4. SECONDARY PPH
• Bleeding usually occurs between 8th-14th day of delivery
• Causes are :
• Retained bits of placenta or membranes
• Infection and separation of slough over a deep cervico-vaginal laceration
• Endometritis and subonvolution of the placental site
• Withdrawal bleeding following oestrogen therapy for suppression of lactation
• Rare : chorion epithelioma, carcinoma of cervix, infected fibroid or fibroid polyps
and puerperal
5. DIAGNOSIS
• Bleeding usually bright red and varying amount
• Varying degree of anemia and evidence of sepsis
• Int. examination : subinvolution and often patulous cervical os
• USG : retained bits of placenta inside uterine cavity
6. MANAGEMENT
• Supportive therapy
• Blood transfusion
• Inj. Methergine 0.2 mg IM
• Antibiotics as routine
• Conservative
• Admission and careful watch for period of 24 hrs
• Active
• Explore the uterus under general anaesthesia
• Products are removed by ovum forceps
• Gentle curretage is done by using flushing curretage
• Methergine 0.2 mg IM
• Material send for histological examination
• Bleeding from sloughing of wound of cervico-vaginal canal controlled by suture
8. DEFINITION
• Placenta is not separated and expelled within 30 minutes after
delivery of baby.
• Normal expulsion of placenta :
• Separation through the spongy layer of the decidua
• Descent into lower segment and vagina
• Expulsion
9. INTERFERENCE IN PHYSIOLOGICAL PROCESS MAY CAUSE :
SEPARATED UNSEPARATED
• Placenta completely
separated but retained
• Placenta unseparated from
uterine wall but does not
invade myometrium
(simple adeherent)
• Placenta is unseparated
and invades the
myometrium (morbid
adherent placenta)
13. DIAGNOSIS MADE AFTER 15
MINUTES SPENT FOLLOWING
DELIVERY OF BABY, WHERE THERE
IS NO SIGN OF PLACENTAL
SEPARATION.
14. DIAGNOSIS : SEPARATED
PLACENTA
UTERUS Well contracted, os closed
PELVIC EXAMINATION Lower pole of placenta may be felt through the
os
ULTRASONOGRAPHY - Myometrium is thick all along
- clear demarcation between placenta and
myometrium
15. INITIAL MANAGEMENT
• Call for extra help – senior obstetrician
• IV access.
• FBC, group, cross matching, diagnostic test (RFT,LFT), coagulation profile and ask
for 2 unit of blood.
• Monitor vitals
• Bladder catheterization
• If it was a physiological management, revert to active management
- Give Oxytocin
- Try controlled cord traction
16. MANAGEMENT : SEPARATED
PLACENTA
Uterus is
contracted and
os is closed
Give oxyocin
placental
expulsion
give glyceryl trinitrate
( 400 μg sublingual or
50 μg iv).
controlled cord
traction
Manual removal of
placenta
IF FAILED
17. DIAGNOSIS : UNSEPARATED
PLACENTA (SIMPLE ADHERENT)
UTERUS - Relaxed on palpation
PELVIC EXAMINATION - Placenta cannot be felt through os
ULTRASONOGRAPHY - Myometrium thickened in all areas
except where placenta is attached
18. MANAGEMENT : UNSEPARATED
PLACENTA (SIMPLE ADHERENT)
• Oxytocin IV infusion (20 units in 500 ml saline)
/ 10 unit IM
• Umbilical vein is catheterized with nasogastric tube
+ One of the following (Normal saline/PGF2a/
Oxytocin/Misoprostol)
• If failed : manual removal of placenta
21. • Grades of morbid adherent placenta
depends on : depth of attachment and
invasion into muscular layer of uterus.
• Accreta : chorionic villi attach to
myometrium, rathen than within
decidua basalis
• Increta : chorionic villi invade the
myometruim
• Percreta : chorionic villi invade through
perimetrium ( uterine serosa )
22. PLACENTA ACCRETA -
DEFINITON
• Form in which placenta is anchored to the myometrium completely or partially
without intervening decidua
• Incidence increasing due to increase in caesarean section rates.
ETIOLOGY – absence of decidua basalis and poor development of
fibrinoid layer
23. RISK FACTORS
1. Prior uterine surgery (cesarean section, myomectomy, curettage,
manual removal of placenta)
2. Placenta previa
3. Multiparity
4. Uterine anomalies, submucous fibroids
Risk in unscarrred uterus : 3%
Placenta previa with one prior cesarean section : 11%
Placenta previa with two prior cesarean section : 40%
Placenta previa with two or more prior cesarean section : 67%
24. DIAGNOSIS
ANTENATAL
• Hematuria +/-
• Ultrasonography with color
Doppler
• MRI - good sensitivity
INTRANATAL
• Profuse bleeding during
manual removal of placenta
• Shock features
25. ULTRASONOGRAPHY FINDINGS:
1. Myometrial thickness <1cm (from serosa to retroplacental
vessels)
2. Large intraplacental blood lakes
3. Loss/thinning of normal hypoechoic area behind the placenta
(clear areas)
4. Loss of normal continuous line at serosal-bladder interface
(bladder line)
5. Focal nodular projections into the bladder
26. COLOUR DOPPLER FINDINGS
:
1. Increase in vascular lakes
with turbulent flow
2. Hypervascularity of serosal
bladder interface
27.
28. MANAGEMENT :
ANTENATALLY
INITIAL MANAGEMENT:
1. Multidisciplinary team approach – SENIOR OBSTETRICIAN
2. Elective cesarean section is scheduled with given counselling to patients
and relatives
3. Kept blood products ready
4. Placenta should be localized, extent of penetration determined
5. Operative procedure, decision to conserve uterus, measures to reduce
bleeding must be planned
29. OBSTETRIC MANAGEMENT
1. Focal placenta accreta
- Placental tissues are removed to the extent with a possibility of excessive
bleeding (may be controlled by oxytocics or intrauterine packing).
- If uterus fails to contract, early decision of hysterectomy is inidicated.
2. Total placenta accreta
- Hysterectomy is performed in parous women
- If future childbirth is desired and no bleeding, placenta is left in situ ligating
the umbilical cord at its attachment with placenta.
- Antibiotics and methotrexate is given and follow up.
- Uterine artery embolization can be done for conservation in case of massive
bleeding
33. DEFINITION
• Collapse of fundus into uterine cavity – uterus being
turned inside out partially completely.
• Rare but life- threatening, can cause severe
maternal morbidity and mortality.
• Incidence is about 1:2000-1:20,000 deliveries.
• Leads to shock, massive hemorrhage,
pulmonary embolism, infection and uterine
sloughing
34. CLASSIFICATION
I DEGREE II DEGREE III DEGREE IV DEGREE
• Uterine fundus
descends into
cavity
• Does not
protrude through
the os
• Fundus
protrudes
through the os.
• Fundus
protrudes
through the
introitus
• Complete
inversion of the
uterus and
vagina.
BASED ON EXTENT OF INVERSION
• May occur before or after expulsion of placenta
35.
36.
37. • SPONTANEOUS (40%)
• Due to localized atony on placental site over the fundus associated with
intraabdominal pressure (coughing, sneezing or bearing-down effort)
• IATROGENIC
• Pulling the cord when uterus is atony
• Fundal pressure when uterus is relaxed – faulty technique in manual
removal
ETIOLOGY
38. RISK FACTOR
• Injudicious attempts of removal of placenta
• Fundal attachment of the placenta
• Fetal macrosomia
• Short umbilical cord.
• Uterine overdistension.
• Prolonged labour
• Uterine malformations
• Invasive placentation
39. DIAGNOSIS
• SYMPTOMS
• Acute lower abdominal pain with bearing down sensation.
• Profuse bleeding per vagina.
• Symptoms of shock.
• SIGNS :
• Features of shock ( hypotension, tachycardia )
• Pallor
• Per abdomen examination : cupping or dimpling of fundal surface
• Pear shaped mass protrudes outside vulva with broad end pointing downward,
reddish purple in colour ( complete )
40. • PER VAGINA :
• 1st degree : Only dimpling of the fundus
• 2nd degree : Cupping of the fundus and a mass can be felt
protruding through the cervix inside the vagina
• 3rd degree : Cupping of the fundus and a mass is felt outside the
vulva. Sometimes swelling remains covered with unseparated
placenta
41. INITIAL MANAGEMENT
• Call for help. A senior obstetrician, nurse, and anaesthetist must be
summoned. Involve multidisciplinary people.
• Stop oxytocin infusion
• Insert 2 large bore IV cannula, begins fluid resuscitation
• Draw blood for CBC, coagulation profile, cross matching
• Start blood transfusion as soon as possible
• Continuous monitoring of vital signs
• Transfer to theatre and arrange appropriate analgesia
43. MANUAL REPLACEMENT
• Patient is under general anesthesia.
• A hand is placed in the vagina with fingers around the inverted fundus and pushing
the fundus toward umbilicus along the axis of vagina
44. • If cervix felt as a constricting ring, One of Uterine relaxants is administered
1. Glyceryl trinitrate 50-200mcg IV
2. Terbutaline 0.25 mg subcutaneous/IV
3. Magnesium sulfate 4-6 g IV
4. Inhalational anaesthetic (halothane, enflurane)
• After replacement, hand should remained inside until uterus become
contracted.
• Remove placenta after uterus become contracted or prior to replacement.
45. HYDROSTATIC METHOD (
O’SULLIVAN’s METHOD
• Patient is under general anesthesia
• Patient is placed in Trendelenburg position
• A sterile douche system is prepared using warmed normal saline and an
ordinary IV administration set
• Posterior fornix is identified
46. • The nozzle of the douche is placed in the posterior fornix
• At the same time, labia is sealed over the nozzle with other hand
• An assistant is asked to start the douche with full pressure (the water
reservoir is raised for at least 2 metres)
• Water will distend the posterior fornix of the vagina gradually, so it
stretches.
• This causes the circumference of the orifice to increase, relieves
cervical constriction and results in correction of the inversion.
47. SURGICAL METHOD
ABDOMINAL APPROACH
HUNTINGTON PROCEDURE HAULTAIN PROCEDURE
Traction on round ligaments Vertical incision made on posterior uterine surface,
constriction ring is cut
VAGINAL APPROACH
SPINELLI PROCEDURE CASCARIDES PROCEDURE
Incision of constriction cervical ring
anteriorly
Incision of constricting cervical ring
posteriorly.
49. AMNIOTIC FLUID EMBOLISM
SYNDROME (AFES)
• Sudden cardiovascular collapse, altered mental status and DIC
due to entry of amniotic fluid, fetal debris and fetal antigens into
the maternal circulation through maternal venous channels in the
uterus or cervix.
• Anaphylactoid reaction.
• Rare : 1-12 per 100,000 deliveries.
50. CRITERIA
• Occur during labour, cesarian delivery, dilation and evacuation or within 4 hrs
postpartum.
Acute
hypotension
Acute
hypoxia
Coagulopathy
51. RISK FACTORS
OPENING UP OF VENOUS
CHANNELS IN THE UTERUS
SITUATIONS WHICH CAUSING
UNDUE INCREASE IN
INTRAUTERINE PRESSURE
1. Placenta previa
2. Abruptio placenta
3. Cervical lacerations
4. Uterine atony
5. Caesarian section
6. Instrumental delivery
1. Labor induction
2. Eclampsia
52.
53. DIAGNOSIS
SYMPTOMS SIGNS
1.Tachypnea
2.Restlessness
3.Nausea, Vomiting
4.Paresthesia
5.Altered sensorium
6.Convulsions, coma
1.Cold extremities
2.Hypotension
3.Crepititations, rhonchi
4.Bleeding from venipuncture
sites
5.Vaginal bleeding
INVESTIGATIONS FINDINGS
Pulse Oximetry Severe hypoxia (<60% saturation)
ABG Hypoxia, metabolic acidosis,
hypocapnea (pCO2 <30)
Chest Xray Pulmonary infiltrates, loss of lung
volume
Blood test Low hematocrit, peripheral smear
shows thrombocytopenia and
schistocytes (if DIC +)
Serum Creatinine Increase
Serum electrolyte Metabolic acidosis, anion gap >20
ECG Abnormal pattern
54. INITIAL MANAGEMENT
• Call senior obstetrician, anaesthetist, haematology. Involve multidisciplinary people
• Admit patient to ICU
• Take blood samples for
- Hb, peripheral smear, electrolytes, serum creatinine, LFT, prothrombin time.
-grouping and cross match
-DIC investigations
• Place intra arterial line for ABG
55. OBSTETRIC MANAGEMENT
• Non reassuring FHR
• Rapid progressive deterioration of mother’s clinical status
URGENT DELIVERY
• VAGINAL
• -cervix fully dilated
• Fetal head descend to at least +2/+3 station
• C-SEC
• Adequate blood products should be kept in operation room
