post partum hemorrhage

Question 1

Definition

Answer 1

• Post partum hemorrhage is defined as the loss of excessive amounts blood (>500ml in vaginal delivery) after delivery.

Question 2

classification

Answer 2

• It may be divided according to:
  a) early (primary) – with 24hrs post partum
  b) late (secondary) – 24hrs to 6 weeks post partum
• according to etiology: i) Atony
  ii) trauma
  examples:
  b. atonic uterine hemorrhage
  c. due to lacerations
  d. bleeding from placental implantation site
  e. coagulations defects small maternal blood volume

Question 3

diagnosis

Answer 3

● Blood lost (> 500mL) during the 1st 24 hour after delivery is – early (primary) postpartum hemorrhage.
● Between 24 hour and 6 week after delivery is- late (secondary) postpartum hemorrhage (usually occur between 5- 12 days and is due to retained placental tissue or clot. And secondary infection is common)
● Ultrasound examination to reveal present of absent of retained products.
● Carefully curette the uterus, send it for histology. (to exclude choriocarcinoma)

Question 4

management

Answer 4

1.Primary PPH
● Give oxytocin 5n slowly
● Call emergency ambulance unit – if not in hospital.
● Give high-flow O² as soon as available.
● Set up IVI ( 2 large-bore cannulae)
● Call anaesthetist ( a CVP line may help guide fluid replacement, but not if causes delay)
● If shocked give Haemaccel® or flesh blood of the patient’s ABO and Rh group fast until systolic BP > 100mmHg and urine flows > 30mL
● Is the placental delivered? If not, explore the uterus.
● If the placental is complete, put the patient in lithotomy position with adequate analgesia and good lighting. Check for and repair trauma.
● If the placental has not been delivered but has separated, attempt to deliver it by controlled cord traction after rubbing up a uterine contraction.
● If this fail, ask an experienced obstetrician to remove it under general anaesthesia.
● Beware of renal shut-down.
2.Secondary PPH
● Secondary infection is common.
● Uterine involution may be incomplete.
● If bleeding is slight and there’s no sign of infection, it may managed conservatively.
● In heavier, more blood lost, check for retained product using US, or tender uterus with an open os, require exploration.
● Give antibiotics (e.g ampicilin 500mg/6h IV, metronidazole 1g/12h PR) if there’re signs of infection.
● Carefully curette the uterus (it’s easily perforated at this stage)
● Send curetting for histology (excludes choriocarcinoma)