overview management of postpartum haemorrhage

38
Antepartum & Postpartum Hemorrhage (APH &PPH) Al-Momtan

Upload: ahmed

Post on 05-Dec-2014

2.764 views

Category:

Health & Medicine


8 download

DESCRIPTION

 

TRANSCRIPT

Page 1: Overview management of postpartum haemorrhage

Antepartum & Postpartum

Hemorrhage (APH &PPH)

Al-Momtan

Page 2: Overview management of postpartum haemorrhage

Antepartum & Postpartum Hemorrhage

• Obstetrics is "bloody business."

• Death from hemorrhage still remains a leading cause of maternal mortality.

• Hemorrhage was a direct cause of more than 18 percent of 3201 pregnancy-related maternal deaths.

Page 3: Overview management of postpartum haemorrhage

Postpartum Hemorrhage

• In spite of marked improvements in management, PPH remains a significant contributor to maternal morbidity and mortality both in developing and developed countries.

• One of the most challenging complications a clinician will face.

• Prevention, early recognition and prompt appropriate intervention are the keys to minimizing its impact.

Page 4: Overview management of postpartum haemorrhage

DEFINITION:

The loss of >500ml of blood from the genital tract inthe first 24 hrs after delivery

(or)

< 500 ml with haemodynamic changes in the mother.

(or)

>1000 ml – cesarean section within 24 hrs.

(or)

> 1400 ml – Elective cesarean hysterectomy

(or)

> 3000 ml – Emergency cesarean hysterectomy

Page 5: Overview management of postpartum haemorrhage

- In a recent ACOG study PPH is defined as Haematocrit change of 10% or the need for red cell transfusion.

Severe PPH - > 1500ml blood loss

or

Drop in Hb concentration 40g/l.

or

4 units of blood transfusion.

Secondary PPH - Blood loss between 24 hrs and 6 weeks

Post-delivery.In general, early PPH involves heavier bleeding and greater morbidity.

Page 6: Overview management of postpartum haemorrhage

Incidence:

Subjective : 2 – 11%

Objective : 20%

Classification of primary PPH

Atonic PPH – 80%

Traumatic PPH – 15%

Retained placenta, membranes,

coagulation failure – 5%

Page 7: Overview management of postpartum haemorrhage

Haematological Changes in Pregnancy

• 40% expansion of blood volume by 30 weeks

• 600 ml/min of blood flows through intervillous space

• Appreciable increase in concentration of Factors I (fibrinogen), VII, VIII, IX, X

• Plasminogen appreciably increased

• Plasmin activity decreased

• Decreased colloid oncotic pressure secondary to 25% reduction in serum albumin

Page 8: Overview management of postpartum haemorrhage

Reduced Maternal Blood Volume

• Small stature

• Severe preeclampsia/eclampsia

• Early gestational age

Page 9: Overview management of postpartum haemorrhage

PPH

Page 10: Overview management of postpartum haemorrhage

PPH• The etiologies of early PPH are most easily understood as abnormalities of

one or more of four basic processes.

• The four “T” processes.

• Previous PPH!!

Page 11: Overview management of postpartum haemorrhage

The Four “T”

ToneTissue

TraumaThrombin

Page 12: Overview management of postpartum haemorrhage

PPH Risk Factors

• Many factors affect a woman’s risk of PPH.

• Each of these risk factors can be understood as predisposing her to one or more of the four “T” processes.

Page 13: Overview management of postpartum haemorrhage

PPH Risk Factors

Page 14: Overview management of postpartum haemorrhage

PPH Risk Factors

Page 15: Overview management of postpartum haemorrhage

PPH Risk Factors

Page 16: Overview management of postpartum haemorrhage

PPH Risk Factors

Page 17: Overview management of postpartum haemorrhage

PREVENTION OF PPH

• Although any woman can experience a PPH, the presence of risk factors makes it more likely.

• For women with such risk factors, consideration should be given to extra precautions such as:– IV access– Coagulation studies– Crossmatching of blood– Anaesthesia backup– Referral to a tertiary centre

Page 18: Overview management of postpartum haemorrhage

PREVENTION OF PPH

• UTEROTONIC DRUGS

– Routine oxytocic administration in the third stage of labour can reduce the risk of PPH by more than 40%

– The routine prophylaxis with oxytocics results in a reduced need to use these drugs therapeutically

– Management of the third stage of labour should therefore include the administration of oxytocin after the delivery of the anterior shoulder.

Page 19: Overview management of postpartum haemorrhage

Intranatal:

• Hasty delivery of the baby is to be avoided.

• Adequate amount of blood should be cross matched and

available when haemorrhage is anticipated.

• Coagulation studies are done in cases of Abruptio

placenta and retained dead fetus.

Page 20: Overview management of postpartum haemorrhage

Active Management of 3rd Stage of Labour:

1. Uterotonic Agents:

• 10 units of oxytocin IM or

• Syntometrine (5 unitsofoxytocinand0.5mgergonovine maleate).

•Misoprostol, a prostaglandin E1 analogue, 600gorally.

2. Early cord clamping

3. Controlled cord traction.

Page 21: Overview management of postpartum haemorrhage

MANAGEMENT OF PPH

• Early recognition of PPH is a very important factor in management.

• An established plan of action for the management of PPH is of great value when the preventative measures have failed.

• Lab:- CBC / BG / Cross match of 4-6 units of blood - KFT / Coagulation profile- Give FFP / cryoprecipitate if coagulation test results are abnormal - Give platelet concentrates if the platelet count is < 50 X 109/L & bleeding continues

Page 22: Overview management of postpartum haemorrhage

MANAGEMENT OF PPH

Page 23: Overview management of postpartum haemorrhage

MANAGEMENT OF PPH

Page 24: Overview management of postpartum haemorrhage
Page 25: Overview management of postpartum haemorrhage

DRUG THERAPY FOR PPH

Page 26: Overview management of postpartum haemorrhage
Page 27: Overview management of postpartum haemorrhage

MANAGEMENT OF PPH

Page 28: Overview management of postpartum haemorrhage

MANAGEMENT OF PPH

Page 29: Overview management of postpartum haemorrhage
Page 30: Overview management of postpartum haemorrhage
Page 31: Overview management of postpartum haemorrhage
Page 32: Overview management of postpartum haemorrhage

MANAGEMENT OF PPH

Page 33: Overview management of postpartum haemorrhage

Evaluation of response- Monitor pulse, blood pressure, blood gas status, & acid-base status + monitoring central venous pressure. - Measure urine output using an indwelling catheter- Order regular FBC counts and coagulation tests to guide blood component therapy

Page 34: Overview management of postpartum haemorrhage

Summary: remember 4 Ts

• “TONE”• Rule out Uterine Atony

• Palpate fundus.• Massage uterus.• Oxytocin• Methergine• Hemabate

Page 35: Overview management of postpartum haemorrhage

Summary: remember 4 Ts

• “Tissue”• R/O retained placenta

• Inspect placenta for missing cotyledons.

• Explore uterus.• Treat abnormal

implantation.

Page 36: Overview management of postpartum haemorrhage

Summary: remember 4 Ts

• “TRAUMA”• R/O cervical or vaginal

lacerations.

• Obtain good exposure.• Inspect cervix and

vagina.• Worry about slow

bleeders.• Treat haematomas.

Page 37: Overview management of postpartum haemorrhage

Summary: remember 4 Ts

• “THROMBIN” • Check labs if suspicious.

Page 38: Overview management of postpartum haemorrhage

Thank you..