Post Partum Haemorrhage PPH DONE BY MARAH ALHIARY

Post Partum Haemorrhage (PPH) DONE BY : MARAH AL-HIARY

Objectives : 1) definition 2) causes 3) types 4) management 5) complication

Definition: Significant blood loss after getting birth >500 ml after vaginal delivery. >1000 ml after cesarean section. ( if you can determine the amount of bleeding precisely ). Or - Decrease 10% or more in hematocrit baseline. Or - Need blood transfusion. Or - Change of mother’s vitals (hypotension, tachycardia) , oliguria , lightheadedness , dizziness , syncope. These changes will only occur after the patient has lost a significant amount of blood.

*-*PPH ACCORDING TO THE TIME OF ONSET: *Primary Within 24 hours following delivery. *Secondary After the first 24 hours following delivery up to 12 weeks.

Causes of PPH : * Causes : 4 T : 1) Tone (Uterine atony) 2) Tissue (retained tissues) 3) Trauma 4) Thrombin (Abnormal coagulation)

PPH IS AN IMPORTANT ISSUE - Affect 2% of all women get birth. - One quarter of maternal death globally. - Leading cause of maternal death in low income countries or developing countries. - Not affect mortality only but also interfere with maternal morbidity , while blood loss may cause shock and organ dysfunction.

1)TONE(UTERINE ATONY): 1) uterine over distention, so anything that makes the uterus stretch out too much: - multiple pregnancy - more than 4 previous deliveries - polyhydramnios - baby >4 kg - maternal obesity - previous PPH - induction of labor 2) uterine muscles fatigue during the delivery process - prolonged labor > 12 h - prolonged 3 rd stage. 3) prior C-sections or uterine surgery. 4) full bladder (develop in females that are unable to pass urine following anesthesia). 5) some obstetric medications like anesthetics - especially halothane, as well as magnesium sulfate, nifedipine, and terbutaline can all increase the risk of uterine atony.

2)TRAUMA: any kind of injuries to the birth canal: cervical or vaginal lacerations or hematomas , perineal tears or uterine rupture. 1) large fetus. 2) difficult delivery. 3) and iatrogenic causes like an episiotomy or operative vaginal delivery.

3)TISSUE: - Retained products of conception (especially placenta). - prior uterine surgery, especially when the placenta implants itself near a scar from the previous surgery.

4)THROMBIN (COAGULATION DISORDER): * Primary : von willebrand disease. * Secondary to obs. condition : preeclampsia , placental abruption , amniotic fluid embolism these can lead to DIC.

PREVENTION: Efficient prevention >> efficient outcomes >>lower mortality and morbidity Achieved by : 1 - proper antenatal care & Antenatally identify patient at risk of PPH. 2 - proper management for systemic condition. 3 - Avoid unnecessary instrumental delivery. 4 - active management of third stage of labor. ***All pregnant women who have had a previous CS should have placental site determined (Abnormal placentation)

ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR: - cornerstone for the prevention of PPH. - package of interventions performed during the third stage of labor. *- Include: 1) The administration of a prophylactic uterotonic after the delivery of a baby, 2) Early cord clamping and cutting, 3) The controlled traction of the umbilical cord, 4) Uterine massage

UTEROTONICS AGENTS: 1 - syntocinon (synthetic oxytocin ) 2 - ergometrine / ergonovine or methylergonovine (ergot alkaloids ) 3 - combination of both. 4 - misoprostol (prostaglandin E 1 analogues ) 5 - carbetocin (longer acting relative of oxytocin) * In females with no risk factors or at low risk for uterine atony, any single one of these agents is recommended. * In females at high risk for uterine atony, combinations like oxytocin and misoprostol or oxytocin and methylergonovine are recommended.

PPH LIFE-THREATENING LIFE SAVING SUPPORTIVE MANAGEMENT DEFINITIVE MANAGEMENT

SUPPORTIVE MANAGEMENT: 1 - call for help 2 - A B C A stands for airway, so you’ll want to protect the airway, especially when there’s loss of consciousness. B stands for breathing, so you’ll want to administer Oxygen through a non-rebreather mask. C stands for circulation - meaning measuring vital signs and establishing the degree of hypovolemia 3 - inserting two large caliber peripheral IV catheters - of at least 14 gauge or even larger. And starting fluid resuscitation immediately, with 500 milliliters of normal saline or lactated Ringer’s solution given over 30 minutes then adjusted accordingly 4 - blood sample for CBC , blood group , cross match and clotting profile 5 - apply Foley's catheter to empty bladder 6 - empty uterus and vagina from clots 7 - Cross match 4 -6 units of blood

DEFINITIVE MANAGEMENT (UNDERLYING CAUSE ) *** Uterine atony: * Diagnosis : palpation soft , boggy and enlarged. Vaginal examination bleeding not from vaginal or cervical laceration. * management : 1 -uterine massage & uterotonic medication

Cont of Uterine atony management : 2 - bimanual uterine compression 3 - if (1+2) fall to stop bleeding + patient is hemodynamically stable intrauterine balloon tamponade can be done (Bakri Postpartum balloon ) 4 - Another technique is uterine artery embolization ( not sever bleeding + stable patient ) 5 - bleeding not stop , surgical ligation of the uterine arteries. 6 - B- lynch suture by laparotomy we make suture to compress the uterus. 7 - hysterectomy ( refractive atony / placental invasion /uterine rupture/vessel lacerations).

Trauma: *** Trauma: *1 - Cervical and vaginal lacerations Diagnosis : speculum examination. Managment : surgically suturing the laceration under local anesthesia. *2 - Hematomas : symptoms include labial, rectal, or pelvic pressure or pain. For small hematomas in hemodynamically stable females, IV fluids are given and the hematoma typically resorbs on its own. For rapidly expanding hematomas, or in hemodynamically unstable females, IV fluids and blood transfusions, along with incision and drainage of the hematoma may be required. *3 - Perineal tears Diagnosis : can be seen on inspection Managment : perineal tears may be sutured under local or general anesthesia. (depending on degree ) *4 -Uterine rupture : Diagnosis : sudden and severe abdominal pain. / ultrasound is needed to see the accumulation of blood. Managment : emergency surgery to repair or remove the uterus.

Tissue: (placenta accreta or related disorders, or when there’s an accessory placental lobe. ) placenta accreta per se, placenta is burrowed deep into the endometrium, but doesn’t reach the myometrium. placenta increta, placenta has invaded the myometrium, but doesn’t go all the way through. placenta percreta, placenta invades all the way through the myometrium, and may extend to neighboring organs.

Tissue: Diagnosis: closely inspecting the placenta after delivery. On palpation, the uterus feels firm, ultrasound will show the retained placental tissue as a hyperechoic mass. * Managment: depends on the depth of invasion: - Small, focal accreta can usually be removed with curettage - Burrowed more deeply into a large portion of the uterine wall hysterectomy ***(manual removal of placenta accreta should not be attempted)

Thrombin: * Can progress to DIC normal hemostasis can’t occur. * Diagnosis: -lab abnormalities like a prolonged PT/ PTT/ low platelets/ high INR/ or low levels of deficient clotting factors. ** Fibrinogen may be low, or normal, but keep in mind that a normal fibrinogen level, between 150 and 400 milligrams per deciliter, is low for a postpartum female, since fibrinogen levels usually increase during pregnancy. * Managment: blood transfusions - red blood cells, platelets, fresh frozen plasma.

uterine inversion : uterine inversion can also cause postpartum hemorrhage. With uterine inversion, the uterine fundus descends through the cervix and into the vagina like turning a bag inside out. * Diagnosis: on palpation - empty pelvis, the uterine fundus is missing from the pelvis. * Managment: 1) administering uterine relaxants like magnesium sulfate, halogenated anesthetics, and nifedipine. 2) Then, the uterus can be manually put back in place. 3) If unsuccessful, surgery may be required to put the uterus back in place.

* Complications of PPH: 1) Sheehan’s syndrome ? ? ? 2) Postpartum infection 3) DIC 4) Anemia 5) Transfusion hepatitis 6) Asherman’s syndrome ? ? ?

SECONDARY PPH: Causes of Secondary PPH 1) Endometritis 2) Retained placental tissue 3) Sub-involution of the uterus (failure of the uterus to return to its normal pregnancy size) 4) Ruptured pseudo-aneurysms and arteriovenous malformations (rare)

*** Endometritis: • Combination of ampicillin (clindamycin if penicillin allergic) and metronidazole • In cases of endomyometritis (tender uterus) or overt sepsis, add gentamicin *** Retained tissues: O Surgical measures (Evacuation of retained tissues) O If excessive or continuing bleeding Carries a high risk for uterine perforation.

Thank you