Postpartum Hemorrhage Flashcards
What is the definition of postpartum hemorrhage?
Excessive bleeding during or following the 3rd stage of labour that affects the general condition of the patient
- vaginal birth: >500ml
- C section: > 1000ml
What are the types of post-partum hemorrhage?
PRIMARY
- during 3rd stage of labour or within 24hrs after delivery
SECONDARY
- after the 1st 24hrs from delivery till the end of puerperium (6 weeks)
What are the causes of postpartum hemorrhage?
PRIMARY
- tone
- tissue
- trauma
- thrombin
SECONDARY
- retained placental fragment
- infections
- submucous fibroid polyp
- choriocarcinoma
- local lesion
- puerperal inversion
- E-withdrawal bleeding
What are the pathological causes of tone dysfunction & their risk factors?
1- Over-distended uterus
- polyhydramnios
- multiple gestation
- macrosomia
2- muscle exhaustion
- prolonged labour
- high parity
- precipitate labour
3- intra-amniotic infections
- systemic fevers
- prolonged PROM
4- uterine distortion
- congenital anomalies
- fibroid uterus
- prolonged tocolytics
What are the pathological causes of tissue dysfunction & their risk factors?
1- retained products of conception
- incomplete placenta or fetal membranes at delivery
- previous uterine surgery
2- abnormal placenta
- placenta Previa
- placenta accreta
What are the pathological causes of trauma & their risk factors?
1- uterine inversion
- high parity
- fundal placenta
- cord traction
2- lacerations
- precipitate labour
- instrumental delivery
- rigid perineum
3- extension of Caesarian incision
- deep fetal engagement
- fetal malposition
4- uterine rupture -> previous surgery
What are the pathological causes of thrombin dysfunction & their risk factors?
1- inherited -> Hemophilia A, Von Villebrand’s Deficiency
- history of coagulopathies or liver disease
2- acquired -> ITP, HELLP, DIC
- pre-eclampsia
- IUFD
- severe infection
- placental abruption
- amniotic fluid embolism
3- therapeutic -> anticoagulants
- history of DVT or pulmonary embolism
What are the symptoms of retained placenta in case of PPH?
1- placenta not delivered
2- placenta delivered
- bleeding without pain -> atony
- bleeding with pain -> traumatic
- severe pain -> inversion
- fluid blood with no clots -> coagulopathy
What will be the clinical picture of a patient with PPH?
1- Compensated: postural hypotension
- HR < 100
- SBP is normal
- blood loss 750-1000cc
2- Mild: increased PR + thirst + weakness -
- HR 100-120
- SBP: slight fall
- blood loss 1000 - 1500cc
3- Moderate: pallor, oliguria, confusion
- HR 120 - 140
- SBP 80 - 60
- blood loss 1500 - 2000cc
4- Severe: Anuria, air hunger, coma, death
- HR >140
- SBP 60 - 40
- blood loss > 2000cc
What is the clinical picture of hemorrhagic shock?
- tachycardia
- rapid weak pulse (thready)
- hypotension
- pallor
- cyanosis of fingers
- cold clammy sweat
- oliguria or anuria
- dimness of vision
- mental confusion
How is diagnosis of PPH suspected?
ABDOMINAL EXAM
- uterus is large & lax -> atonic bleeding
- uterus is contracted -> traumatic bleeding
VAGINAL EXAM
- amount of bleeding & color
- biannual examination to assess uterine size & shape
- exploration of lower genital tract for any lesions
What is the difference between atonic & traumatic PPH?
ATONIC
- soft lax uterus
- fundal level is high
- degree of shock is not proportionate with amount of vaginal bleeding
- predisposing factor for uterine atony
TRAUMATIC
- hard, globular uterus
- fundal level corresponds to date
- degree of shock is proportionate to amount of vaginal bleeding
- history of difficult labour or instrumental delivery
What are the complications of PPH?
- anemia
- shock
- renal failure
- Sheehan’s syndrome
- Asherman’s syndrome
- DIC
- thrombo-embolism
- transfusion reaction / hepatitis
- postpartum infections
What are the uterotonic drugs used for prevention of PPH?
OXYTOCIN
- acts within 2 mins & lasts 30 mins when give IM
- safe in HTN
METHERGINE
- acts within 4 mins & lasts 4 hours when given IM
- causes tonic contractions
- increases risk of hypertension, vomiting, & headache
MISOPROSTOL
CARBETOCIN (analog of oxytocin)
How is primary PPH managed?
1- Resuscitation
- 2 wide IV lines -> 16 cannulae
- Fluid replacement -> colloids or crystalloids 1000ml, fresh blood, or FFP
- warmth
- O2 inhalation
- hydrocortisone 100mg IV
- antibiotics
- foot of bed slightly elevated or anti-shock garments
2- Monitor vital signs
3- Cross match 6 units of blood & clotting screening
How is placental hemorrhage managed before delivery of placenta?
1- give oxytocin + massage uterus gently
2- umbilical vein injection (oxytocin)
3- deliver placenta actively
- Brandt-Andrew’s method
- Crede method
- Manual removal under GA
What should be suspected in case of failure of manual removal of placenta under GA?
1- uterine rupture -> hysterectomy OR cut cord short + methotrexate
2- constriction ring -> acute tocolysis (terbutalline SC) then complete manual delivery
3- placenta accreta spectrum -> hysterectomy OR cut cord short + methotrexate
How is post partum hemorrhage managed after delivery of placenta?
1- inspect placenta & fetal membranes for any missing part
2- massage uterus & give methergin
3- if no response -> explore cavity manually under GA
4- if atony persists -> bimanual compression under GA (5-30mins)
5- intra-myometrial injection of PG-F2a
6- uterine tamponade
7- Transcatheter arterial embolization
8- exploratory laparotomy
What are the advantages of transcatheter arterial embolization?
- ease of bleeder detection
- rapid control of hemorrhage
- lower incidence of re-bleeding
- avoidance of surgical risks
- fertility preservation
- shorter hospitalization
What are the techniques used in exploratory laparotomy to control hemorrhage?
1- haemostatic suturing techniques
- B-Lynch Suture (C section)
- Hayman suture (vaginal delivery)
- Cho multiple square sutures
2- Artery ligation -> ovarian, then uterine, then internal iliac
3- emergency hysterectomy
How is DIC managed?
1- Fresh blood transfusion
2- coagulation factor VII
3- Fibrinogen 4 - 10 gms IV
4- FFP -> initial 4 units then 1 unit/6 units RBCs
5- antifibrinolysis: tranexamic acid
6- maintain INR <1.5 control
How is secondary PPH managed?
1- blood transfusion if severe
2- Methergin & antibiotics
3- Surgical removal of retained products
4- treat any local genital tract cause
