Post Partum Hemorrhage Uterine Rupture
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Post Partum Hemorrhage Uterine Rupture
Women’s Hospital School of Women’s Hospital School of Medicine Zhejiang UniversityMedicine Zhejiang University
Wang ZhengpingWang Zhengping
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Post partum hemorrhage
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Post partum hemorrhage
Past partum hemorrhage denotes excessive bleeding (≥500ml in vaginal delivery) during the first 24 hours after delivery
Common cause of death and diseases in pregnant women globally
Leading cause of death in pregnant women in China
Incidence 2%-3% of total number of deliveries
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Etiology
Uterine atony: 70%
Obstetric lacerations: 20%
Retained placental tissue: 10%
Coagulation:1%
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Uterine atony
General factors: extreme nervousness, sedative, anesthesia, tocolytics, weak
Obstetric factors: prolonged labour, fatigue, placenta previa, placenta abruptio, severe anemia
Uterine factors: uterine muscular fiber underdevelopment, such as uterine deformity or myoma; uterine overstretched, such as macrosomia, multiple pregnancy, polyhydramnios
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Placental factors
Incomplete placental separation Retained placenta Placental incarceration (嵌顿 ) Placental adhesion Placental implantation (accreta, increta,
percreta) Residual placenta and amniotic membrane
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Implantation of placenta
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Birth canal injury
Laceration during labour are usually
associated with: Poor vulval elasticity Strong labour force, emergency delivery,
macrosomia Inadequate skills at assisted vaginal delivery Inadequate cessation of bleeding during
episiotomy repair, missing out tears at cervix or fornices
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Coagulation disorder
Complications associated with obstetric: amniotic fluid embolism, pregnancy induced hypertensive diseases, placenta abruptio and intrauterine demise
Pregnancy liver disease: acute fatty liver, severe hepatitis
Hematology diseases: primary thrombocytopenic purpura, aplastic anemia etc
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Clinical presentation
Vaginal bleeding: If bleeding occurs immediately after delivery of baby,
consider birth canal injury If bleeding occurs minutes after delivery of baby,
consider placenta factors If bleeding occurs minutes after delivery of placenta,
main reasons are uterine atony or retained products of conception
Persistent bleeding and blood do not coagulate, consider coagulation disorder causing PPH
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Clinical presentation
Vaginal hematoma
Shock: dizziness, paleness, weak pulse, low blood pressure etc
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Diagnosis
Estimation of blood loss
Ascertain cause of post partum hemorrhage
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Estimation of blood loss
Visual observation: only 50%-70% of blood loss Container: kidney dish, measuring cup Surface area: blood stained 10cmx10cm = 10ml Weighing: 1.05g = 1ml Hct<=30%, Hb50-70g/L, blood loss >1000ml Hourly urine output <25ml, blood loss >2500ml Shock index = pulse rate/systolic pressure
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Shock index (SI)
SI <=0.5, normal blood volume
SI = 0.5-1, blood loss <20%, 500-750ml
SI = 1, blood loss 20-30%, 1000-1500ml
SI = 1.5, blood loss 30-50%, 1500-2500ml
SI = 2, blood loss 50-70%, 2500-3500ml
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Ascertain cause
Uterine atony Fundus goes up Uterine consistency soft, water bag like After uterine massage or using oxytocin, uterus
harden, per vaginal bleeding lessen Categorize into primary and secondary, with
direct and indirect causes
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Ascertain cause
Placental factors: Placenta not delivered within 10 minutes of
delivery of baby, with massive per vaginal bleed, consider placental factors
Residual placenta is a common cause of post partum hemorrhage
Must examine the placenta and membrane carefully
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Ascertain cause
Birth canal injury Cervical tear Vaginal tear Vulval tear
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Degree of vulval tear
Degree I: vulval skin and vaginal opening mucosa tear, not reaching muscular layer
Degree II: tear into perineal body muscular layer, involving posterior vaginal wall mucosa, may extend up on both sides, making it hard to recognise original anatomy
Degree III: external anal sphincter tear, may involve vaginal rectal septum and anterior rectal wall
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Degree of vulval tear
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Ascertain cause
Coagulation disorder: Patients with blood disorder or DIC caused by
delivery etc Sustained per vaginal bleeding, non-clotting,
difficulty in hemostasis May have bleeding at any parts of the body Diagnose based on history, bleeding
characteristics, platelet count, prothrombin time, fibrinogen etc tests
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Management
Principal of management for post partum hemorrhage is: Rapid hemostasis according to the cause Replenish volume, correct shock Prevent infection
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Management of uterine atony
Remove cause Uterine massage:
Abdominal fundus massage Abdominal-vaginal bimanual uterine massage
Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy
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Uterine massage
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Management of uterine atony
Remove cause Uterine massage:
Abdominal fundus massage Abdominal-vaginal bimanual uterine massage
Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy
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Management of uterine atony Remove cause Uterine massage:
Abdominal fundus massage Abdominal-vaginal bimanual uterine massage
Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy
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Uterine packing
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Management of uterine atony Remove cause Uterine massage:
Abdominal fundus massage Abdominal-vaginal bimanual uterine massage
Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy
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Pelvis vessel ligation
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Management of uterine atony Remove cause Uterine massage:
Abdominal fundus massage Abdominal-vaginal bimanual uterine massage
Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy
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B-Lynch suture
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Management of uterine atony Remove cause Uterine massage:
Abdominal fundus massage Abdominal-vaginal bimanual uterine massage
Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy
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Arterial embolism
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Management of uterine atony Remove cause Uterine massage:
Abdominal fundus massage Abdominal-vaginal bimanual uterine massage
Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy
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Management of placental factors
Retained placenta – remove separated placenta
quickly
Residual placenta or membrane – curettage
Placental adhesion – manual removal of placenta
Placental implantation – never separate forcefully,
usually hysterectomy
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Management of laceration
Thorough hemostasis
Stitch according to anatomical layering
First stitch must be 0.5cm above top end
When stitching do not leave dead space
Avoid stitching through rectal mucosa
Manage cervical tear
Manage birth canal hematoma
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Manage cervical tear
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Management of coagulation disorder
First exclude bleeding caused by uterine atony, placental factors and birth canal injury
Actively transfuse fresh whole blood, platelets, fibrinogen or prothrombin complex, clotting factors etc
If DIC set in, manage DIC
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Prevention
Comprehensive antenatal care, screen for high risk factors, intervene accordingly
Appropriate labour management Aggressive post partum monitoring: 2 hours post
partum is the peak of post partum hemorrhage, patient must be monitored in labour room for 2 hours
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Rupture of uterus
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Definition
The body uterine or lower uterine segment happens to rupture during late pregnancy or labor
Rupture of the pregnant uterus is a obstetric catastrophe and major cause of maternal death
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Etiology
Descending of presenting part obstruction: narrow pelvis, cephalo-pelvic disproportion, soft tissue obstruction, fetal malposition, fetal abnormality
Inappropriate use of oxytocin 、 prostaglandin etc Uterine scar: fibroidectomy, caesarean section Surgical trauma
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Clinical presentation
Happens at late pregnancy or during labour, more during labour
Complete rupture and incomplete rupture Spontaneous rupture or traumatic rupture Body rupture or lower segment rupture It is usually a progressive process, separated
into 2 stages, impending rupture and uterine rupture
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Threatened uterine rupture
Obstructed descend of fetal presenting part, prolong labor
Appearance of pathologic retraction ring Mother shows distress, rapid breathing and
heart rate, unbearable pain Urination difficulty, hematuria Fetal heart rate change or unclear
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Complete uterine rupture
At the point rupture, patient experiences sudden abdominal tearing pain, uterine contraction ceases, temporary relieve of abdominal pain
Following blood, amniotic fluid, fetus going into the abdominal cavity, abdominal pain progressively worsen
Patient presents with rapid breathing, paleness, weak pulse, decreasing blood pressure etc shock manifestations
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Complete uterine rupture
Tenderness and rebound tenderness throughout abdomen
Fetal parts and small uterine body may be easily palpable under abdominal wall, disappearing of fetal movement and fetal heart
Vaginal examination: may have fresh bleeding, originally dilated cervix becomes smaller, ascend of fetal presenting part, if site of rupture is low, may be able to palpate uterine wall rupture per vaginal
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Complete uterine rupture
Uterine body scar rupture, usually complete rupture, no obvious impending rupture presentations
As the scar tear progressive widens, pain and other presentations progressively worsen, but might not have typical tearing pain
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Incomplete uterine rupture
Usually seen in lower segment caesarean section scar Usual pain symptoms and signs are not obvious, may have
obvious tenderness at the site of incomplete rupture Incomplete rupture involving uterine artery, may lead to
acute massive bleeding Rupture occurring in lateral uterine walls within the broad
ligaments, may cause broad ligament hematoma, during which a tender mass is palpable one side of the uterine body and progressively enlarges
Irregular fetal heart
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Diagnosis
Typical uterine rupture is easily diagnose based in the history, symptoms and signs
Incomplete uterine rupture, as signs and symptoms are not obvious, diagnosis is difficult.
Ultrasound examination: may show position between fetus and uterus, confirming site of rupture
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Differential diagnosis
1. Severe placenta abruptio Unbearable abdominal pain, uterine tenderness Disproportion between bleeding volume and
degree of anemia Ultrasound may shows retro-placental
hematoma, fetus is intrauterine Usually associated with pregnancy induced
hypertensive diseases or trauma
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Differential diagnosis
2. Intrauterine infection Usually seen in premature rupture of membrane,
prolonged labour, multiple vaginal examination May have abdominal pain and uterine tenderness
etc Temperature rise Abdominal examination: fetus is intrauterine White blood cell and neutrophil counts rise
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Management of impending uterine rupture
Suppress uterine contraction: give inhaled anesthesia or intravenous generalized anesthesia, intramuscular pethidine 100mg etc to relieve uterine contraction
Oxygen Prepare for emergency surgery Immediate caesarean section, prevent uterine
rupture
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Management of uterine rupture
Regardless whether fetus is alive, actively manage shock and operate soonest possible
Type of surgery: decided based on maternal condition, degree of uterine rupture, duration of rupture and degree of infection
Tear repair: neat tear, no obvious infection Hysterectomy: big tear, irregular tear or obvious
infection, perform subtotal hysterectomy. If tear extends to cervix, perform total hysterectomy
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Management of uterine rupture
During surgery carefully inspect cervix, vagina, bladder, urethra, rectum and all neighboring structures, repair accordingly if damage found
Give high dose broad spectrum antibiotics perioperatively to prevent infection
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Transfer
Uterine rupture presenting with shock, resuscitate immediately on site
If transfer is necessary, it must be done under the condition where blood transfusion, fluid infusion, resuscitation. abdomen must be bandaged before transporting
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Prevention
Build more efficient and comprehensive antenatal care Patients of high risk should admit 1-2 weeks before
expected date of delivery Strengthen observation ability of doctors and midwives,
pick up abnormality during labour promptly Strict indication for caesarean section and all vaginal
surgery, strict surgical steps, avoid careless surgery, pick up surgical damage promptly
Strict indication of usage of oxytocin
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