34. Postpartum hemorrhage. Inversio uteri

Question 1

what is postpartum hemorrhage (PPH)?

Answer 1

an obstetric emergency associated with high rates of maternal morbidity and mortality worldwide.
occurs in approx. 4% of deliveries

defined as cumulative blood loss ≥ 1000 mL or bleeding associated with signs/symptoms of hypovolemia within 24 h’ of birth regardless of delivery route.

Question 2

1° PPH (early) ?

Answer 2

hemorrhage occurs in the first 24 h’ after delivery

Question 3

2° PPH (late, delayed)?

Answer 3

hemorrhage occurs from 24 h’ to 12 w’ after delivery

Question 4

etiology of PPH

Answer 4

Tone: 1. Uterine atony (the most common cause)
2. Uterine inversion

Trauma: 3. Genital tract laceration (second most common cause)
4. Uterine rupture

Tissue: 5. Retained products of conception (POC)
*Usually on the basis of abnormal placental implantation (placenta accreta spectrum)

Thrombin: 6. Congenital coagulopathy (von Willebrand’s disease)
7. Acquired coagulopathy (DIC, TTP)

Question 5

what is the most common cause of PPH?

Answer 5

uterine atony

Question 6

when does PPH from Von-willebrand disease present?

Answer 6

bleeding several days after delivery, because the Pregnancy induces a temporary increase of vWF, which takes several days to decrease to pre-pregnancy levels

Question 7

management of persistent, uncontrolled bleeding after a specific treatment approach of PPH (with or without hemodynamic instability) -12

Answer 7

1. Continuous monitoring of vital signs
2. Ensure 2 large IV access lines
3. Labs (every 30 min’) – CBC, PT, PTT, fibrinogen, blood gas, electrolytes
4. IV fluids, blood products, and vasopressors to support circulation
5. Prepare operation room and inform OB emergency team
6. Consider tranexamic acid (TXA) infusion
7. Consider prophylactic antibiotics
8. Intrauterine balloon tamponade (Bakri)
9. B-lynch compression sutures
10. Uterine artery ligation
11. Uterine artery or internal iliac artery embolization
12. Hysterectomy (last resort, if all other measures failed)

Question 8

postpartum hemorrhage can lead to?

Answer 8

Sheehan syndrome
postpartum necrosis of the pituitary gland
Blood loss during delivery/postpartum hemorrhage → hypovolemia → vasospasm of hypophyseal vessels → ischemia of the pituitary gland → ‘empty sella syndrome’ on imaging.
*can also occur without clinical evidence of hemorrhage.

Question 9

what is uterine inversion?

Answer 9

The uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out.
Rare complication of vaginal or cesarean delivery, but when it occurs, it is a life-threatening obstetric emergency

Question 10

1st degree uterine inversion

Answer 10

incomplete (fundus within the endometrial cavity)

Question 11

2nd degree uterine inversion

Answer 11

complete (fundus protrudes through the cervical os)

Question 12

3rd-degree uterine inversion

Answer 12

prolapse (fundus protrudes to or beyond the introitus)

Question 13

4th degree uterine inversion

Answer 13

total (both the uterus and vagina are inverted)

Question 14

risk factors of uterine inversion

Answer 14

• Macrosomia
• Rapid or prolonged labor and delivery
• Short umbilical cord
• Use of uterine relaxants
• Uterine anomalies or tumors (leiomyoma)
• Retained placenta
• Placenta accreta spectrum

Question 15

how can uterine inversion present?

Answer 15

1. Mild to severe vaginal bleeding
2. mild to severe lower abdominal pain.
3. Smooth, round mass protruding from the cervix or vagina
4. non-palpable uterus.
5. Rapid progression into hemorrhagic shock.

Question 16

treatment of uterine inversion

Answer 16

1. Hemodynamic support with fluids, blood products, and vasopressors as needed.
2. Manually replace the inverted uterus to its normal position.
3. If hemodynamically unstable and failed manual replacement → proceed to surgery (laparotomy + incision of the cervix constriction ring).
4. If hemodynamically stable and failed manual replacement → give uterine relaxants (nitroglycerin, terbutaline, Magnesium-sulphate) and attempt additional manual replacement (oxytocin infusion should be started before removing the intrauterine hand).

Question 17

how is manually replacing the inverted uterus to it’s normal position performed?

Answer 17

Johnson maneuver
Accomplished by placing a hand inside the vagina and pushing the fundus along the long axis of the vagina toward the umbilicus