Post Partum Hemorrhage PPH Definition Blood loss in

Post Partum Hemorrhage PPH

Definition: Blood loss in excess of 500 ml with vaginal delivery or in excess of 1000 ml following delivery by caesarian section.

Types: 1 - Early PPH: more common. occurs immediately or slowly over the 1 st 24 hours. 2 - Late PPH: occurs after 24 hours but within 6 weeks post delivery.

Causes: 1 - Uterine atony. 2 - Genital tract trauma. 3 - Retained placental tissue. 4 - Low placental implantation. 5 - Coagulation disorders. 6 - Uterine inversion.

Uterine atony: Is the cause of 75 to 80 % of PPH.

Factors predisposing to uterine atony: 1 - Over distention of the uterus. 2 - Multiple gestation. 3 - Polyhydraminos. 4 - Fetal macrosomia. 5 - Prolonged labor. 6 - Grand multiparity. 7 - Oxytocic augmented labor. 8 - Preciptious labor. 9 - Mg. So 4 ttt of pre eclampsia. 10 - coriamnionitis. 11 - Halagenated Anaesthetics. 12 - Uterine Leiomyoma.

Genital tract trauma: Second most common cause of PPH. 1 - laceration of the cervix and vagina. 2 - laceration over the perineal body, periurethral area, over the ischeal spines. 3 - during low transverse c-section.

Retained placental tissue: 1 - Incomplete placental seperation. 2 - Partial placental accreta. n In ½ the patients with delayed PPH, placental reminants are present when uterine curettage is performed.

Low placental implantation: This leads to PPH because the lower uterine segment has less musculature.

Coagulation disorders: 1 - TTP. 2 - Amniotic fluid embolism. 3 - Abruptio placentae. 4 - ITP. 5 - Von Willebrand’s disease.

Uterine inversion: The inside out turning of the uterus during the 3 rd stage of labor due to improper management.

Obstetric History

Obstetric History Personal data: name, age. n Gravidity + parity + abortion + ectopic pregnancy. n Presenting complain. n History of current pregnancy. - was the pregnancy planned? - previous booked visit (how many). - regularity of menstrual cycle. - LMP EDD. - GA (40 - “present date – EDD”). n

n n n n n Events of pregnancy in 1 st, 2 nd and 3 rd trimester: A) symptoms of pregnancy. B) complication of pregnancy. C) use of drugs and supplement. D) further tests carried out. Past obstetric history. Past gynecological history: - menstrual history. - contraceptive sexual history. Gynecological surgical history. Past medical history. Surgical history. Drug history allergies. Family history. Social history.

Obstetric examination n General examination. n Ex. of the chest. n Ex. of the breast. n Ex. of the thyroid. n Abdominal Ex. n Ex. of the lower limb. n Special points in the examination: fundal height.

n Pelvic examination: - inspection. - collection of cytologic specimen. - palpation. - rectal and recto-vaginal examination.

Examination in active bleeding n Vital signs. n Palpation of the fundus. n Inspection of vagina and cervix. n Pelvic examination. n Manual exploration of uterine cavity.

Initial management of PPH

check patient status. n early recognition of PPH. n monitor vital signs and oxygen. n establish IV access, place urinary catheter. n Baseline lab value. n Alert anesthesia and blood bank. n Central hemodynamic monitoring. n Correct anemia and coagulation disorders and blood products. n

Determine underlying cause of PPH n Examine the uterus, placenta and genital tract. n Etiology will determine further management.

Uterine Atony By manual massage and/or compression, exclude retained placental fragments, uterine rupture. Medical Uterotonic therapy: 1 - rapid oxytocin infusion IV, IM or intramyometially. 2 - methylergonovine. 3 - 15 -methyl-prostaglandin F 2 alpha IM or IMM. 4 - Dinoprostone PEG 2 rectally. n

n If no response to above management consider: 1 - uterine packing. 2 - angiography and embolization. 3 - explorative laparotomy with surgical options: - vessel ligation. - hysterectomy.

Lower genital tract laceration n Cervical, vaginal or perineal tears. n Determine source of bleeding. n Establish surgical hemostasis. n Evacuate hematoma. If not responsive to above consider surgical options: - uterine packing - artery ligation. - hysterictomy.

Retained placental fragments n Manual exploration and removal. n Curettage.

Abnormal placentation n Placenta accreta. n Conservative surgery curettage, local repair. n Further surgical management: - laparotomy. - artery ligation. - hysterictomy. n Consider angiography and embolization.

Uterine inversion n Immediate intravascular volume expansion with IV crystalloids. n Surgical procedure may be required. Uterine rupture n Laparotomy. n Repair of scar or hysterectomy.

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