post partum hemorrhage uterine rupture

Post Partum Hemorrhage Uterine Rupture

Women’s Hospital School of Women’s Hospital School of Medicine Zhejiang UniversityMedicine Zhejiang University

Wang ZhengpingWang Zhengping

Post partum hemorrhage

Post partum hemorrhage

Past partum hemorrhage denotes excessive bleeding (≥500ml in vaginal delivery) during the first 24 hours after delivery

Common cause of death and diseases in pregnant women globally

Leading cause of death in pregnant women in China

Incidence 2%-3% of total number of deliveries

Etiology

Uterine atony: 70%

Obstetric lacerations: 20%

Retained placental tissue: 10%

Coagulation:1%

Uterine atony

General factors: extreme nervousness, sedative, anesthesia, tocolytics, weak

Obstetric factors: prolonged labour, fatigue, placenta previa, placenta abruptio, severe anemia

Uterine factors: uterine muscular fiber underdevelopment, such as uterine deformity or myoma; uterine overstretched, such as macrosomia, multiple pregnancy, polyhydramnios

Placental factors

Incomplete placental separation Retained placenta Placental incarceration （嵌顿） Placental adhesion Placental implantation (accreta, increta,

percreta) Residual placenta and amniotic membrane

Implantation of placenta

Birth canal injury

Laceration during labour are usually

associated with: Poor vulval elasticity Strong labour force, emergency delivery,

macrosomia Inadequate skills at assisted vaginal delivery Inadequate cessation of bleeding during

episiotomy repair, missing out tears at cervix or fornices

Coagulation disorder

Complications associated with obstetric: amniotic fluid embolism, pregnancy induced hypertensive diseases, placenta abruptio and intrauterine demise

Pregnancy liver disease: acute fatty liver, severe hepatitis

Hematology diseases: primary thrombocytopenic purpura, aplastic anemia etc

Clinical presentation

Vaginal bleeding: If bleeding occurs immediately after delivery of baby,

consider birth canal injury If bleeding occurs minutes after delivery of baby,

consider placenta factors If bleeding occurs minutes after delivery of placenta,

main reasons are uterine atony or retained products of conception

Persistent bleeding and blood do not coagulate, consider coagulation disorder causing PPH


Vaginal hematoma

Shock: dizziness, paleness, weak pulse, low blood pressure etc

Diagnosis

Estimation of blood loss

Ascertain cause of post partum hemorrhage

Estimation of blood loss

Visual observation: only 50%-70% of blood loss Container: kidney dish, measuring cup Surface area: blood stained 10cmx10cm = 10ml Weighing: 1.05g = 1ml Hct<=30%, Hb50-70g/L, blood loss >1000ml Hourly urine output <25ml, blood loss >2500ml Shock index = pulse rate/systolic pressure

Shock index (SI)

SI <=0.5, normal blood volume

SI = 0.5-1, blood loss <20%, 500-750ml

SI = 1, blood loss 20-30%, 1000-1500ml

SI = 1.5, blood loss 30-50%, 1500-2500ml

SI = 2, blood loss 50-70%, 2500-3500ml

Ascertain cause

Uterine atony Fundus goes up Uterine consistency soft, water bag like After uterine massage or using oxytocin, uterus

harden, per vaginal bleeding lessen Categorize into primary and secondary, with

direct and indirect causes

Ascertain cause

Placental factors: Placenta not delivered within 10 minutes of

delivery of baby, with massive per vaginal bleed, consider placental factors

Residual placenta is a common cause of post partum hemorrhage

Must examine the placenta and membrane carefully

Ascertain cause

Birth canal injury Cervical tear Vaginal tear Vulval tear

Degree of vulval tear

Degree I: vulval skin and vaginal opening mucosa tear, not reaching muscular layer

Degree II: tear into perineal body muscular layer, involving posterior vaginal wall mucosa, may extend up on both sides, making it hard to recognise original anatomy

Degree III: external anal sphincter tear, may involve vaginal rectal septum and anterior rectal wall

Degree of vulval tear

Ascertain cause

Coagulation disorder: Patients with blood disorder or DIC caused by

delivery etc Sustained per vaginal bleeding, non-clotting,

difficulty in hemostasis May have bleeding at any parts of the body Diagnose based on history, bleeding

characteristics, platelet count, prothrombin time, fibrinogen etc tests

Management

Principal of management for post partum hemorrhage is: Rapid hemostasis according to the cause Replenish volume, correct shock Prevent infection

Management of uterine atony

Remove cause Uterine massage:

Abdominal fundus massage Abdominal-vaginal bimanual uterine massage

Uterotonic agents: oxytocin/ ergot derivatives/prostaglandins Uterine packing Pelvis vessel ligation B-Lynch suture Arterial embolism Hysterectomy

Uterine massage

Management of uterine atony

Remove cause Uterine massage:



Management of uterine atony Remove cause Uterine massage:



Uterine packing

Pelvis vessel ligation

B-Lynch suture

Arterial embolism

Management of placental factors

Retained placenta – remove separated placenta

quickly

Residual placenta or membrane – curettage

Placental adhesion – manual removal of placenta

Placental implantation – never separate forcefully,

usually hysterectomy

Management of laceration

Thorough hemostasis

Stitch according to anatomical layering

First stitch must be 0.5cm above top end

When stitching do not leave dead space

Avoid stitching through rectal mucosa

Manage cervical tear

Manage birth canal hematoma

Manage cervical tear

Management of coagulation disorder

First exclude bleeding caused by uterine atony, placental factors and birth canal injury

Actively transfuse fresh whole blood, platelets, fibrinogen or prothrombin complex, clotting factors etc

If DIC set in, manage DIC

Prevention

Comprehensive antenatal care, screen for high risk factors, intervene accordingly

Appropriate labour management Aggressive post partum monitoring: 2 hours post

partum is the peak of post partum hemorrhage, patient must be monitored in labour room for 2 hours

Rupture of uterus

Definition

The body uterine or lower uterine segment happens to rupture during late pregnancy or labor

Rupture of the pregnant uterus is a obstetric catastrophe and major cause of maternal death

Etiology

Descending of presenting part obstruction: narrow pelvis, cephalo-pelvic disproportion, soft tissue obstruction, fetal malposition, fetal abnormality

Inappropriate use of oxytocin 、 prostaglandin etc Uterine scar: fibroidectomy, caesarean section Surgical trauma


Happens at late pregnancy or during labour, more during labour

Complete rupture and incomplete rupture Spontaneous rupture or traumatic rupture Body rupture or lower segment rupture It is usually a progressive process, separated

into 2 stages, impending rupture and uterine rupture

Threatened uterine rupture

Obstructed descend of fetal presenting part, prolong labor

Appearance of pathologic retraction ring Mother shows distress, rapid breathing and

heart rate, unbearable pain Urination difficulty, hematuria Fetal heart rate change or unclear

Complete uterine rupture

At the point rupture, patient experiences sudden abdominal tearing pain, uterine contraction ceases, temporary relieve of abdominal pain

Following blood, amniotic fluid, fetus going into the abdominal cavity, abdominal pain progressively worsen

Patient presents with rapid breathing, paleness, weak pulse, decreasing blood pressure etc shock manifestations


Tenderness and rebound tenderness throughout abdomen

Fetal parts and small uterine body may be easily palpable under abdominal wall, disappearing of fetal movement and fetal heart

Vaginal examination: may have fresh bleeding, originally dilated cervix becomes smaller, ascend of fetal presenting part, if site of rupture is low, may be able to palpate uterine wall rupture per vaginal


Uterine body scar rupture, usually complete rupture, no obvious impending rupture presentations

As the scar tear progressive widens, pain and other presentations progressively worsen, but might not have typical tearing pain

Incomplete uterine rupture

Usually seen in lower segment caesarean section scar Usual pain symptoms and signs are not obvious, may have

obvious tenderness at the site of incomplete rupture Incomplete rupture involving uterine artery, may lead to

acute massive bleeding Rupture occurring in lateral uterine walls within the broad

ligaments, may cause broad ligament hematoma, during which a tender mass is palpable one side of the uterine body and progressively enlarges

Irregular fetal heart

Diagnosis

Typical uterine rupture is easily diagnose based in the history, symptoms and signs

Incomplete uterine rupture, as signs and symptoms are not obvious, diagnosis is difficult.

Ultrasound examination: may show position between fetus and uterus, confirming site of rupture

Differential diagnosis

1. Severe placenta abruptio Unbearable abdominal pain, uterine tenderness Disproportion between bleeding volume and

degree of anemia Ultrasound may shows retro-placental

hematoma, fetus is intrauterine Usually associated with pregnancy induced

hypertensive diseases or trauma

Differential diagnosis

2. Intrauterine infection Usually seen in premature rupture of membrane,

prolonged labour, multiple vaginal examination May have abdominal pain and uterine tenderness

etc Temperature rise Abdominal examination: fetus is intrauterine White blood cell and neutrophil counts rise

Management of impending uterine rupture

Suppress uterine contraction: give inhaled anesthesia or intravenous generalized anesthesia, intramuscular pethidine 100mg etc to relieve uterine contraction

Oxygen Prepare for emergency surgery Immediate caesarean section, prevent uterine

rupture

Management of uterine rupture

Regardless whether fetus is alive, actively manage shock and operate soonest possible

Type of surgery: decided based on maternal condition, degree of uterine rupture, duration of rupture and degree of infection

Tear repair: neat tear, no obvious infection Hysterectomy: big tear, irregular tear or obvious

infection, perform subtotal hysterectomy. If tear extends to cervix, perform total hysterectomy

Management of uterine rupture

During surgery carefully inspect cervix, vagina, bladder, urethra, rectum and all neighboring structures, repair accordingly if damage found

Give high dose broad spectrum antibiotics perioperatively to prevent infection

Transfer

Uterine rupture presenting with shock, resuscitate immediately on site

If transfer is necessary, it must be done under the condition where blood transfusion, fluid infusion, resuscitation. abdomen must be bandaged before transporting

Prevention

Build more efficient and comprehensive antenatal care Patients of high risk should admit 1-2 weeks before

expected date of delivery Strengthen observation ability of doctors and midwives,

pick up abnormality during labour promptly Strict indication for caesarean section and all vaginal

surgery, strict surgical steps, avoid careless surgery, pick up surgical damage promptly

Strict indication of usage of oxytocin

post partum hemorrhage uterine rupture

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