POSTPARTUMHAEMORRHAGE DR SUKANDA JAILI O&G DEPARTMENT SGH
Major cause of death PPH is still the largest cause of maternal death, responsible for 24% in 1995 and 20.0% in 1996. Over the last 6 report PPH account for 25% of all maternal death.
Postpartum Haemorrhage 50% associated with substandard care 3 main factors involved; 1. Home deliveries (46.7%) 2. Delay in resuscitating the mother 3. Delay in transportation to GH
National MMR by Ratio 1950-2000 220 PPH 200 180 HDP 160No. of Deaths 140 Obst. 120 Embolism 100 Medical 80 Condition 60 Obst. Trauma 40 20 Puerperal 0 Sepsis 1991 - 1993 1994 - 1996 1997 - 1999 2000 - 2002 2003 - 2005 2006-2008
DEFINITION 1 PPH BLOOD LOSS FROM THE GENITAL TRACT IN EXCESS OF 500 ML IN THE FIRST 24 HOURS OF DELIVERY 2 PPH EXCESSIVE BLEEDING FROM THE GENITAL TRACT AFTER THE FIRST 24 HOURS POST PARTUM UNTIL 6 WEEKS AFTER DELIVERY.
Postpartum Haemorrhage: ‘Risk Management’ ‘At risk’ patients should deliver in hospital Active management of 3rd stage 20 - 40 units oxytocin in 500mls of Hartman’s soln. at 30 dpm Closer post-natal observation for 2-3 hours Cases of ragged membranes need at least 24 hours monitoring in hospital and given proper counseling and appropriate antibiotics
RETAINED PLACENTA RESUSCITATION! DO NOT CONTINUE WITH CCT WITH SUCH PATIENT OXYTOCIN SHOULD BE GIVEN MRP IN OT UNDER GA WITH ANAESTHETIC BACK UP FOR RESUSCITATION LOOK FOR GENITAL TRACT TRAUMA START OXYTOCIN INFUSION AFTER MRP ANTIBIOTICS
MORBIDLY ADHERENT PLACENTA IN CASES OF ACCRETA, IF NO BLEEDING, MAY TREAT CONSERVATIVELY WITH MEDICATION OTHERWISE, REQUIRE LAPAROTOMY HYSTERECTOMY
GENITAL TRACT INJURY INJURY TO EPISIOTOMY VAGINA CERVIX UTERUS EXTENSION TO BROAD LIGAMENTS
GENITAL TRACT INJURY RISK FACTORS INSTRUMENTAL DELIVERY BIG BABY SHOULDER DYSTOCIA PRECIPITATE LABOUR
GENITAL TRACT INJURY EXAMINATION – BEST UNDER ANAESTHESIA IN OT ‘WALK THE CERVIX’ HIGH INDEX OF SUSPICION OF EXTENSION TO BROAD LIGAMENTS AND UTERUS IF LACERATION INVOLVING CERVIX AND FORNICES ANTIBIOTICS
GENITAL TRACT INJURY - UTERINE RUPTURE HIGH INDEX OF SUSPICION PREVIOUS SCAR DIFFICULT DELIVERY (INTERNAL PODALIC VERSION) GRANDMULTIPARA OBSTRUCTED LABOUR
GENITAL TRACT INJURY - UTERINE RUPTURE WHAT ARE THE SIGNS? CTG CHANGES MATERNAL TACHYCARDIA PER VAGINAL BLEEDING SCAR TENDERNESS DECREASE UTERINE CONTRACTION HAEMATURIA
RESUSCITATION WELL DOCUMENTED ORGANIZED EARY REFERRAL COMMUNICATION
SECONDARY PPH USUALLY PRESENTS IN THE 2ND AND 3RD WEEK POST PARTUM HVS FOR CULTURE START ANTIBIOTICS IF DIAGNOSIS OF RETAINED POC, FOR EXPERIENCED PERSONNEL TO PERFORM EVACUATION – HIGH RISK OF PERFORATION DIFFICULT TO DIFFERENTIATE POC AND BLOOD CLOT BY US IN 1ST 2 WEEKS POSTPARTUM
MONITORING ICU/ HDU MONITORING VITAL SIGN MONITORING EVERY 15 MINUTES - BP, PR, RR, SA O2, CVP FLUID RESUSCITATION DOCUMENTED URINE OUTPUT ON GOING HAEMORRHAGE NOTED DRAIN, PAD RESULTS TRACED STAT INFORM PATIENT AND RELATIVES
Case illustration A 35 year old Malay lady in her 4th pregnancy, had a history of PPH in her previous pregnancies. She was diagnosed to have pre eclampsia during this pregnancy and was on oral antihypertensive medication. At 38 weeks of gestation she was admitted to a private facility and was induced with prostaglandins.
The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery. Exploration did not reveal any retained products. The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.
She was transferred to a general hospital for further resuscitation but arrived in a moribund state and succumbed soon after.
Case illustration A 30 year Malay lady in her third pregnancy at 38 weeks of gestation came in labour at a district hospital. Her antenatal period had been uneventful. She delivered vaginally at 7.02pm. Active management of 3rd stage instituted and the placenta was delivered via CCT. Her delivery was conducted by a staff nurse.
After the placenta was delivered it was noted that there was active bleeding from the vagina. A green branula was inserted and the on-call doctor was informed. Over the phone the doctor ordered for uterine massage to be done, to give patient iv ergometrine 0.5mg and iv Pitocin 40 unit in 500mls NS started while awaiting for him to come.
On examination, the patient was alert, the blood pressure was normal but the pulse rate was 96b/min. Abdominal examination done showed that the uterus was contracted.Despite that the patient was still actively bleeding. Another iv line was inserted and blood was sent for FBC, GXM and PT/PTT. She was given NS running fast.
Another doctor was called to help manage the patient. Further examination showed a cervical laceration which the doctor tried to repair but failed. The patient continued to bleed, so vaginal packing was done and she was planned for transferred to the general hospital.The placenta was also re-examine for it’s completeness. By this time, the patient’s blood loss was about 1 L. the patient was conscious but lethargic, her BP was 90/60mmHg and PR was 110b/min.
While awaiting for arrangements for transfer to the referral center to be made, another 2 iv lines inserted and she was rapidly infused with NS and later transfused with blood. A Foley’s catheter was inserted to monitor urine output and her vital signs was monitored every 15 minutes.
She arrived at the general hospital at 10.20pm accompanied by a doctor and 2 staff. Upon arrival the estimated blood loss was about 2L and she had 4 iv lines (all green). 2 unit of blood has already been transfused plus the crystalloids and the 3rd and 4th unit of blood transfusion was still in progress.
Examination upon arrival showed very pale patient, drowsy but still responding to call, the BP was 80/40mmHg and the PR was 130b/min. The uterus was contracted and she was still actively bleeding from the vagina.
EUA was done and the cervical laceration was sutured. Despite that patient continued to bleed. A laparotomy was done and it showed that there was another cervical laceration which extended up to the lower segment of the uterus. As it was not able to be repaired, a hysterectomy was performed.
Post operatively she was managed for 2 days in ICU. The estimated blood loss through out was 5.4L and she was transfused a total of 21 unit of blood and 4 cycles of DIVC regime. She was discharged well on day 6 post delivery.