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    2. Postpartum Hemorrhage Definition Loss of 500 ml or more of blood following vaginal delivery. (Hg. may occur before, during or after delivery of the placenta ) Or 1000 ml of blood loss for cesarean section Early PPH ?Blood lost during the first 24 hrs after delivery Late PPH ?Blood lost between 24hró6weeks after delivery

    3. Postpartum Hemorrhage Incidence 5-8% It is the most common cause of excessive blood loss in pregnancy Hemorrhage (including APH, PPH, abortion & ectopic) is the leading obstetric cause of maternal mortality in Saudi Arabia & underdeveloped countries It is the third leading cause of MM in USA

    4. Morbidity & Mortality Women compromised by anemia or intercurrent illness are at increased risk of complications Anemia Morbidity related to blood transfusion? hepatitis, HIV, transfusion rection Morbidity related to hypovolemic shock Renal failure (acute tubular necrosis)

    5. Morbidity & Mortality Shehanís syndrome ? postpartum hypotension ?partial or complete necrosis of the anterior pituitary ?panhypopituitrism -Characterized by ?failure to lactate, amenorrhea, hypothyroidism, adrenal insufficiency & ? breast size & loss of pubic & axillary hair. -Incidence 1:10000 deliveries Sterility resulting from Hysterectomy performed to control severe Hg

    6. Etiology of PPH 1-Uterine atony With separation of the placenta many uterine blood vessels are severed abruptly? the bleeding that results is controlled by contraction & retraction of the myometrium to compress the blood vessels Uterine atony results when there is failure of the myometrium to contract It accounts for 50% of the cases of PPH

    7. 1-Uterine Atony Predisposing causes: Uterine over distension ?twins, polyhydramnious or large infant Grandmultiparity Prolonged labor Dysfunctional labor Oxytocin induction or augmentation of labor

    8. Contd/Uterine Atony Predisposing Causes Instrumental deliveries Uterine infections General anesthesia with halogenated compounds Previous HG or blood transfusion Uterine lieomyoma Intrauterine manipulation Abruptio placenta with couvelaire uterus

    9. Etiology of PPH 2-Obstetric lacerations 20%of PPH It may involve the vagina, vulva, cervix or uterus Predisposing causes : Precipitate delivery, operative delivery & large infant Hematomas ? laceration of blood vessels underneath vaginal or vulvar epithelium

    10. Etiology of PPH contd/Obstetric lacerations Excessive bleeding from the episiotomy ? if it involves varicosities or arteries, if the episiotomy is large, early episiotomy or delayed repair Rupture uterus ? risk factors: CS or uterine surgery, IOL with PG or oxytocin, grandmultiparity & malpresentation

    11. Etiology of PPH 3-Retained placental tissue 5-10% of PPH Predisposing causes: placenta accreta, mismanegement of the 3rd stage of labor, succenturiate placenta U/S or sonohysterography are helpful in the DX of pt. with retained placental tissue

    12. Etiology of PPH 4-Low laying placenta ?as the lower segment is less contractile ? excessive bleeding from the placental site after delivery 5-Inversion of the uterus Due to strong traction on an umbilical cord attached to a fundal placenta 1:2000-6000 deliveries Immediate replacement is mandatory to prevent life threatening Hg

    13. Etiology of PPH 6-Coagulation defects -Consumptive coagulopathy ? due to abruptio placenta, retained dead fetus, amniotic fluid embolism, severe PET, septicemia or abortion -Medical causes of coagulation defects ? Von Willbrandís disease, ITP, leukemia, dilutional coagulopathy (when >8 U of blood transfused)

    14. MANAGEMENT 1-Predelivery preparation -Type & screen blood for all Pt in labor -High risk Pt ? Cross matching ? Large bore IV catheter ? Severely anemic Pt transfused

    15. 2-Management at delivery Oxytocin IM or IV with the delivery of the anterior shoulder ? ? blood loss at delivery & ? PPH by 40% Uterine massage after delivery of the fetus Delivery of the placenta by controlled cord traction Inspection of the placenta for completeness

    16. 3-Management in the immediate post partum period Manual removal of the placenta MRP -Timing of MRP ? immediately if there is HG ?Wait for 30 if there is no Hg -Usually performed under GA -Prophylactic antibiotics given

    17. Contd/Management in the immediate post partum period Repair of lacerations -Episiotomy should be repaired immediately -The vagina & cx should be inspected & any lacerations repaired -Lacerations extending into the broad ligament require laparotomy -Large hematomas require operative management

    18. 4-Evaluation of persistent bleeding 1-Manually compress the uterus 2-Obtain blood for X-matching if not done 3-Start IV fluids or blood replacement 4-Insert a 2nd IV catheter 5-Cathterize the bladder 6-Start IV oxytocin 7-Inspect the cx & vagina

    19. 4-Evaluation of persistent bleeding 8-Manually explore the uterine cavity ? in vaginal delivery following CS, when intrauterine manipulation has been performed, when abnormal uterine contour has been noted or preterm delivery ?Ensure that there are no retained placental tissue & that the uterus is intact ? Look for possible structural abnormalities of the uterus

    20. 5-Measures to control bleeding 1-Bimanual compression & massage of the uterus 2-Curettage ? When manual exploration fails to remove fragments of adherent placenta ? It may result in perforation or ashermanís syndrome 3-Utrotonic agents -Oxytocin 20-40 U/L IV infusion 10-15ml/min -Methylergonovine 0.2 mg IM (contraindicated in hypertensive Pt) -PGF2a ?intramyometrial injection or IM -Misoprostol rectally

    21. 5-Measures to control bleeding 4-Radiographic embolization of uterine arteries or internal iliac 5-Operative management a-Pressure occlusion of the aorta ?to provide time to identify the source of bleeding B-Uterine artery ligation C-Internal iliac ligation D-B-lynch suture E-Hysterectomy 6-uterine packing

    22. Consumptive coagulopathy DIC Pregnancy induces hypercoagulbility ? factor I(fibrinogen), VII, VIII, IX, X ?Plasminogen but ? plasmin activity Causes of Obstetric coagulopathy: A-Activation of the extrinsic coagulation pathway through the release of thromboplastin from tissue destruction 1-Abruptio placenta (the most common cause ) 2-Intrauterine fetal death (IUFD) & delayed delivery ?occurs if the dead fetus is retained for >1 month (25%) Rare before that

    23. Causes of Obstetric coagulopathy: B-Direct activation of factor X by proteases as present in mucin. Amniotic fluid contains abundant mucin from fetal cells ?rapid DIC with amniotic fluid embolism C-Septicemia ?release of bacterial endotoxins ?disruption of vascular endothelium ?tissue factor is released ? activation of the extrinsic coagulation pathway D-Abortion results in coagulopathy when there is prolonged retention of a dead fetus, septic abortion E-HELLP syndrome ? Deposition of fibrin in endothelial cells of blood vessels (consumptive coagulopathy) ?microangiopathic hemolysis

    24. Clinical evidence of defective hemostasis Exessive bleeding at the site of modest trauma Characterizes defective hemostasis eg. Bleeding from venipuncture sites, nicks from shaving, trauma from insertion of a catheter, spontaneous bleeding from nose or gums, continuous oozing from cut surfaces during surgery, petechiae.

    25. Lab. evidence of defective hemostasis 1-Hypofibrinogenemia <100 mg/dl 2-?Fibrinogen degradation products 3-Thromboctopenia 4-Prolonged PT & PTT

    26. Amniotic fluid embolism Abrupt onset of hypotension, hypoxia, and cosumptive coagulopathy one of these manifestation may dominate 1:20000 deliveries

    27. Amniotic fluid embolism Clinical presentation ?In the late stages of labor or immediately postpartum ?Gasping for air, seizures, cardiorespiratory arrest, DIC, Hg, & death (60-90%) ?Fetal survival ~70% ?No data that any type of intervention ? improves the prognosis

    28. Treatment of coagulopathy 1-Fresh frozen plasma 2-PLatlets transfusion 3-Cryoprecipitate 4-PRBC 5-Heparin ? for IUFD Should not be used in cases of abruptio placenta, septicemia 6-Antibiotics ?for Pt with septicemia or septic abortion