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Post Partum Hemorrhage

Post Partum Hemorrhage. Amanpreet Dhaliwal & Jessica Kapralik. Case: Ms. P. 29 yo F, G5P4 Uncomplicated prenatal course; asymptomatic bacteriuria (E.coli) in the first trimester, treated with oral cephalexin Has preeclampsia

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Post Partum Hemorrhage

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  1. Post Partum Hemorrhage Amanpreet Dhaliwal & Jessica Kapralik

  2. Case: Ms. P • 29 yoF, G5P4 • Uncomplicated prenatal course; asymptomatic bacteriuria (E.coli) in the first trimester, treated with oral cephalexin • Has preeclampsia • Delivers at 39 weeks vaginally, after delivering her placenta, she has been experiencing vaginal bleeding (est 1 L) • Post partum hemorrhage: • 1-5 - 15 % of births • Risk of mortality : 1/1000 - 1/100 000 • Most preventable cause of maternal mortality

  3. Definitions • 1. Blood loss after child birth causing hypovolemia or symptoms • Hypovolemia: hypotension, tachycardia, oliguria, O2 saturation < 95% • Symptoms: pallor, light headedness, weakness, palpitations, diaphoresis, restlessness, confusion, air hunger, syncope • 2. Estimated blood loss ≥500 mL after vaginal birth or ≥1000 mL after cesarean delivery • 3. 10%  in postpartum hemoglobin from antepartum levels • Primary: 1st 24 hrs after birth • Secondary 24 hrs – 12 weeks after birth • Severity varies • Minor: 500 to 1000 mLs • Major >1000 mLs • Moderate: 1000 to 2000 mLs • Severe >2000 mLs

  4. Pathophysiology Hemostasis Post Partum In late delivery blood flow is 15-20 % of cardiac output or 500-700 mL/min Placenta detaches from the uterus, the myometrium contracts and constricts the vessels supplying the placenta Coagulation pathways are activated to clot off where the placenta detached Bleeding occurs when one of these pathways fail

  5. Etiology & DDx Hemostasis Post Partum 4T’s • Tone – Uterineatony, distendedbladder • 1/20 birthsand 80% of PPH • Overdistention • Fatigue • Relaxants • Infection • Inversion • Tonic feeling uterusmay not be tonic throughout • Firmuterus + persistent bleedingrequires vaginal exam for ballooning or lacerations • Tissue – Placenta accreta, retainedplacentalproducts or clots, choriocarcinoma • Trauma – Anyinjury in the birth canal • Thrombin– coagulopathy (pre-existing or acquired) • Late PPH • Retainedplacentalproducts • Endometritis • Sub involution of uterus

  6. Risk Factors • Pregnancy –Related • Uterine overdistention • Abnormal placentation • Abruption • Severe preeclampsia • Fetal demise • placenta previa • precipitous labor • first stage of labor longer than 24 hours • Other Factors • Obesity • high parity • Asian or Hispanic ethnicity • uterine infection

  7. Investigations • Assess degree of blood loss • Lower genital tract exam – Tone, Tissue, Trauma • Lab Studies- CBC, lytes, INR, aPTT, blood type and screen • Coagulation test: • red-topped tube of blood • no clot in 7-10 min indicates coagulation problem

  8. Initial Management • Assemble team and notify appropriate departments (obstetrics, nursing, anesthesiology, blood bank, lab)

  9. Initial Management • Initiate uterine massage and/or manual compression • Fundal massage stimulates the atonic uterus to contract • Massage should be maintained while other interventions are being initiated and continued • Establish large bore (two 16 or 18 gauge) IV access for administration of fluids, blood, medications

  10. Initial Management • Uterine tamponade • Either a balloon or a pack can be used

  11. Initial Management • Oxygenation; intubate if indicated • 10-15 L/min • Fluid resuscitation and transfusion • Crystalloid should be infused to prevent hypotension (sBP 90) and maintain urine output at >30 mL/hour • 2 units of pRBCs if hemodynamics do no improve after 2-3L of NS/RL

  12. Initial Management • Uterotonic Drugs • Uterine atony is the most common cause • Oxytocin (40 units in 1 L of NS or RL)- drug of choice • If oxytocin is not immediately available or does not control PPH • Add ergot: • Methylergonovine (methylergometrine) 200 micrograms IM q2-4 hrs up to a maximum of 1 mg (five doses). • Ergonovine(ergometrine) is an alternative to methylergonovine; its actions and contraindications are similar to methylergonovine • Add carboprost • Carboprosttromethamine (PGF2alpha, Hemabate) 250 micrograms IM q15-90 minutes, as needed, to a maximum of 2 mg (eight doses).

  13. Initial Management • Remove retained products of conception • Any retained placental fragments or fetal membranes • US can be helpful for dx of retained tissue • Curettage with 16 mm suction catheter or large blunt curette is performed if manual removal is unsuccessful

  14. 2o interventions • Repair vaginal and cervical lacerations • Inspect entire birth canal from perineum to cervix for significant lacerations, uterine rupture, dehiscence • Arterial Embolization • If woman is hemodynamically stable and where personnel and facility is available • Gelfoam is the preferred agent for embolization of uterine or hypogastric arteries (duration of occlusion is temporary: 2-6 wks) • Laparatomy should be performed if women is not stable

  15. Surgical Tx • Indications for laparotomy • For management of uterine atony unresponsive to conservative interventions

  16. Surgical Tx • Hysterectomy • Last resort for treatment of atony • Should not be delayed in women who require prompt control of uterine hemorrhage to prevent death • Continued blood loss can lead to disseminated intravascular coagulation (DIC) due to massive loss of coagulation factors

  17. Complications • Death • Hypovolemic shock and organ failure: renal failure, stroke, MI • postpartum hypopituitarism (Sheehan syndrome) • Infarction of pituitary causing hyposecretion of all pituitary hormones • Classic presentation: failure to lactate post-delivery • Fluid overload (pulmonary edema, dilutionaloagulopathy) • Abdominal compartment syndrome • Due to intra abdominal hypertension • Anemia • Transfusion-related complications : electrolyte abnormalities • ARDS • Venous thrombosis and embolism • Unplanned sterilization due to need for hysterectomy • Ashermansyndrome • Related to curettage if performed for retained products of conception

  18. Case Summary • CC: 29 yo F, G5P4 with > 1L blood loss in 4th stage of labour • HPI: Uneventful pregnancy; bacturia, uneventful birth • Want to ask about previous pregnancies and births especially in regards to bleeding and complications during delivery • RF: overall low risk pregnancy, high parity only factor • DDx: Atony most likely, could be any of 4 T’s • Investigations: • Volume assessment • Pelvic exam • No FHx of bleeding disorders, could do blood test • Treatment: Based on etiology - should include use of uterotonics, fluid resuscitation & uterine massage

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