Flabby condition of uterus. Postpartum haemorrhage, bright red, partly clotted. • BELLADONNA- Pressing downwards as if contents of abdomen would issue from the vulva; >standing & sitting erect; worse mornings. • CINNAMONUM CEYLANICUM- Bearing down sensation. Uterine haemorrhages caused by overlifting during puerperal state.
  39. 39. CONCLUSIONS •Be prepared •Practice prevention •Assess the loss •Assess the maternal status •Resuscitate vigorously and appropriately •Diagnose the cause •Treat the cause

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