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Post partum Haemorrage

Post partum Haemorrage. Obstetric Emergency Follow Vaginal or C/S Best definition - Diagnosed Clinically Excessive Bleeding makes patient symptomatic Other def- EBL > 500 ml -NVD EBL > 1000 ml –C/S. Other definitions of PPH

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Post partum Haemorrage

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  1. Post partum Haemorrage • Obstetric Emergency • Follow Vaginal or C/S • Best definition - Diagnosed Clinically Excessive Bleeding makes patient symptomatic Other def- EBL > 500 ml -NVD EBL > 1000 ml –C/S

  2. Other definitions of PPH 10% loss of Hb Concentration Most likely we underestimate EBL

  3. Etiology • Uterine atony > 90%( 1/20 deliveries ) • Uterine, Cervical or Vaginal lacerations(1/8 deliveries) • Coagulopathy • Other-Uterine inversion, Uterine rupture, poor haemostasis

  4. Risk factors

  5. Management • Fundal massage • IV access- 16 G • Uterotonic drugs- Syntocin 10 to 40 units • Ergometrine- 500mcg( C.I -Asthma, HT ) • Misoprostel 1000 mcg( 1RCT and 1 non RCT )

  6. Advanced Mx of PPH • > 1000 ml best Mx in Theatre • Notify Obstetric and Anaesthetic Consultant • Notify Blood bank, Haematologist and Theatre • PGF2α (Carboprost) 250mcg every 15 mins max 2 mg • Infuse large amount of IV fluids to prevent Hypotension

  7. T/F Blood products - Pack cells - FFP (All clotting factors) - Cryoprecipitate( Fibrinogen.factor V,VIII, XIII and VWF) - Platelets( 1 unit=50 ml, 6 units increase by 30,000) •EUA -Check Vagina, Cervix,Uterus

  8. Tamponade Uterine packs used variable success Foley Catheter- # 24 30 ml balloon to 60ml leave for 12-24 hours Sengstaken- Blackemore tube

  9. Laparotomy • Involve Gyne Oncologist if possible • Best Vertical midline incision • Uterine vessel ligation ± Utero Ovarian • Hypogastric artery ligation • B-Lynch suture (compress the uterus) ( simple to learn,safe, fertility preserves)

  10. • Recombinant facer VIIa ( Novo seven) (Obs & Gyne 2003 case report) - Effective when conventional methods fail - Bypassing inhibitors to factor VIII and IX Dose 60mcg/Kg to 100 mcg/Kg

  11. Precautions before closing the abdomen •Haemostasis •Inspect bladder and Ureters

  12. 2°PPH 24 Hours to 6 weeks Incidence 0.5 to 2% Pathogenesis – Uterine atony 2º to retained products or infection But exact cause unknown

  13. Treatment No RCT Uterotonics Antibiotics If retained products D&C

  14. 132 Consecutive women 75 D&C Tx Successful 90% 57 Med Tx Successful 72% Complication of Surgery Perforation 3% Uterine adhesions US does not distinguish which patient need surgery or medical Tx

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