POSTPARTUM HEMORRHAGE Nahida Chakhtoura M D Postpartum hemorrhage

POST-PARTUM HEMORRHAGE Nahida Chakhtoura, M. D.

� Postpartum hemorrhage (PPH): leading cause of maternal mortality worldwide � Prevalence rate: 6% � Africa has highest prevalence rate: 10. 5% � In Africa and Asia PPH accounts for more than 30% of all maternal deaths � Maternal death rates attributable to PPH vary considerably between developed and developing countries, suggesting that deaths from PPH are preventable

� Uterine Atony �Placenta: retained placenta, placental tissue or membrane, incomplete separation �Full bladder �Antepartum hemorrhage: placenta previa or placental abruption �Overstretched uterus: high parity, multiple pregnancy, polyhydramnios, macrosomia, fibroids

� Uterine Atony �Prolonged active phase �Medical factors: anemia, coagulopathy �Others: severe pre-eclampsia and eclampsia, precipitate labor, induction/ augmentation, IUFD, h/o PPH, c/s, gen. anesthesia, chorioamnionitis or endometritis

� Genital Trauma �Perineum �Vaginal �Cervix �Uterus walls � Risk Factors �Mistimed episiotomy �Induced labor �Precipitate labor �C/S �Forceps Delivery �Prolonged labor �Previous uterine surgery �Anemia �Delay in Tx

� Priorities �Call for Help! �Rapid assessment of patient’s condition �Identify source of bleeding �Stop the bleeding �Stabilize/resuscitate �Prevent further bleeding

� Atonic PPH �Massage the uterus to promote contraction and expel clots �Oxytocin 10 IU IM �Assess EBL �Type and cross, CBC, coagulation profile �Start IVF: if shock 1 L NS or LR in 15 min up to 3 L �Foley catheter �Check placenta and membranes. If placenta cannot be delivered, manually extract �Examine cervix, vagina, and perineum

� If bleeding persists… �Oxytocin 20 units in 1 L of IVF @ 60 drops per min �Add other IV access �Continue uterine massage � Assess clotting status and transfuse if necessary �Consider transferring to higher level �Uterine or utero-ovarian ligation; hypogastric artery ligation �Uterine balloon �B-lynch suture �Hysterectomy �Document properly

� Traumatic PPH �Lithotomy position �Identify site of bleeding and repair

� Close monitoring over next 24 -48 hrs �Uterine tone �VS; Ins and Outs �Blood loss �Serial CBC

� Developing �Active Countries management of labor �Uterine massage �Draining the bladder � 10 U oxytocin IM �Misoprostol �Uterine packing �Hysterectomy

� Fausto Astudillo-Davalos, M. D. � Mabel Marotta � Danielle Kramer � Nahida Chakhtoura, M. D.