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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

Dr. Yasir Katib


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Postpartum Haemorrhage

  • Introduction

  • Risk Factors

  • Prevention

  • Treatment

  • Pelvic Haematoma

  • Umbrella Pack

  • Uterine Inversion

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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)

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PPH - Introduction

  • Factors Predisposing to Myometrial Dysfunction

    • Uterine Overdistention

      • Multiple Pregnancy

      • Fetal Macrosomia

      • Hydramnios

      • Oxytocin-stimulated Labour

      • Uterine Relaxants

      • Amnionitis

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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.

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PPH – Risk Factors(Obstetric Haemorrhage >1 L)

  • Placental abruption

  • Placenta previa

  • Multiple pregnancy

  • Obesity

  • Retained placenta

  • Induced labour

  • Episiotomy

  • Birth weight > 4 kg

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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

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PPH – Tx (Manual)

  • Manual digital exploration of uterus to r/o possibility of retained placental fragments

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PPH – Tx (Manual)

  • If not detected, manual massage of uterus should be started

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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.)

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PPH – Tx (Surgical)

  • Inspection for laceration of maternal tissues could be a likely cause of continued vaginal or cervical bleeding

  • Repair

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PPH – Tx (Surgical)

  • 1st degree – involves fourchet, perineal skin & vaginal mucosal membrane

  • 2nd degree – also involves muscles of perineal body; rectal sphincter remains intact

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PPH – Tx (Surgical)

  • 3rd degree – extends not only through the skin, mucous membrane & perineal body, but includes the anal sphincter

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PPH – Tx (Surgical)

  • 4th degree laceration – extends through the rectal mucosa

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PPH – Tx (Surgical)

  • Cervical laceration – NB to secure base of laceration (often a major source of bleeding); but difficult to suture

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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)

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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