Postpartum Seizure and Subarachnoid Haemorrhage Secondary ...
Overview management of postpartum haemorrhage
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Antepartum & Postpartum
Hemorrhage (APH &PPH)
Al-Momtan
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Antepartum & Postpartum Hemorrhage
• Obstetrics is "bloody business."
• Death from hemorrhage still remains a leading cause of maternal mortality.
• Hemorrhage was a direct cause of more than 18 percent of 3201 pregnancy-related maternal deaths.
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Postpartum Hemorrhage
• In spite of marked improvements in management, PPH remains a significant contributor to maternal morbidity and mortality both in developing and developed countries.
• One of the most challenging complications a clinician will face.
• Prevention, early recognition and prompt appropriate intervention are the keys to minimizing its impact.
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DEFINITION:
The loss of >500ml of blood from the genital tract inthe first 24 hrs after delivery
(or)
< 500 ml with haemodynamic changes in the mother.
(or)
>1000 ml – cesarean section within 24 hrs.
(or)
> 1400 ml – Elective cesarean hysterectomy
(or)
> 3000 ml – Emergency cesarean hysterectomy
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- In a recent ACOG study PPH is defined as Haematocrit change of 10% or the need for red cell transfusion.
Severe PPH - > 1500ml blood loss
or
Drop in Hb concentration 40g/l.
or
4 units of blood transfusion.
Secondary PPH - Blood loss between 24 hrs and 6 weeks
Post-delivery.In general, early PPH involves heavier bleeding and greater morbidity.
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Incidence:
Subjective : 2 – 11%
Objective : 20%
Classification of primary PPH
Atonic PPH – 80%
Traumatic PPH – 15%
Retained placenta, membranes,
coagulation failure – 5%
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Haematological Changes in Pregnancy
• 40% expansion of blood volume by 30 weeks
• 600 ml/min of blood flows through intervillous space
• Appreciable increase in concentration of Factors I (fibrinogen), VII, VIII, IX, X
• Plasminogen appreciably increased
• Plasmin activity decreased
• Decreased colloid oncotic pressure secondary to 25% reduction in serum albumin
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Reduced Maternal Blood Volume
• Small stature
• Severe preeclampsia/eclampsia
• Early gestational age
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PPH
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PPH• The etiologies of early PPH are most easily understood as abnormalities of
one or more of four basic processes.
• The four “T” processes.
• Previous PPH!!
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The Four “T”
ToneTissue
TraumaThrombin
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PPH Risk Factors
• Many factors affect a woman’s risk of PPH.
• Each of these risk factors can be understood as predisposing her to one or more of the four “T” processes.
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PPH Risk Factors
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PPH Risk Factors
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PPH Risk Factors
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PPH Risk Factors
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PREVENTION OF PPH
• Although any woman can experience a PPH, the presence of risk factors makes it more likely.
• For women with such risk factors, consideration should be given to extra precautions such as:– IV access– Coagulation studies– Crossmatching of blood– Anaesthesia backup– Referral to a tertiary centre
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PREVENTION OF PPH
• UTEROTONIC DRUGS
– Routine oxytocic administration in the third stage of labour can reduce the risk of PPH by more than 40%
– The routine prophylaxis with oxytocics results in a reduced need to use these drugs therapeutically
– Management of the third stage of labour should therefore include the administration of oxytocin after the delivery of the anterior shoulder.
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Intranatal:
• Hasty delivery of the baby is to be avoided.
• Adequate amount of blood should be cross matched and
available when haemorrhage is anticipated.
• Coagulation studies are done in cases of Abruptio
placenta and retained dead fetus.
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Active Management of 3rd Stage of Labour:
1. Uterotonic Agents:
• 10 units of oxytocin IM or
• Syntometrine (5 unitsofoxytocinand0.5mgergonovine maleate).
•Misoprostol, a prostaglandin E1 analogue, 600gorally.
2. Early cord clamping
3. Controlled cord traction.
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MANAGEMENT OF PPH
• Early recognition of PPH is a very important factor in management.
• An established plan of action for the management of PPH is of great value when the preventative measures have failed.
• Lab:- CBC / BG / Cross match of 4-6 units of blood - KFT / Coagulation profile- Give FFP / cryoprecipitate if coagulation test results are abnormal - Give platelet concentrates if the platelet count is < 50 X 109/L & bleeding continues
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MANAGEMENT OF PPH
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MANAGEMENT OF PPH
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DRUG THERAPY FOR PPH
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MANAGEMENT OF PPH
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MANAGEMENT OF PPH
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MANAGEMENT OF PPH
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Evaluation of response- Monitor pulse, blood pressure, blood gas status, & acid-base status + monitoring central venous pressure. - Measure urine output using an indwelling catheter- Order regular FBC counts and coagulation tests to guide blood component therapy
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Summary: remember 4 Ts
• “TONE”• Rule out Uterine Atony
• Palpate fundus.• Massage uterus.• Oxytocin• Methergine• Hemabate
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Summary: remember 4 Ts
• “Tissue”• R/O retained placenta
• Inspect placenta for missing cotyledons.
• Explore uterus.• Treat abnormal
implantation.
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Summary: remember 4 Ts
• “TRAUMA”• R/O cervical or vaginal
lacerations.
• Obtain good exposure.• Inspect cervix and
vagina.• Worry about slow
bleeders.• Treat haematomas.
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Summary: remember 4 Ts
• “THROMBIN” • Check labs if suspicious.
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Thank you..