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H.MOGHAVVEMI M.DOBSTETRICIAN AND GYNECOLOGIST

Uterine Atonia

Death triad

Hemorrhage

Infection

Hypertension

Death triad

Hemostasis at the Placental Site

• Hemostasis at the placental implantation site is achieved first by contraction of the myometrium.

• This is followed by subsequent clotting and obliteration of their lumens

• It is therefore readily apparent that fatal postpartum hemorrhage can result from uterine atony despite normal coagulation.

• Conversely, if the myometrium within and adjacent to the denuded implantation site contracts vigorously, fatal hemorrhage from the placental implantation site is unlikely even in circumstances when coagulation may be severely impaired

Timing of bleeding

• Antepartum placenta previa Abruption• Postpartum Uterin atonia Genital tract trauma

Postpartum Hemorrhage

Postpartum hemorrhage describes an event rather than a diagnosis.

Obstetrics is “bloody business”.

• Hemorrhage was a direct cause of more than 17 percent of pregnancy-related maternal deaths in the United States .

• Obstetrical hemorrhage accounts for almost half of all postpartum deaths in developing countries

• Hemorrhage was the major factor death in UK.

Definition

Traditionally, postpartum hemorrhage has been defined as the loss of 500 mL of blood or more after completion of the third stage of labor.

Definition

• Pritchard and associates (1962) used precise methods and found that approximately 5 percent of women delivering vaginally lost more than 1000 mL of blood.

• They also reported that estimated blood loss is commonly only approximately half the actual loss.

Obstetric hemorrhage

• According to the 2002 Confidential Enquiry into Maternal and Child Health (CEMACH), however, most maternal deaths from hemorrhage in the

United Kingdom were associated with substandard care.

• Moreover, from Japan, Nagaya and associates (2000) concluded that many hemorrhage-

related maternal deaths were preventable and were associated with inadequate facilities.

Etiology

• Obstetrics & Gynecology: June 2012 - Volume 119 - Issue 6 - p 1137–1142• Placental and Uterine Pathology in Women Undergoing

Peripartum Hysterectomy• Hernandez, Jennifer S. MD; Nuangchamnong, Nina MD; Ziadie,

Mandolin MD; Wendel, George D. Jr MD; Sheffield, Jeanne S. MD• Abstract• OBJECTIVE: To estimate if peripartum hysterectomies performed

for intractable uterine atony have pathologic findings consistent with infection more often than those hysterectomies performed for other indications.

Obstetrics & Gynecology 2012 - 119 - 6 - 1137–1142June Volume Issue p

• RESULTS: Of 324,654 deliveries during the study period, 558 (1.7%) women underwent emergent peripartum hysterectomies; 190 (34%) were for intractable uterine atony.

• CONCLUSION: Patients requiring emergent peripartum hysterectomies as a result of intractable uterine atony are more likely to have clinical and pathologic findings consistent with acute inflammation and infection.

Obstet .Gynecol 2009 Aug;114(2 Pt 1):224-9. doi: 10.1097/AOG.0b013e3181ad9442.

• The frequency and complication rates of hysterectomy accompanying cesarean delivery.

• Shellhaas CS1, Gilbert S, Landon MB, Varner MW, Leveno KJ, Hauth JC, Spong CY, Caritis SN, Wapner RJ, Sorokin Y, Miodovnik M, O'Sullivan MJ, Sibai BM, Langer O, Gabbe SG; Eunice Kennedy Shriver National Institutes of Health and Human Development Maternal-Fetal Medicine Units Network

• OBJECTIVE: • To estimate the frequency, indications, and

complications of cesarean hysterectomy.

RESULTS :

• A total of 186 cesarean hysterectomies (0.5%) were performed from a cohort of 39,244 women who underwent cesarean delivery. The leading indications for hysterectomy were placenta accreta (38%) and uterine atony (34%).

• Of the hysterectomy cases with a diagnosis recorded as accreta, 18% accompanied a primary cesarean delivery, and 82% had a prior procedure (P<.001).

• Of the hysterectomy cases with atony recorded as a diagnosis, 59% complicated primary cesarean delivery, whereas 41% had a prior cesarean).

complications Cesarean hysterectomy

• Transfusion of red blood cells (84%. • Other blood products (34%). • Fever (11%). • Subsequent laparotomy (4%).• Ureteral injury (3%). • Death (1.6%).• Accreta hysterectomy cases were more likely

than atony hysterectomy cases to require ureteral stents (14% compared with 3%.

CONCLUSION :

• The rate of cesarean hysterectomy has declined modestly in the past decade.

• Despite the use of effective therapies and procedures to control hemorrhage at cesarean delivery, a small proportion of women continue to require hysterectomy to control hemorrhage from both uterine atony and placenta accreta.

Am J Obstet .Gynecol 2008 Feb;198(2):173.e1-5. doi: 10.1016/j.ajog.2007.11.003.

• Maternal-Fetal Medicine Units Network cesarean registry: impact of shift change on cesarean complications.

• Bailit JL1, Landon MB, Lai Y, Rouse DJ, Spong CY, Varner MW, Moawad AH, Simhan HN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, O'Sullivan MJ, Sibai BM, Langer O; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

• Abstract• OBJECTIVE: • This study was undertaken to evaluate the effect of change of

shift for physicians and nurses on complications associated with cesarean delivery.

CONCLUSION :

• Physician change of shift does not appear to be associated with an increase in morbidities. However, cesarean delivery during nursing change of shift is associated with increased risk of neonatal facial nerve palsy and hysterectomy. Further investigation is needed to understand the cause of this association.

Am J Obstet .Gynecol 2013 Nov;209(5):449.e1-7. doi: 10.1016/j.ajog.2013.07.007. Epub 2013 Jul 16.

• Incidence, risk factors, and temporal trends in severe postpartum hemorrhage.

• Kramer MS1, Berg C, Abenhaim H, Dahhou M, Rouleau J, Mehrabadi A, Joseph KS.

• Author information • Abstract• OBJECTIVE: • Because the diagnosis of postpartum hemorrhage (PPH) depends

on the subjective estimate of blood loss and varies according to mode of delivery, we examined temporal trends in severe PPH, defined as PPH plus receipt of a blood transfusion, hysterectomy, and/or surgical repair of the uterus.

RESULTS :

• Significant risk factors included maternal age ≥35 years,

• Multiple pregnancy• Preeclampsia• Placenta previa or Abruption• Cervical laceration • Uterine rupture• Instrumental vaginal delivery • Cesarean delivery

• Anesthesia & Analgesia: • May 2010 - Volume 110 - Issue 5 - p 1368–1373 doi: 10.1213/ANE.0b013e3181d74898• Obstetric Anesthesiology: Research Reports• The Epidemiology of Postpartum Hemorrhage in a

Large, Nationwide Sample of Deliveries• Bateman, Brian T. MD*; Berman, Mitchell F. MD,

MPH†; Riley, Laura E. MD‡; Leffert, Lisa R. MD*

• Section Editor(s): Wong, Cynthia A.

RESULTS :• In 2004, PPH complicated 2.9% of all deliveries uterine atony accounted for 79% of the cases of PPH. PPH was associated with 19.1% of all in-hospital deaths after delivery. The overall rate of PPH increased 27.5% from 1995 to 2004, primarily

because of an increase in the incidence of uterine atony; the rates of PPH from other causes including retained placenta and coagulopathy remained relatively stable during the study period. Logistic regression modeling identified age <20 or ≥40 years, cesarean delivery, hypertensive diseases of pregnancy, polyhydramnios, chorioamnionitis, multiple gestation, retained placenta, and antepartum hemorrhage as independent risk factors for PPH from uterine atony that resulted in transfusion. Excluding maternal age and cesarean delivery, one or more of these risk factors were present in only 38.8% of these patients.

CONCLUSION :

• PPH is a relatively common complication of delivery and is associated with substantial maternal morbidity and mortality.

• It is increasing in frequency in the United States.

• PPH caused by uterine atony resulting in transfusion often occurs in the absence of recognized risk factors.

• Clinical Obstetrics & Gynecology: • March 2010 - Volume 53 - Issue 1 - pp 147-156• Postpartum Hemorrhage: Epidemiology, Risk Factors, and

Causes• OYELESE, YINKA MD*; ANANTH, CANDE V. PHD, MPH†

• Abstract• Postpartum hemorrhage (PPH) is a leading cause of death and

morbidity relating to pregnancy. Uterine atony is the leading cause of PPH.

• Trauma increases the risk for postpartum hemorrhage. • Women with PPH in a pregnancy are at increased risk of PPH in

a subsequent pregnancy.• Awareness of these facts, and anticipation and prevention of

uterine atony, have the potential to significantly reduce the mortality and morbidity from postpartum hemorrhage.