g. postpartum hemorrhage

8/8/2019 g. Postpartum Hemorrhage

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POSTPARTUM

HEMORRHAGE



DEFINITION

• Traditionally, loss of 500 mL of blood

or more after completion of the thirdstage of labor

• Hemorrhage after the first 24 hoursis designated late postpartumhemorrhage



HEMOSTASIS AT THEPLACENTAL SITE

• Near term, it is estimated that approximately 600mL/min of blood flows through the intervillousspace. With separation of the placenta, there isalso separation of the many uterine arteries and

veins that carry blood to and from the placenta.Usually, hemostasis in the absence of surgicalligation depends on intrinsic vasospasm andformation of blood clot locally.



HEMOSTASIS AT THEPLACENTAL SITE

• At the placental implantation site, mostimportant for achieving hemostasis arecontraction and retraction of the myometriumto compress the formidable number of relatively large vessels and obliterate theirlumens.

• Adherent pieces of placenta or large blood clotsprevent effective contraction and retraction of the myometrium and thereby impairhemostasis at the implantation site.



SHEEHAN SYNDROME

• classical case is characterized by failure of lactation,amenorrhea, breast atrophy, loss of pubic and axillaryhair, hypothyroidism, and adrenal cortical insufficiency

• do not develop in most women who hemorrhageseverely

• varying degrees of anterior pituitary necrosis withimpaired secretion of one or more trophic hormonesaccount for the endocrine abnormalities. In all of these,the appearance of the pituitary was abnormal and thesella turcica was either totally or partially empty.



UTERINE ATONY

• the overdistended uterus is prone to be hypotonic afterdelivery

• woman with a large fetus, multiple fetuses, or hydramniosis prone to hemorrhage from uterine atony.

• woman of high parity may be at increased risk for uterine

atony.• mismanagement of the third stage of labor involves an

attempt to hasten delivery of the placenta short of manual removal.

• constant kneading and squeezing of the uterus thatalready is contracted likely impedes the physiological

mechanism of placental detachment, causing incompleteplacental separation and increased blood loss.



MANAGEMENT AFTERDELIVERY OF PLACENTA

• The fundus should always be palpated to makecertain that the uterus is well contracted. If it isnot firm, vigorous fundal massage is indicated.

• 20 U of oxytocin in 1000 mL of lactated Ringeror normal saline proves effective whenadministered intravenously at approximately10 mL/min (200 mU of oxytocin per minute)

simultaneously with effective uterine massage.



MANAGEMENT AFTERDELIVERY OF PLACENTA

• Ergot Derivatives, intramuscularmethylergonovine (0.2 mg), may stimulate theuterus to contract sufficiently to controlhemorrhage. May cause dangeroushypertension, especially in women withpreeclampsia.

• Prostaglandins such as the rectally

administered prostaglandin E2 20-mgsuppositories have been used for uterine atony



BLEEDING UNRESPONSIVE TOOXYTOCICS

• Use bimanual uterine compression• Obtain help!• Add a second large-bore intravenous catheter so

that crystalloid with oxytocin may be continued

at the same time blood is given.• Begin blood transfusions.• Explore the uterine cavity manually for retained

placental fragments or lacerations.• Thoroughly inspect the cervix and vagina after

adequate exposure.• Insert a Foley catheter to monitor urine output,

which is a good measure of renal perfusion.



Bimanual compression

HEMORRHAGE FROM



HEMORRHAGE FROMRETAINED PLACENTAL

FRAGMENTS• Placenta Acreta - placental villi isattached to the myometrium

• Placenta Increta - placental villiinvade the myometrium

• Placenta Percreta - placental villipenetrate the myometrium



ETIOLOGY

• Abnormal placental adherence isfound when decidual formation isdefective.

• Placenta previa

• Prior cesarean delivery.

• Undergone curettage.• Gravida 6 or more



CLINICAL COURSE ANDDIAGNOSIS

• Early in pregnancy, the maternal serum alpha-fetoprotein level may be increased

• Antepartum hemorrhage is common, but in the greatmajority of women bleeding before delivery is theconsequence of coexisting placenta previa.

• Myometrial invasion by placental villi at the site of aprevious cesarean scar may lead to uterine rupturebefore labor

• Ultrasound Doppler color flow mapping – (1) a distance less than 1 mm between the uterine serosal

bladder interface and the retroplacental vessels – (2) the presence of large intraplacental lakes



MANAGEMENT

• immediate blood replacement therapy

• prompt hysterectomy

• uterine or internal iliac artery ligation or

angiographic embolization• "conservative" management was manual

removal of as much placenta as possibleand then packing of the uterus

• weekly methotrexate therapy was givenpostpartum



UTERINE INVERSION

• always the consequence of strong tractionon an umbilical cord attached to a placentaimplanted in the fundus

DIAGNOSIS• abdominal palpation of the crater-like

depression and vaginal palpation of thefundal wall in the lower segment and cervix



TREATMENT

• Assistance, including an anesthesiologist, issummoned immediately.

• The freshly inverted uterus with placenta alreadyseparated from it may often be replaced simply by

immediately pushing up on the fundus with the palmof the hand and fingers in the direction of the longaxis of the vagina.

• Preferably two intravenous infusion systems aremade operational, and lactated Ringer solution and

blood are given to treat hypovolemia.



TREATMENT

• Tocolytic drugs such as terbutaline, ritodrine, ormagnesium sulfate have been used successfullyfor uterine relaxation and repositioning

• After removing the placenta, the palm of the hand

is placed on the center of the fundus with thefingers extended to identify the margins of thecervix. Pressure is then applied with the hand soas to push the fundus upward through the cervix.

• Oxytocin is started to contract the uterus while

the operator maintains the fundus in normalrelationship.



GENITAL TRACTLACERATIONS

ETIOLOGY DIAGNOSTIC AID MANAGEMENT

Perineal lacerations Injury to the lower portion of the vagina

Thorough examination Suturing of the externalintegument withoutapproximation of underlyingperineal & vaginal fascia

Vaginal lacerations Isolated laceration involvingthe middle or upper third of

the vagina but unassociatedwith lacerations of theperineum or cervix areobserved less commonly

Thorough inspection of theupper vagina

Extensive repair of thelaceration

Levator ani Overdistention of the birthcanal may result inseparation of muscle fibersif the injury involves thepubococcygeus muscle

Thorough inspection Extensive repair of thelaceration

Injuries to the cervix Difficult forcep rotation or deliveries performedthrough an incompletelydilated cervix

Laparotomy in thepresence of damage of thisseverity, intrauterineexploration

Surgical repair



PUERPERAL HEMATOMAS

• 1 in 300 to 1 in 1000 deliveries• Risk factors

– Nulliparity, episiotomy, and forceps delivery – hematomas may develop following injury to a blood

vessel without laceration of the superficial tissues• Classification of hematomas – Vulvar often involve branches of the pudendal

artery, including the posterior rectal, transverseperineal, or posterior labial artery

– Vulvovaginal – Paravaginal involve the descending branch of theuterine artery

– Retroperitoneal



• In its early stages, the hematoma forms arounded swelling that projects into the upperportion of the vaginal canal and may almostocclude its lumen

• If the bleeding continues, it dissectsretroperitoneally, and thus may form a tumorpalpable above the Poupart ligament, or it maydissect upward, eventually reaching the lowermargin of the diaphragm

• Branches of the uterine artery may be involvedwith these types of hematomas.



VULVAR HEMATOMAS

DIAGNOSIS

• severe perineal pain and usually rapid appearance of atense, fluctuant, and sensitive tumor of varying sizecovered by discolored skin

• Symptoms of pressure, if not pain or inability to void,should prompt a vaginal examination with discovery of a round, fluctuant tumor encroaching on the lumen

• When the hematoma extends upward between thefolds of the broad ligament, it may escape detectionunless a portion of the tumor can be felt on abdominalpalpation or unless hypovolemia develops



TREATMENT

• Smaller vulvar hematomas identified after leavingthe delivery room may be treated expectantly

• if the pain is severe or the hematoma continues to

enlarge, the best treatment is prompt incision• done at the point of maximal distention along withevacuation of blood and clots and ligation of bleeding points

• The cavity may then be obliterated with mattress

sutures. Often, no sites of bleeding are identifiedafter the hematoma has been drained.



• In such cases, the vagina, not the hematoma cavity,is packed for 12 to 24 hours

• With hematomas of the genital tract, bloodloss is nearly always considerably more thanthe clinical estimate

• Hypovolemia and severe anemia should beprevented by adequate blood replacement

• Subperitoneal and supravaginal hematomas aremore difficult to treat

• They can be evacuated by incision of the perineum;

but unless there is complete hemostasis, which isdifficult to achieve by this route, laparotomy isadvisable.



UTERINE RUPTURE

• Complete uterine rupture - all layersof the uterine wall separated

• Incomplete uterine rupture - uterinemuscle separated but visceralperitoneum is intact. Incompleterupture is also commonly referred to

as uterine dehiscence



DIAGNOSIS OF UTERINERUPTURE

• hemoperitoneum from a ruptured uterus may resultin irritation of the diaphragm with pain referred to thechest uterine

• electronic fetal monitoring finding tends to besudden, severe heart rate decelerations that mayevolve into late decelerations, bradycardia, andundetectable fetal heart action

• occasionally, maternal hypovolemia from concealedhemorrhage.

• cessation of contractions following uterine rupture• loss of station may be detected by pelvic examination



MANAGEMENT

• In cases of scar separation withoutbleeding following VBAC, exploratorylaparotomy is not indicated.

• With frank rupture during a trial of labor,however, hysterectomy may be required.

• In selected cases, suture repair with

uterine preservation may be performed

Cl ifi ti f C f Ut i R t



Uterine Injury or Anomaly Sustained BeforeCurrent Pregnancy

Uterine Injury or Abnormality During CurrentPregnancy

1. Surgery involving the myometrium 1. Before delivery

Cesarean delivery or hysterotomy Persistent, intense, spontaneous contractions

Previously repaired uterine rupture Labor stimulation—oxytocin or prostaglandins

Myomectomy incision through or to theendometrium

Intra-amnionic instillation—saline or prostaglandins

Deep cornual resection of interstitial oviduct Perforation by internal uterine pressure catheter

Metroplasty External trauma—sharp or blunt

2. Coincidental uterine trauma External version

Abortion with instrumentation—curette, sound Uterine overdistention—hydramnios, multifetalpregnancy

Sharp or blunt trauma—accidents, bullets, knives 2. During delivery

Silent rupture in previous pregnancy Internal version

3. Congenital anomaly Difficult forceps delivery

Pregnancy in undeveloped uterine horn Breech extraction

Fetal anomaly distending lower segment

Vigorous uterine pressure during delivery

Difficult manual removal of placenta

3. Acquired

Placenta increta or percreta

Gestational trophoblastic neoplasia

Adenomyosis

Sacculation of entrapped retroverted uterus

Classification of Causes of Uterine Rupture

g. postpartum hemorrhage

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