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Post Partum Heamorrhage
Dr Nabil Riskalla FRCOG
Senior Consultant Obs/Gyne
Definition:
 Primary: >500ml 1st 24 hrs Vag delivery
 >1000ml C.S N.B HB%
 Secondary:
excessive bleeding 1st 6 weeks
mostly retained part or infection
Incidence:
 2-8% of hospital deliveries
 Main cause of maternity Death
Risk Factors
 Grand Multipara
 Multiple pregnancies
 Polyhydramnios
 Prolonged labour
 Deep anesthesia
 A.P.H previa abruption
 H/O PPH or Fibroid
 Multiple cesarian section / retained placenta
 Instrumental delivery
 Big baby. Obstructed delivery
Main causes
 Uterine atony 90%
 Retained placenta Part/Whole
 Trauma ( soft tissue laceration)
 Defective coagulation
Management
1. Prevention
 Assessment of risk
 Sytometern with anterior shoulder vaginal delivery (beware of 2nd twin
 PGF 2alpha. IM or intrauterine & C.S ( beware of bronchospasm)
 Do not manipulate uterine fundus
2. Diagnosis
 Estimation of blood loss (visual)
 Vital signs Pulse, BP
 Look for sweating palor, drowsiness
 Feel uterine fundus
 Ask midwife to check placenta
 Assess perineum
 5 ml of blood in test tube
 If bleeding is not heavy- think unexplained shock Rupture Uterus, Uterine
inversion, Amniotic Fluid Embolism
3. Treatment
 A. immediate
 Positioning, O2, Morphine
 Correct hypovolemia: large IV cannula
fluid: saline, haemacele or plasma
 Send blood of HB, coagulation, grouping &crossmatch 5 units, U&E
 Rub for contraction and massage
 If placenta retained controlled cord traction
 Drugs: Iv Oxytocin, Ergometrin, PGF2 alpha
Operative
 Transfer to theatre. Position, good Light, Anaesthesia
1. If placenta retained> 30minutes
 Manual removal if whole
 Retained cotyledon- Polyp forceps
 Placenta Accreta
Conservative : primigravida , cut cord short, antibiotics, mesotrexate..
Radical: Multigrada, consent & S.T.A.H
2. If atonic uterus
 Bimanual compression
 Hot uterine douche/ no packing
 If bleeding persists: Laparotomy
bilateral internal iliac artery ligation
if fails: S.T.A.H
3. Traumatic (laceration)
 Valva, vagina or cx
need suturing
 Rupture uterus - Laparotomy
or laparoscopy for suturing the rent or S.T.A.H
Complication
1. DIC
Diagnosis
 Decreased platelet and HB
 Increase APTT and INR
 Decreased fibrinogen
 Increased fibrinogen deg product
Treatment
 Fresh blood transfusion
 Fresh frozen plasma
 Cryo-precipitat
2. Renal Failure
diagnosis and treatment
post patum hemorrage presentation that elaborte the clinical features of PPH

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post patum hemorrage presentation that elaborte the clinical features of PPH

  • 1. Post Partum Heamorrhage Dr Nabil Riskalla FRCOG Senior Consultant Obs/Gyne
  • 2. Definition:  Primary: >500ml 1st 24 hrs Vag delivery  >1000ml C.S N.B HB%  Secondary: excessive bleeding 1st 6 weeks mostly retained part or infection
  • 3. Incidence:  2-8% of hospital deliveries  Main cause of maternity Death
  • 4. Risk Factors  Grand Multipara  Multiple pregnancies  Polyhydramnios  Prolonged labour  Deep anesthesia  A.P.H previa abruption  H/O PPH or Fibroid  Multiple cesarian section / retained placenta  Instrumental delivery  Big baby. Obstructed delivery
  • 5. Main causes  Uterine atony 90%  Retained placenta Part/Whole  Trauma ( soft tissue laceration)  Defective coagulation
  • 6. Management 1. Prevention  Assessment of risk  Sytometern with anterior shoulder vaginal delivery (beware of 2nd twin  PGF 2alpha. IM or intrauterine & C.S ( beware of bronchospasm)  Do not manipulate uterine fundus
  • 7. 2. Diagnosis  Estimation of blood loss (visual)  Vital signs Pulse, BP  Look for sweating palor, drowsiness  Feel uterine fundus  Ask midwife to check placenta  Assess perineum  5 ml of blood in test tube  If bleeding is not heavy- think unexplained shock Rupture Uterus, Uterine inversion, Amniotic Fluid Embolism
  • 8. 3. Treatment  A. immediate  Positioning, O2, Morphine  Correct hypovolemia: large IV cannula fluid: saline, haemacele or plasma  Send blood of HB, coagulation, grouping &crossmatch 5 units, U&E  Rub for contraction and massage  If placenta retained controlled cord traction  Drugs: Iv Oxytocin, Ergometrin, PGF2 alpha
  • 9. Operative  Transfer to theatre. Position, good Light, Anaesthesia 1. If placenta retained> 30minutes  Manual removal if whole  Retained cotyledon- Polyp forceps  Placenta Accreta Conservative : primigravida , cut cord short, antibiotics, mesotrexate.. Radical: Multigrada, consent & S.T.A.H 2. If atonic uterus  Bimanual compression  Hot uterine douche/ no packing  If bleeding persists: Laparotomy bilateral internal iliac artery ligation if fails: S.T.A.H
  • 10. 3. Traumatic (laceration)  Valva, vagina or cx need suturing  Rupture uterus - Laparotomy or laparoscopy for suturing the rent or S.T.A.H
  • 11. Complication 1. DIC Diagnosis  Decreased platelet and HB  Increase APTT and INR  Decreased fibrinogen  Increased fibrinogen deg product Treatment  Fresh blood transfusion  Fresh frozen plasma  Cryo-precipitat 2. Renal Failure diagnosis and treatment