Company LOGO OBSTETRICAL HEMORRHAGE 763 Placental abruption 14119

Company LOGO �� OBSTETRICAL HEMORRHAGE ��

�� 763 �� ( �� ( Placental abruption 141(19) Laceration/uterine rupture 125(16) Uterine atony 115(15) Coagulopathies 108(14) Company Logo

�� ( �� ( Placenta previa 50(7) Uterine bleeding 47(6) Placental adherens 44(6) Retained placenta 32(4) (Chichakli & Colleagues, 1999 as cited Cunningham et al, 2005. ) Company Logo

�� Antepartum Hemorrhage Company Logo

Definition �� 20 �� (Cunningham, Leveno, Bloom, Hauth, Gilstrap & Wenstrom, 2005( Company Logo

�� 1 �� 1. 1 �� ( Placenta previa( 1. 2 �� (Abruptio placentae( 1. 3 �� ( Rupture of the uterus( 1. 4 �� vasa previa 1. 5 �� marginal sinus Company Logo

�� (Abruptio placentae) �� Company Logo

��. 1 Revealed hemorrhage �� External hemorrhage �� 80% 2 Concealed hemorrhage �� Internal hemorrhage �� 20% 3. Combined hemorrhage �� Mixed �� 1 �� 2 �� )Cunningham et al. , 2005) Company Logo

�� 1. Hypovolumic shock 2. Hypofibrinogenemia 3. DIC 4. Postpartum Hemorrhage 5. Renal failure 6. Sheehan’s syndrome Company Logo

�� 1. Preterm birth 2. Fetal distress �� Asphyxia �� Uteroplacenta insufficiency 3. �� Asphyxia Company Logo

�� Placenta previa Company Logo

Definition �� (Lower uterine segment) �� (Genovese, 2000: 849; Pillitteri, 1999 : 382( Company Logo

�� 1. Low lying placenta �� internal os �� 2 ��. 2. Marginal placenta previa �� os �� 2 ��. 3. Partial placenta previa �� internal os �� 4. Complete placenta previa Company Logo

Company Logo

�� 1. �� 2. Ultrasound sensitivity �� 95 3. Double setup Company Logo

�� ( uterine rupture ) Perinatal and mothernal motarity Company Logo

v. Definition v uterine wall tear after fetal viability Company Logo

v v v Type - Complete rupture - Incomplete rupture v rupture - dehiscence Company Logo

v Incident 1 : 100 – 1: 11, 000 Company Logo

v v v v Causes - previous scar - difficult obstetrics procedure - severe abdominal trauma - grand multiparity - oxytocic drugs - obstructed labor - placenta percreta or increta Company Logo

v v v Diagnosis 1. sign and symptom 1. 1 threatened uterine rupture - tetanic contraction - suprapubic tenderness - Bandl’s ring Company Logo

v 1. 2 uterine rupture v - decrease pain v - tear sensation v - with shock? v - FHB loss v - fetal part v - PV – float , become higher station v - hematuria Company Logo

v v v DDx - Abruptio placenta -Placenta previa -Ectopic pregnancy -tetanic uterine contraction -colpotthexis Company Logo

Rx - keep in mild - get rid of threatened uterine rupture - Rx shock - Exploratory laparotomy - hypogastric arteries ligation - blood tranfusion - antibiotic Company Logo

v Complication v - APH & PPH v - Infection v - increase perinatal- mothernal mortality v - fetal asphyxia v Company Logo

Vasa Previa rupture v Definition v umbilical or placental vv. insert at fetal membrane pass internal cervical os ( velamentous insertion ) Company Logo

v Incident 1: 2000 -3000 Company Logo

v Diagnosis v- Pre- rom: PV – synchronous pulse v : amnioscopy v : u /s v - Post- rom : fetal hemoglobin (alkali denaturation test ) v : placental and membrane exam Company Logo

v. DDx v : prolapse of the umbilical cord v : placenta previa Company Logo

v v Rx : keep in mind v : c/s in pre-rom period Dx v : rom case – rapid termination of labor Company Logo

v v Prognosis – fetal dead 60 -70% Company Logo

�� Postpartum hemorrhage Company Logo

�� , �� (Sheir, Sarid, Levy, Seidman & Hallak, 2005 ) �� 1. Retained placenta �� 2. Failed to progress during 2 nd stage of labor 3. Placenta accreta 4. Laceration Company Logo

�� 5. Instrumental delivery 6. Large size newborn 7. Hypertensive disorder 8. Induction of labor 9. Augmentation of labor with oxytocin Company Logo

�� , �� (Stone, Paterson & Saunder, 1993) ��. 1 Prolonged labor. 2 Augmentation labor. 3 History of postpartum hemorrhage. 4 Episiotomy, Especially mediolateral. 5 Preeclamsia Company Logo

�� (. 6 Over distension uterus. 7 Operative delivery. 8 Asia or Hispanic ethnicity. 9 Chorioamniotis Company Logo

�� Primary • Uterine atony • Retained placentaespecially placenta accreta • Defects in coagulation • Uterine inversion Secondary • Subinvolution of placental site • Retained products of conception • Infection • Inherited coagulation defects Company Logo

A Stepwise Approach to the Management of Postpartum Hemorrhage 1 2 3 �� Company Logo

A Stepwise Approach to the Management of Postpartum Hemorrhage 1 �� Initial Assessment and Treatment Resuscitation • large bore IV (s) • oxygen by mask • monitor BP, PR, RR, I/O • retained Foley catheter • +/- oxygen saturation Assess Etiology • Tone • Tissue • Trauma • Thrombin Laboratory Tests • CBC • coagulation screen • M/G Company Logo

A Stepwise Approach to the Management of Postpartum Hemorrhage “Tone” • massage • compress • drugs “Tissue” • manual removal • curettage “Trauma” 2 • correct inversion • repair laceration • identify rupture �� “Thrombin” • reverse • anticoagulation • replace factors Company Logo

A Stepwise Approach to the Management of Postpartum Hemorrhage 3 3. 1 �� 3. �� ) �� 3. 2 �� ( �� 1. Get Help • anesthesiologist • lab and ICU 2. �� • �� • �� BP�� 4 �� • �� , �� 4. 1 Abdominal packing / umbrella packing 4. 2 Arterial embolization / Recombinant Factor VIIa Company Logo

DRUG THERAPY FOR PPH v Oxytocin IV 10 -40 unit �� Lactated Ringer 1 L �� IM 10 unit v. Methylergonovine IM �� IV �� 0. 2 ��. �� 2 -4 �� v - 15 methyl PGF 2 a 0. 25 ��. IM �� 1590 �� 8 �� Company Logo

Bimanual compression Company Logo

Uterine packing Company Logo

B lynch sutures Company Logo

Uterine artery ligation Company Logo

Right hypogastric artery ligation Company Logo

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