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Post Partum Hemorrhage Uterine Rupture

Post Partum Hemorrhage Uterine Rupture. Women ’ s Hospital School of Medicine Zhejiang University Wang Zhengping. Post partum hemorrhage. Post partum hemorrhage. Past partum hemorrhage denotes excessive bleeding ( ≥ 500ml in vaginal delivery) during the first 24 hours after delivery

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Post Partum Hemorrhage Uterine Rupture

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  1. Post Partum Hemorrhage Uterine Rupture Women’s Hospital School of Medicine Zhejiang University Wang Zhengping

  2. Post partum hemorrhage

  3. Post partum hemorrhage • Past partum hemorrhage denotes excessive bleeding (≥500ml in vaginal delivery) during the first 24 hours after delivery • Common cause of death and diseases in pregnant women globally • Leading cause of death in pregnant women in China • Incidence 2%-3% of total number of deliveries

  4. Etiology • Uterine atony: 70% • Obstetric lacerations: 20% • Retained placental tissue: 10% • Coagulation:1%

  5. Uterine atony • General factors: extreme nervousness, sedative, anesthesia, tocolytics, weak • Obstetric factors: prolonged labour, fatigue, placenta previa, placenta abruptio, severe anemia • Uterine factors: uterine muscular fiber underdevelopment, such as uterine deformity or myoma; uterine overstretched, such as macrosomia, multiple pregnancy, polyhydramnios

  6. Placental factors • Incomplete placental separation • Retained placenta • Placental incarceration（嵌顿 ） • Placental adhesion • Placental implantation (accreta, increta, percreta) • Residual placenta and amniotic membrane

  7. Implantation of placenta

  8. Birth canal injury • Laceration during labour are usually associated with: • Poor vulval elasticity • Strong labour force, emergency delivery, macrosomia • Inadequate skills at assisted vaginal delivery • Inadequate cessation of bleeding during episiotomy repair, missing out tears at cervix or fornices

  9. Coagulation disorder • Complications associated with obstetric: amniotic fluid embolism, pregnancy induced hypertensive diseases, placenta abruptio and intrauterine demise • Pregnancy liver disease: acute fatty liver, severe hepatitis • Hematology diseases: primary thrombocytopenic purpura, aplastic anemia etc

  10. Clinical presentation • Vaginal bleeding: • If bleeding occurs immediately after delivery of baby, consider birth canal injury • If bleeding occurs minutes after delivery of baby, consider placenta factors • If bleeding occurs minutes after delivery of placenta, main reasons are uterine atony or retained products of conception • Persistent bleeding and blood do not coagulate, consider coagulation disorder causing PPH

  11. Clinical presentation • Vaginal hematoma • Shock: dizziness, paleness, weak pulse, low blood pressure etc

  12. Diagnosis • Estimation of blood loss • Ascertain cause of post partum hemorrhage

  13. Estimation of blood loss • Visual observation: only 50%-70% of blood loss • Container: kidney dish, measuring cup • Surface area: blood stained 10cmx10cm = 10ml • Weighing: 1.05g = 1ml • Hct<=30%, Hb50-70g/L, blood loss >1000ml • Hourly urine output <25ml, blood loss >2500ml • Shock index = pulse rate/systolic pressure

  14. Shock index (SI) • SI <=0.5, normal blood volume • SI = 0.5-1, blood loss <20%, 500-750ml • SI = 1, blood loss 20-30%, 1000-1500ml • SI = 1.5, blood loss 30-50%, 1500-2500ml • SI = 2, blood loss 50-70%, 2500-3500ml

  15. Ascertain cause • Uterine atony • Fundus goes up • Uterine consistency soft, water bag like • After uterine massage or using oxytocin, uterus harden, per vaginal bleeding lessen • Categorize into primary and secondary, with direct and indirect causes

  16. Ascertain cause • Placental factors: • Placenta not delivered within 10 minutes of delivery of baby, with massive per vaginal bleed, consider placental factors • Residual placenta is a common cause of post partum hemorrhage • Must examine the placenta and membrane carefully

  17. Ascertain cause • Birth canal injury • Cervical tear • Vaginal tear • Vulval tear

  18. Degree of vulval tear • Degree I: vulval skin and vaginal opening mucosa tear, not reaching muscular layer • Degree II: tear into perineal body muscular layer, involving posterior vaginal wall mucosa, may extend up on both sides, making it hard to recognise original anatomy • Degree III: external anal sphincter tear, may involve vaginal rectal septum and anterior rectal wall

  19. Degree of vulval tear

  20. Ascertain cause • Coagulation disorder: • Patients with blood disorder or DIC caused by delivery etc • Sustained per vaginal bleeding, non-clotting, difficulty in hemostasis • May have bleeding at any parts of the body • Diagnose based on history, bleeding characteristics, platelet count, prothrombin time, fibrinogen etc tests

  21. Management • Principal of management for post partum hemorrhage is: • Rapid hemostasis according to the cause • Replenish volume, correct shock • Prevent infection

  22. Management of uterine atony • Remove cause • Uterine massage: Abdominal fundus massage Abdominal-vaginal bimanual uterine massage • Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins • Uterine packing • Pelvis vessel ligation • B-Lynch suture • Arterial embolism • Hysterectomy

  23. Uterine massage

  24. Management of uterine atony • Remove cause • Uterine massage: Abdominal fundus massage Abdominal-vaginal bimanual uterine massage • Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins • Uterine packing • Pelvis vessel ligation • B-Lynch suture • Arterial embolism • Hysterectomy

  25. Management of uterine atony • Remove cause • Uterine massage: Abdominal fundus massage Abdominal-vaginal bimanual uterine massage • Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins • Uterine packing • Pelvis vessel ligation • B-Lynch suture • Arterial embolism • Hysterectomy

  26. Uterine packing

  27. Management of uterine atony • Remove cause • Uterine massage: Abdominal fundus massage Abdominal-vaginal bimanual uterine massage • Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins • Uterine packing • Pelvis vessel ligation • B-Lynch suture • Arterial embolism • Hysterectomy

  28. Pelvis vessel ligation

  29. Management of uterine atony • Remove cause • Uterine massage: Abdominal fundus massage Abdominal-vaginal bimanual uterine massage • Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins • Uterine packing • Pelvis vessel ligation • B-Lynch suture • Arterial embolism • Hysterectomy

  30. B-Lynch suture

  31. Management of uterine atony • Remove cause • Uterine massage: Abdominal fundus massage Abdominal-vaginal bimanual uterine massage • Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins • Uterine packing • Pelvis vessel ligation • B-Lynch suture • Arterial embolism • Hysterectomy

  32. Arterial embolism

  33. Management of uterine atony • Remove cause • Uterine massage: Abdominal fundus massage Abdominal-vaginal bimanual uterine massage • Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins • Uterine packing • Pelvis vessel ligation • B-Lynch suture • Arterial embolism • Hysterectomy

  34. Management of placental factors • Retained placenta – remove separated placenta quickly • Residual placenta or membrane – curettage • Placental adhesion – manual removal of placenta • Placental implantation – never separate forcefully, usually hysterectomy

  35. Management of laceration • Thorough hemostasis • Stitch according to anatomical layering • First stitch must be 0.5cm above top end • When stitching do not leave dead space • Avoid stitching through rectal mucosa • Manage cervical tear • Manage birth canal hematoma

  36. Manage cervical tear

  37. Management of coagulation disorder • First exclude bleeding caused by uterine atony, placental factors and birth canal injury • Actively transfuse fresh whole blood, platelets, fibrinogen or prothrombin complex, clotting factors etc • If DIC set in, manage DIC

  38. Prevention • Comprehensive antenatal care, screen for high risk factors, intervene accordingly • Appropriate labour management • Aggressive post partum monitoring: 2 hours post partum is the peak of post partum hemorrhage, patient must be monitored in labour room for 2 hours

  39. Rupture of uterus

  40. Definition • The body uterine or lower uterine segment happens to rupture during late pregnancy or labor • Rupture of the pregnant uterus is a obstetric catastrophe and major cause of maternal death

  41. Etiology • Descending of presenting part obstruction: narrow pelvis, cephalo-pelvic disproportion, soft tissue obstruction, fetal malposition, fetal abnormality • Inappropriate use of oxytocin、prostaglandin etc • Uterine scar: fibroidectomy, caesarean section • Surgical trauma

  42. Clinical presentation • Happens at late pregnancy or during labour, more during labour • Complete rupture and incomplete rupture • Spontaneous rupture or traumatic rupture • Body rupture or lower segment rupture • It is usually a progressive process, separated into 2 stages, impending rupture and uterine rupture

  43. Threatened uterine rupture • Obstructed descend of fetal presenting part, prolong labor • Appearance of pathologic retraction ring • Mother shows distress, rapid breathing and heart rate, unbearable pain • Urination difficulty, hematuria • Fetal heart rate change or unclear

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