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Post-Partum Hemorrhage

Post-Partum Hemorrhage. Nahida Chakhtoura, M.D. Epidemiology. Postpartum hemorrhage ( PPH): leading cause of maternal mortality worldwide Prevalence rate: 6% Africa has highest prevalence rate: 10.5% In Africa and Asia PPH accounts for more than 30% of all maternal deaths

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Post-Partum Hemorrhage

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  1. Post-Partum Hemorrhage Nahida Chakhtoura, M.D.

  2. Epidemiology • Postpartum hemorrhage (PPH): leading cause of maternal mortality worldwide • Prevalence rate: 6% • Africa has highest prevalence rate: 10.5% • In Africa and Asia PPH accounts for more than 30% of all maternal deaths • Maternal death rates attributable to PPH vary considerably between developed and developing countries, suggesting that deaths from PPH are preventable

  3. Etiology • Uterine Atony • Placenta: retained placenta, placental tissue or membrane, incomplete separation • Full bladder • Antepartum hemorrhage: placenta previa or placental abruption • Overstretched uterus: high parity, multiple pregnancy, polyhydramnios, macrosomia, fibroids

  4. Etiology • Uterine Atony • Prolonged active phase • Medical factors: anemia, coagulopathy • Others: severe pre-eclampsia and eclampsia, precipitate labor, induction/ augmentation, IUFD, h/o PPH, c/s, gen. anesthesia, chorioamnionitis or endometritis

  5. Etiology • Genital Trauma • Perineum • Vaginal walls • Cervix • Uterus • Risk Factors • Mistimed episiotomy • Induced labor • Precipitate labor • C/S • Forceps Delivery • Prolonged labor • Previous uterine surgery • Anemia • Delay in Tx

  6. Management • Priorities • Call for Help! • Rapid assessment of patient’s condition • Identify source of bleeding • Stop the bleeding • Stabilize/resuscitate • Prevent further bleeding

  7. Management • Atonic PPH • Massage the uterus to promote contraction and expel clots • Oxytocin 10 IU IM • Assess EBL • Type and cross, CBC, coagulation profile • Start IVF: if shock  1L NS or LR in 15min up to 3L • Foley catheter • Check placenta and membranes. If placenta cannot be delivered, manually extract • Examine cervix, vagina, and perineum

  8. Management • If bleeding persists… • Oxytocin 20 units in 1L of IVF @ 60 drops per min • Add other IV access • Continue uterine massage • Assess clotting status and transfuse if necessary • Consider transferring to higher level • Uterine or utero-ovarian ligation; hypogastric artery ligation • Uterine balloon • B-lynch suture • Hysterectomy • Document properly

  9. Management • Traumatic PPH • Lithotomy position • Identify site of bleeding and repair

  10. Continuing Management • Close monitoring over next 24-48hrs • Uterine tone • VS; Ins and Outs • Blood loss • Serial CBC

  11. Management • Developing Countries • Active management of labor • Uterine massage • Draining the bladder • 10 U oxytocin IM • Misoprostol • Uterine packing • Hysterectomy

  12. Thank You! • Fausto Astudillo-Davalos, M.D. • Mabel Marotta • Danielle Kramer • Nahida Chakhtoura, M.D.

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