34- Post Partum Haemorrjhage

POST PARTUM HAEMORRHAGE

DEFINITION PPH is defined as a blood loss in excess of 500 c.c. after vaginal delivery, and more than 1000 c.c. following C.S

TYPES OF PPH 

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Primary PPH: Immediate bleeding, or within first 24 hours, after delivery. It is the most important variety as it is associated with acute blood loss that may be life threatening. Secondary PPH: Bleeding which is delayed > 24 hours, and till the end of puerperium. It is uncommon, the bleeding tends to be mild and chronic, and may even present as a gynaecological problem.

PRIMARY POST PARTUM HAEMORRHAGE INCIDENCE: The incidence of PPH varies from 0.5 - 4 % depending on the proper management of labour.  AETIOLOGY: 

1. Placental site haemorrhage (atonic PPH) 2. Traumatic laceration of the genital tract (traumatic PPH). 3. Disseminated Intravascular Coagulation (DIC)

PLACENTAL SITE HAEMORRHAGE (Atonic PPH) 1. 2. 3. 4. 5. 6. 7.

Over distension of the uterus (e.g. over sized baby, polyhydramnios and twins). Prolonged labour (maternal exhaustion and dehydration) Antepartum haemorrhage (placenta praevia and accidental haemorrhage). Grand multiparity (lax and weak uterine muscles). Precipitate labour (rapid delivery gives no time for efficient uterine retraction). Nervous shock & full bladder lead to reflex atony of the uterus. Retained separated placenta (partial or complete). In these cases the myometrium cannot contract and retract sufficiently due to presence of retained placental tissue

LACERATIONS OF THE GENITAL TRACT (Traumatic PPH)

1. 2.

Perineal, vaginal, or cervical lacerations Rupture of the uterus

DISSEMINATED INTRAVASCULAR COAGULOPATHY (DIC) 1. 2. 3.

Abruptio placenta Retained IUFD Amniotic fluid embolism (AFE).

CLINICAL PICTURE 

History: Ask for the presence of a risk factor – Atonic PPH: over distended uterus, multifetal pregnancy, polyhydramnios, etc. – Traumatic PPH: traumatic or instrumental delivery.

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General Examination: Check for signs of hypovolaemic shock Pallor, rapid weak pulse, low B.P., subnormal temperature, and oliguria.

CLINICAL PICTURE 

Abdominal Examination: To check the size and consistency of the uterus.

– Atonic PPH is usually revealed, but may be partially or entirely concealed. – In atonic PPH, palpation of the uterus reveals a soft consistency. The fundal level may be higher than expected if bleeding is partially concealed. – In traumatic PPH, the uterus is firm, and vaginal bleeding continues in spite of a well contracted uterus. The cause of traumatic PPH should be confirmed by PV examination.

CLINICAL PICTURE  Vaginal

Examination: Preferably done under anaesthesia

– To detcetd bleeding from a perineal, vaginal, or cervical laceration. – To explore digitally the uterine cavity for retained parts, and for exclusion of uterine rupture.

COMPLICATIONS OF PPH 1. 2. 3. 4.

5.

Maternal mortality (PPH represents about 34% of MMR in egypt). Haemorrhagic shock (due to exessive rapid blood loss, and possible DIC) Acute renal failure (2ry to hypovolaemic shock). Puerperal sepsis (2ry to low immunity and possible manipulations and retained products) Sheehan's syndrome (hypopituitrism leading to 2ry amenorrhea due to hypovolaemic shock)

MANAGEMENT OF PPH 

Prevention: 1. Proper antenatal care (ANC):     

Previous history of PPH Grand multiparity (uterine muscle atony) Hydramnios, twins, oversized fetus (over distension of uterine muscle). Placenta praevia and abruptio placenta (causes of APH). Correction of anaemia during pregnnacy

MANAGEMENT OF PPH 

Prevention: 1. Proper management of the 1st and 2nd stages of labour:  

Avoid difficult and prolonged labour. Avoid difficult and unnecessary instrumental delivery, especially if conditions are not suitable for safe applications

MANAGEMENT OF PPH 

Prevention: 1. Proper management of the 3rd stage of labour:    

Active management of the 3rd stage; reduces the occurrence of PPH by nearly 50%. Wait for signs of separation before delivery of the placenta. Attempts to express the placenta before its separation are dangerous. Routine use of ecbolics after delivery, especially in high risk cases. Intermittent uterine massage every 15 minutes, and continuous observation for the pulse, temperature, B.P., and vaginal bleeding, throughout the first two hours after delivery

MANAGEMENT OF PPH 

Treatment: – –

Antishock measures and blood transfusion, whenever necessary. Gentle uterine massage: done by placing the thumb abdominally on the uterine fundus and the four fingers of the same hand behind to stimulate the uterus to contract

MANAGEMENT OF PPH Treatment:

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Ecbolics: must be given with uterine massage. These include: 

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Oxytocin given as an I.V. drip (syntocinon); to increase the frequency and strength of uterine contraction. (It should never be given as direct I.V. bolus, as it may cause serious hypotension and arrythmias. Methyl ergometrin (methergin); 0.2–0.5 mg, I.M. or I.V., causes tetanic uterine contractions. Mesoprostol (synthetic prostaglandin); given by rectal route, in a dose of 800 – 1000 ug

MANAGEMENT OF PPH Treatment:

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If bleeding persists the following steps are activated:     

If the placenta was retained; it should be delivered immediately by controlled cord traction or manual removal. If the placenta was already delivered, then perform a vaginal exploration under anaesthesia to reveal: Undiagnosed retained placenta fragments which should be removed, or Vaginal or cervical lacerations that should be sutured and repaired. Bimanual compression of the uterus may be life saving until a laparotomy is performed

Bimanual Compression

MANAGEMENT OF PPH 

Treatment: –

If bleeding persists a Laparotomy is mandatory:  

Subtotal hysterectomy: is the standard procedure if bleeding is uncontrollable. Internal iliac artery ligation: may be attempted if the patient's general condition allows in an attempt to preserve the uterus, if the patient is young and desirous of further fertility. If this procedure fails to control the bleeding, hysterectomy is performed without hesitation

SECONDARY POST PARTUM HAEMORRHAGE

Definition: Bleeding which is delayed > 24 hours, and till the end of puerperium

Causes 

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Retained placental fragments; diagnosed by U.S., and treated by ecbolics and/or D&C. Separation of an infected slough from a laceration in the lower genital tract; give antibiotics. Sloughing of an infected submucous fibroid polyp. Undiagnosed chronic uterine inversion. Rarely choriocarcinoma.

Treatment Treatment is that of the cause.

KEY POINTS IN PPH  

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PPH is an important mostly preventable cause of maternal mortality Uterine atony is the commonest cause for PPH .Genital tract lacerations or DIC are other possible causes. Abdominal palpation of the uterus can differentiate atonic from traumatic PPH. Proper management of the third stage of labour is very important in prevention of PPH. First aid treatment of 1ry PPH is massage and ecbolics, with exclusion of retained placental fragments. If bleeding is severe and uncontrollable, subtotal hysterectomy may be life saving. PPH cannot always be prevented for it occasionally occurs when conditions are in all