Postpartum Hemorrhage

by Shanyar Qadir

Shanyar.com

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Blood loss of: > 500 mL during vaginal delivery > 1,000 mL following cesarean delivery

Measurements are subjective and likely inaccurate

Primary (early): within 24 hrs of delivery Secondary (late): from 24 hrs – 12 wks post-

delivery

Definition

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Defined clinically as excessive bleeding that makes the patient symptomatic

10% drop in hematocrit Signs/symptoms of blood loss

Objective Criteria

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One of the most common obstetrical emergencies

Major cause of maternal morbidity One of the top 3 causes of direct maternal

death in both developing and developed countries

Leading cause of admission to the ICU Incidence

4% after vaginal delivery 6.5% after C/S delivery

Why is it important?

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Causes of PPH can be remembered as the 4 ‘Ts’

Tone Uterine atony

Trauma Injury to cervix, vagina, perineum

Tissue Retained placenta &/or membranes

Thrombin Clotting disorders

Etiology

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Call for help, ABCs O2 by mask initially 2 x 14-gauge IV lines FBC & clotting studies Test for renal function & liver function tests Cross-match at least 6 units of blood IV fluid resuscitation Notify blood bank & consult hematologist Foley catheter into the bladder & fluid balance chart Blood transfusion asap, O- if not available Central venous pressure & arterial lines May need FFP, platelets & cryoprecipitate (consult hematologist) Eliminate the cause

Initial Management

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Most common cause of excessive PPH

Risk Factors: Overworked: Rapid or prolonged labor (most

common) Infected: Chorioamnionitis Relaxed: MgSO4, β-agonists, halothane Overdistended: Multiple pregnancies,

macrosomia, polyhydramnios

Uterine Atony (80%)

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Clinical Findings: A soft uterus (feels like dough) palpable above the

umbilicus.

Management: Uterine massage Uterotonics (oxytocin, ergonovine, misoprostol,

carboprost) Surgical: Uterine packing or compression balloon,

B-Lynch suture, sequential arterial ligation, selective arterial embolization, hysterectomy

Uterine Atony (80%)

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Bimanual Uterine Massage

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CompressionBalloons

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Risk Factors: Difficult delivery (shoulder dystocia, macrosomia) Instrumental delivery (forceps, vacuum extractor)

Clinical Findings: Identifiable lacerations (cervix, vagina, perineum)

in the presence of a contracted uterus.

Management: Surgical repair.

Genital Lacerations (15%)

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Cervical Laceration Repair

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Risk Factors: Accessory placental lobe (most common) Abnormal trophoblastic uterine invasion

Clinical Findings: Missing placental cotyledons in the presence of a

contracted uterus.

Management: Manual removal or uterine curettage under US

guidance.

Retained Placenta (5%)

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PlacentaFetal side

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PlacentaMaternal side

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Succenturiate Placental Lobe

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Manual removal of placenta

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Uterine curettage

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Risk Factors: Abruptio placenta (most common) Severe preeclampsia Amniotic fluid embolism Prolonged retention of a dead fetus

Clinical Findings: Generalized oozing Bleeding from IV sites or lacerations in the presence of a

contracted uterus. Management:

Removal of pregnancy tissues from the uterus Intensive care unit (ICU) support Selective blood-product replacement.

DIC (Rare)

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Risk Factors: Fundal placentation Excessive cord traction Previous uterine inversion.

Clinical Findings: Beefy-appearing bleeding mass in the vagina and

failure to palpate the uterus abdominally. Management:

Elevating the vaginal fornices and lifting the uterus back into its normal anatomic position

IV oxytocin.

Inverted Uterus (rare)

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Progressive degrees of inversion

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Manual replacement of uterine inversion

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Clinical Diagnosis Management

Uterus not palpable

Inversion (rare) ↑ fornices, IV oxytocin

Uterus like dough Atony (80%) Uterine massage, oxytocin, ergot, PG F2α

Tears in vagina, cervix

Laceration (15%) Suture & repair

Placenta incomplete

Retained placenta (5%)

Manual removal or curettage

Diffuse oozing DIC (rare) Remove POC, ICU care, blood products

Summary

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Thank You!

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1. Obstetrics by Ten Teachers, 19e - 20112. Williams Obstetrics, 24e - 20143. A Comprehensive Textbook of Postpartum

Hemorrhage, 2e - 20124. Step Up to Obstetrics & Gynecology – 20145. Obstetrics & Gynecology Lecture Notes – 20136. Postpartum hemorrhage on Wikipedia

(http://en.wikipedia.org/wiki/Postpartum_hemorrhage)

Sources