Postpartum Heamorrhage

POSTPARTUM HEAMORRHAGE PRESENTATION OUTLINE Introduction Classification Definition Incidence Causes Risk factors Pathogenesis of blood loss Complications Secondary postpartum haemorrhage

Introduction • Major cause of maternal haemorrhage • Principal unfavorable factors High frequency of anaemia Absence and lack of access to adequate obstetrics care Strong social pressures-cultural & religious beliefs Poor transportation and gross infrastructural inadequacies Delay effective treatment –blood transfusion

• 2 types- Primary and secondary post partum haemorrage

DEFINITION • Primary Postpartum haemorrhage is defined as blood loss from the genital tract of 500mls or any amount likely to compromise the patient’s heamodynamic status in the first 24 hours after delivery of the baby.

INCIDENCE • 5-8% Generally • • • •

Developing countries?? In U.P.T.H 2003 annual report-3.9% Primary-0.2% Secondary-1.3%

CAUSES 

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Uterine Atony -50%

Grand multiparity, Uterine overdistension, Prolonged labour, Uterine leimyomas, oxytocin use in labour, Previous hx-Intrinsic myometrial dysfunction Operative delivery Excessive manipulation of the uterus, General anaesthesia(halogenated cpds)

Obstetric Lacerations

Episiotomies, Genital tract lacerations, Haematomas Uterine rupture

-20%

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Retained placental Tissue - 5-10% Occurs in placental accreta, manual removal of placenta, mismanaged 3rd stage of labour, succenturiate placenta

•

Coagulation Defects Acquired causes include: DIC 2* retained dead fetus, Amniotic fluid embolism,severe preeclampsia and eclampsia,dilutional coagulopathy,sepsis. others include von willebrands dz,autoimmune thrombocytopenia & leukaemia

Risk factors • Past obstetric hx of coagulopathy, haemorhage or blood transfusion • Anaemia during labour • Grandmultiparity • Multiple gestation &Macrosomia • Oxytocin induction & Augumentaion • Severe preeclampsia &Eclampsia • Vaginal delivery after C/S • General anaesthesia • Precipitate labour

Pathogenesis of blood loss And its Consequences • Increase in blood volume by up to 1.5 liters • Increase in coagulation factors- fibrinogen • Suppression of the fibrinolytic system • Constriction of interlacing myometrial fibers

 Haemorrhage triggers off circulatory, neural and endocrine mechanism.

• Circulatory adaptations and its clinical relevance – Acute loss of 10% circulatory volume-Tachycardia

- 25% loss - vasoconstrction,weak rapid and thready peripheral pulse, & cold skin but normal blood pressure. >25%-Hypotension 30-35% loss - Shock: SBP 70-80mmHg, tarchycardia worsens, sweating and oligouria Further loss leads to ppt fall in CO -fainting and restlessness.

complications • Shock - Acute renal failure - Ischaemic necrosis of the anterior pituitary(Sheehan Syndrome) - DIC -ARDS - Anaemia

• 2. 3. 4. 5.

Complications of treatment Blood transfusion related mortality and morbidity Genital tract infections Subfertility-Asherman’s syndrome Sterility

Secondary post partum haemorrhage • Secondary postpartum haemorrhage is any fresh bleeding from the genital tract after the first 24 hours of delivery up to 6weeks post delivery.

• 2. 3.   

Causes Retained placental fragments Uterine subinvolution Faulty placental implantation Implantation in the lower segment Persistent infection on placental bed