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Postpartum Hemorrhage. Dr. Yasir Katib MB BS, FRCSC. Postpartum Haemorrhage. Introduction Risk Factors Prevention Treatment Pelvic Haematoma Umbrella Pack Uterine Inversion. PPH - Introduction. Acute blood loss – most common cause of hypotension in obstetrics

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postpartum hemorrhage

Postpartum Hemorrhage

Dr. Yasir Katib

MB BS, FRCSC

postpartum haemorrhage
Postpartum Haemorrhage
  • Introduction
  • Risk Factors
  • Prevention
  • Treatment
  • Pelvic Haematoma
  • Umbrella Pack
  • Uterine Inversion
pph introduction
PPH - Introduction
  • Acute blood loss – most common cause of hypotension in obstetrics
  • Usually occurs immediately before or after placental delivery
  • Most commonly results when uterus fails to contract - effective haemostasis dependent on contraction of myometrium (compresses severed vessels)
pph introduction4
PPH - Introduction
  • Factors Predisposing to Myometrial Dysfunction
      • Uterine Overdistention
        • Multiple Pregnancy
        • Fetal Macrosomia
        • Hydramnios
        • Oxytocin-stimulated Labour
        • Uterine Relaxants
        • Amnionitis
pph introduction5
PPH - Introduction
  • Abnormal placentation
    • Placenta accreta – attaches directly into myometrium
    • Placenta increta - extends deep into myometrium
    • Placenta percreta - through the uterine serosa & even into the surrounding organs
    • PPH occurs b/c myometrial tissue present at implantation site insufficient to constrict spiral arteries of the uterus.
    • Attempting to remove the abnormal placenta frequently results in uncontrolled haemorrhage because of large open sinuses in the myometrium.
pph risk factors obstetric haemorrhage 1 l
PPH – Risk Factors(Obstetric Haemorrhage >1 L)
  • Placental abruption
  • Placenta previa
  • Multiple pregnancy
  • Obesity
  • Retained placenta
  • Induced labour
  • Episiotomy
  • Birth weight > 4 kg
pph prevention
PPH – Prevention
  • Active management of 3rd stage of labour & spontaneous delivery of placenta @ time of C/S
  • Umbilical cord clamping within 30s of delivery, gentle cord traction, followed by IM or IV oxytocin before delivery of placenta
  • Oxytocin s length of 3rd stage of labour (~ 5 min) & low incidence of manual removal (2%)
  • In absence of sig. maternal haemorrhage, additional 30 min of expectant management allow ½ of retained placentas to deliver spontaneously
pph tx manual
PPH – Tx (Manual)
  • Manual digital exploration of uterus to r/o possibility of retained placental fragments
pph tx manual9
PPH – Tx (Manual)
  • If not detected, manual massage of uterus should be started
pph tx pharmacologic
PPH – Tx (Pharmacologic)
  • At the same time, initial Tx of oxytocin 10-20 U/1000 mL of NS at rates as high as 500 mL in 10 min.
  • If oxytocin fails, synthetic prostaglandin (Prostin, Upjohn) is 2nd line (0.25 mg IM in deltoid q1-2h X 5 doses)
  • Ergovine (0.2 mg IM) used to be 2nd line
  • Misoprostol (1000 g PR) in patients with refractory uterine bleeding shown (O’Brien et al.)
pph tx surgical
PPH – Tx (Surgical)
  • Inspection for laceration of maternal tissues could be a likely cause of continued vaginal or cervical bleeding
  • Repair
pph tx surgical12
PPH – Tx (Surgical)
  • 1st degree – involves fourchet, perineal skin & vaginal mucosal membrane
  • 2nd degree – also involves muscles of perineal body; rectal sphincter remains intact
pph tx surgical13
PPH – Tx (Surgical)
  • 3rd degree – extends not only through the skin, mucous membrane & perineal body, but includes the anal sphincter
pph tx surgical14
PPH – Tx (Surgical)
  • 4th degree laceration – extends through the rectal mucosa
pph tx surgical15
PPH – Tx (Surgical)
  • Cervical laceration – NB to secure base of laceration (often a major source of bleeding); but difficult to suture
pph tx surgical16
PPH – Tx (Surgical)
  • If uterine bleeding not responsive to pharmacologic methods & no vaginal or cervical lacerations present, surgical exploration may be necessary
  • Laceration of uterine vessels may be found (i.e. longitudinal lacerations of inner myometrium – thought to be an incomplete form of uterine rupture)
pph tx surgical17
PPH – Tx (Surgical)
  • If haemorrhage secondary to atony, vascular ligation often necessary
  • Hypogastric artery ligation fallen out of favour b/c of prolonged OR time, technical difficulties & inconsistent clinical response
  • If bilateral uterovarian vessel ligation does not stop bleeding, temporary occlusion of infundibulopelvic ligament (digital pressure or clamps) should be attempted – ligation indicated if this controls bleeding
pph tx surgical18
PPH – Tx (Surgical)
  • Instead, stepwise progression of uterine vessel ligation should be performed
  • 1st – ligation of ascending branch of uterine arteries (in ~10-15% of atony, unilateral ligation of uterine artery sufficient to control bleeding; bilat will control an additional 75%)
  • If bleeding persists, should attempt to interrupt blood flow between uterus & infundibulopelvic ligament via ligation of anastomosis of ovarian & uterine artery
pph tx radiological
PPH – Tx (Radiological)
  • Advantages – d anaesthetic & surgical risks

- identification & selective occlusion of specific vessels

- avoid hysterectomy

  • Could also use transient transcatheter uterine artery balloon for management of extreme haemorrhage
pph tx radiological21
PPH – Tx (Radiological)
  • Successfully used in postpartum bleeding from atony, bleeding from pelvic vessel laceration, post c-section haemorrhage & bleeding associated with extrauterine pregnancy
  • Complications - postprocedure fever & pelvic

infection (most common)

- reflux of embolic material in

nontargeted pelvic structures

pph pelvic hematoma
PPH – Pelvic Hematoma
  • Blood loss not always visible
  • Occasionally, traumatic laceration of blood vessels can lead to pelvic haematoma formation
  • 3 types
    • Vulvar
    • Vaginal
    • Retroperitoneal
pph pelvic hematoma23
PPH – Pelvic Hematoma
  • Vulvar
    • D/t laceration of vessels in superficial fascia of either the ant. or post. pelvic triangle
    • Usual signs : subacute volume loss & vulvar pain
    • Blood loss limited by Colle’s fascia & urogenital diaphragm & anal fascia
    • B/c of fascial boundaries, mass extends to skin & visible haematoma results
    • Tx – volume support & surgical evacuation of blood & clots, pressure bandage, Foley catheter
pph pelvic hematoma25
PPH – Pelvic Hematoma
  • Vaginal
    • Frequently associated with forceps delivery; may be spontaneous
    • Less common than vulvar
    • Blood accumulates in plane above level of pelvic diaphragm
    • Unusual for large amounts of blood to collect
    • Frequent complaint – severe rectal pressure
    • Exam – large mass protruding into vagina
    • Tx – incision of vagina & evacuation (even if delayed Dx)
pph pelvic hematoma27
PPH – Pelvic Hematoma
  • Retroperitoneal
    • Least common
    • Most dangerous to mother
    • May not be impressive until sudden onset of hypotension/shock
    • D/t laceration of one of vessels originating from hypogastric artery
    • Tx : surgical exploration & ligation of hypogastric vessels unilaterally or bilaterally if needed
pph uterine inversion
PPH – Uterine Inversion
  • Characterized by partial delivery of the placenta, followed by rapid onset of shock ( usually before sig. blood loss) in the mother in the 3rd stage of labour
  • Can be mistaken for partially separated placenta or aborted myoma
  • Uncommon but life-threatening event
  • Incidence : 1/2000 deliveries
pph uterine inversion29
PPH – Uterine Inversion
  • Incomplete – if corpus does not pass through cervix
  • Complete – if corpus passes through the cervix
  • Prolapsed – if corpus extends through vaginal introitus
  • Usually occurs in association with a fundally inserted placenta
pph uterine inversion30
PPH – Uterine Inversion
  • Tx : fluid therapy & restoration of uterus to N position immediately upon recognition of inversion, without removing the placenta
  • If initial efforts fail, use of either -mimetic agents or magnesium sulfate should be tried (esp. if severe maternal hypotension)
  • Occasionally, impossible to reposition uterus vaginally & laparotomy necessary
  • Once inversion corrected, oxytocic or prostaglandin agents should be given
ad