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Post Partum Haemorrhage Case Illustration
Case illustration  <ul><li>A 35 year old Malay lady in her 4th pregnancy,  had a history of PPH  in her previous pregnanci...
<ul><li>The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery. Explorati...
<ul><li>She was transferred to a general hospital for further resuscitation but arrived in a moribund state and succumbed ...
Case illustration <ul><li>A 30 year Malay lady in her third pregnancy at 38 weeks of gestation came in labour at a distric...
<ul><li>After the placenta was delivered it was noted that there was active bleeding from the vagina. A green branula was ...
<ul><li>On examination, the patient was alert, the blood pressure was normal but the pulse rate was 96b/min. Abdominal exa...
<ul><li>Another doctor was called to help manage the patient. Further examination showed a cervical laceration which the d...
<ul><li>While awaiting for arrangements for transfer to the referral center to be made, another 2 iv lines inserted and sh...
<ul><li>She arrived at the general hospital at 10.20pm accompanied by a doctor and 2 staff. Upon arrival the estimated blo...
<ul><li>Examination upon arrival showed very pale patient, drowsy but still responding to call, the BP was 80/40mmHg and t...
<ul><li>EUA was done and the cervical laceration was sutured. Despite that patient continued to bleed. A laparotomy was do...
<ul><li>Post operatively she was managed for 2 days in ICU. The estimated blood loss through out was 5.4L and she was tran...
Principles of managing PPH <ul><li>Speed </li></ul><ul><li>Skills </li></ul><ul><li>Priorities - call for help (Red Alert ...
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Postpartum Haemorrhage : Case Illustration

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SALSO Series - Postpartum Haemorrhage (Case Illustration)

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Postpartum Haemorrhage : Case Illustration

  1. 1. Post Partum Haemorrhage Case Illustration
  2. 2. Case illustration <ul><li>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. </li></ul>
  3. 3. <ul><li>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. </li></ul>
  4. 4. <ul><li>She was transferred to a general hospital for further resuscitation but arrived in a moribund state and succumbed soon after. </li></ul>
  5. 5. Case illustration <ul><li>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. </li></ul>
  6. 6. <ul><li>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. </li></ul>
  7. 7. <ul><li>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. </li></ul>
  8. 8. <ul><li>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. </li></ul>
  9. 9. <ul><li>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. </li></ul>
  10. 10. <ul><li>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. </li></ul>
  11. 11. <ul><li>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. </li></ul>
  12. 12. <ul><li>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. </li></ul>
  13. 13. <ul><li>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. </li></ul>
  14. 14. Principles of managing PPH <ul><li>Speed </li></ul><ul><li>Skills </li></ul><ul><li>Priorities - call for help (Red Alert System) </li></ul><ul><li>- assess the patient’s condition </li></ul><ul><li>- find the cause of bleeding and stop it </li></ul><ul><li>- stabilize and resuscitate the patient </li></ul><ul><li>- prevent further bleeding </li></ul>

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