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PPH Updates 2011

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PPH Updates for 2011.

PPH Updates for 2011.

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  • 1. POSTPARTUMHAEMORRHAGE DR SUKANDA JAILI O&G DEPARTMENT SGH
  • 2. 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.
  • 3. 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
  • 4. 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
  • 5. 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.
  • 6. Causes of maternal Deaths, 1997 & 2007 Causes 1997 2007 No. % No. %PPH 31 19.6 23 16.9PIH/PE 24 15.2 25 18.4Obstetric Embolism 18 11.4 24 17.7Associated Medical conditions 36 22.7 20 14.7Obstetric Trauma 9 5.7 6 4.4APH 3 1.9 2 1.5Puerperal sepsis 3 1.9 3 2.2Abortion 5 3.2 6 4.4Ectopic Pregnancy 2 1.3 7 5.1Associated with Anaesthesia 5 3.2 1 0.7Others 22 13.9 19 15.0TOTAL 158 100 136 100
  • 7. Postpartum Haemorrhage: Etiology Uterine atony (80-90%) Retained placenta or parts of placenta Genital tract lacerations / uterine tears Coagulation disorder (DIVC) Ruptured uterus/Uterine inversion LSCS
  • 8. RISKS Previous PPH Maternal obesity Multiple pregnancy Retained placenta Operative vaginal dellivery Prolong labor Big baby Maternal Haemorrhagic condition
  • 9. 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
  • 10. CAUSES OF 1 PPHA. UTERINE ATONYB. RETAINED PLACENTAC. TRAUMAD. COAGULATION DEFECT
  • 11. CAUSES OF 2 PPHA. RETAINED POCB. ENDOMETRITISC. PLACENTAL SITE TROPHOBLASTIC TUMOUR
  • 12. ESTIMATION OF BLOOD LOSS 1 TAMPON FULLY SOAKED – 30 ML 1 SANITARY PAD FULLY SOAKED – 120 ML 1 SARONG FULLY SOAKED – 500 ML
  • 13. Blood loss,ml Up to 750 750-1500 1500-2000 2000 or more(Blood loss, %BV) (Up to 15%) (15-30%) (30-40%) (40% or more)Pulse rate <100 >100 >120 >140Blood pressure Normal Normal Decreased DecreasedRespiratory rate 14-20 20-30 30-40 >35Urine output (ml/hr) >30 20-30 5-15 Negative Slightly Lethargic, Confusion,CNS-mental status anxious Mildly confusion lethargy, anxious coma Anorexia Anorexia, IleusGastrointestinal vomitingFluid replacement Crystalloid Crystalloid Crystalloid Crystalloid(3:1 rule) + blood + blood
  • 14. MANAGEMENTI. RECOGNISE PPHII. CALL FOR HELP(CODE BLUE)  O & G SPECIALIST  ANAESTHETIST  SISTER ON CALL  BLOOD BANK/HAEMATOLOGISTIII. RESUSCITATION !IV. IDENTIFY AND TREAT SPECIFIC CAUSE
  • 15. RESUSCITATION DONE SIMULTANEOUSLY ASSESS VITAL SIGNS AND CONSCIOUS LEVEL (IF UNCONSCIOUS, FOLLOW BLS) 2 X 14/16 G CANNULA
  • 16. RESUSCITATION TAKE 20 ML OF BLOOD FOR  GXM 4 UNITS PC  FBC  COAGULATION SCREENING  ELECTROLYTES
  • 17. RESUSCITATION INFUSE FLUIDS (COLLOID/CRYSTALLOID) MAINTAIN CIRCULATORY VOLUME WHILE WAITING FOR BLOOD IN DIRE STATES, USE GROUP SPECIFIC BLOOD OR UNMATCHED O RH –VE BLOOD
  • 18. RESUSCITATION RUNNERS – SN/ HO/ MO CONSIDER CENTRAL LINES CBD FOR HOURLY MONITORING OXYGEN
  • 19. RESUSCITATION GIVE WARM BLOOD CORRECT COAGULATION
  • 20.  STABILIZING AND INITIAL RESUSCITATION MUST BE DONE FIRST 1 GOLDEN HOUR IN DH DECISION FOR REFERRAL MUST BE MADE EARLY
  • 21.  DURING TRANSPORTATION  MONITORING  RESUSCITATION  TEMPORARY MEASURE  COMMUNICATION
  • 22. UTERINE ATONY MASSAGE UTERUS OXYTOCIN INFUSION (40 UNITS IN 500 ML NS AT 20 – 30 DPM) ERGOMETRINE IV/IM 0.5 MG CARBOPROST (HAEMABATE) IM 250 UG
  • 23. UTERINE ATONY BIMANUAL COMPRESSION UTERINE PACKING AORTIC COMPRESSION
  • 24. 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
  • 25. UTERINE ATONY SURGICAL TREATMENT CONSERVATIVE MEASURES  BRACE SUTURING – B LYNCH  INTERNAL ILIAC LIGATION HYSTERECTOMY
  • 26. MORBIDLY ADHERENT PLACENTA IN CASES OF ACCRETA, IF NO BLEEDING, MAY TREAT CONSERVATIVELY WITH MEDICATION OTHERWISE, REQUIRE LAPAROTOMY  HYSTERECTOMY
  • 27. GENITAL TRACT INJURY INJURY TO  EPISIOTOMY  VAGINA  CERVIX  UTERUS  EXTENSION TO BROAD LIGAMENTS
  • 28. GENITAL TRACT INJURY RISK FACTORS  INSTRUMENTAL DELIVERY  BIG BABY  SHOULDER DYSTOCIA  PRECIPITATE LABOUR
  • 29. 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
  • 30. GENITAL TRACT INJURY - UTERINE RUPTURE HIGH INDEX OF SUSPICION  PREVIOUS SCAR  DIFFICULT DELIVERY (INTERNAL PODALIC VERSION)  GRANDMULTIPARA  OBSTRUCTED LABOUR
  • 31. GENITAL TRACT INJURY - UTERINE RUPTURE WHAT ARE THE SIGNS?  CTG CHANGES  MATERNAL TACHYCARDIA  PER VAGINAL BLEEDING  SCAR TENDERNESS  DECREASE UTERINE CONTRACTION  HAEMATURIA
  • 32. RESUSCITATION WELL DOCUMENTED ORGANIZED EARY REFERRAL COMMUNICATION
  • 33. 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
  • 34. 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
  • 35. 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.
  • 36.  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.
  • 37.  She was transferred to a general hospital for further resuscitation but arrived in a moribund state and succumbed soon after.
  • 38. 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.
  • 39.  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.
  • 40.  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.
  • 41.  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.
  • 42.  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.
  • 43.  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.
  • 44.  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.
  • 45.  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.
  • 46.  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.
  • 47. THANK YOU