POST PARTUM HAEMORRHAGE

DEFINITION

•RELATED TO THE AMOUNT OF BLOOD LOSS IN EXCESS OF 500ML FOLLOWING BIRTH OF THE BABY.

INCIDENCE

•1% AMONGST HOSPITAL DELIVERIES

TYPES•1] PRIMARY 2] SECONDARY

•PRIMARY – BLEEDING OCCURS FOLLOWING DELIVERY OF THE BABY UP TO 24 HOURS

•PRIMARY IS TWO TYPES:

•A] THIRD STAGE HEMORRHAGE

•B] TRUE POST PARTUM HEMORRHAGE

PRIMARY POSTPARTUM

HAEMORRHAGE…

CAUSES•ATONIC

•TRAUMATIC

•MIXED

•BLOOD COAGULOPATHY

ATONIC UTERUS (80%)•COMMONEST CAUSE OF PPH

•AS LONG AS THE PLACENTA REMAINS UNSEPARATED, BLEEDING IS UNLIKELY.

•WITH THE SEPARATION OF THE PLACENTA, THE UTERINE SINUSES WHICH ARE TORN CANNOT BE COMPRESSED EFFECTIVELY DUE TO THE IMPERFECT CONTRACTION AND RETRACTION OF THE UTERUS AND BLEEDING CONTINUES.

• GRAND MULTIPARA

• OVER – DISTENSION OF THE UTERUS – (MULTIPLE PREGNANCY, HYDRAMINOS, LARGE BABY)

•MALNUTRITION AND ANAEMIA

• APH

• PROLONGED LABOUR (POOR RETRACTION, INFECTION, DEHYDRATION)

• INITIATION OF DELIVERY BY OXYTOCIN (IF & ONLY IF OXYTOCIN CONTINUED)

• PERSISTENT UTERINE DISTENSION (DUE TO PARTIALLY SEPARATED PLACENTA)

•MALFORMATION OF THE UTERUS (PLACENTA IN SEPTUM, BICORNUATE UTERUS)

•MISMANAGED III STAGE OF LABOUR• TOO RAPID DELIVERY OF THE BABY PREVENTING THE UTERINE WALL TO

ADAPT TO THE DIMINISHING CONTENTS.

• PREMATURE ATTEMPT TO DELIVER THE PLACENTA BEFORE IT IS SEPARATED

• PULLING THE CORD

• MANUAL SEPARATION OF THE PLACENTA INCREASES BLOOD LOSS DURING CAESAREAN DELIVERY.

• PRECIPITATE LABOUR

TRAUMATIC (20%) - (EPISIOTOMY, C-SECTION)

COMBINATION OF ATONIC AND TRAUMATIC CAUSES

•RETAINED TISSUES.

•BLOOD COAGULATION DISORDERS, ACQUIRED OR CONGENITAL: • LESS COMMON…

• ABRUPTIO PLACENTA, JAUNDICE IN PREGNANCY, THROMBOCYTOPENIC PURPURA, HELLP SYNDROME OR IN IUD,

DIAGNOSIS AND CLINICAL EFFECTS:•VAGINAL BLEEDING IS VISIBLE OUTSIDE.

• THE EFFECT OF BLOOD LOSS DEPENDS ON• PRE-DELIVERY HAEMOGLOBIN LEVEL

• DEGREE OF PREGNANCY INDUCED HYPERVOLAEMIA

• SPEED AT WHICH BLOOD LOSS OCCURS.

• TRAUMATIC UTERUS WELL CONTRACTED

•ATONIC UTERUS FLABBY AND BECOMES HARD ON MASSAGING.

PROGNOSIS

•MATERNAL DEATH – 10%

PREVENTION•ANTENATAL:• IMPROVEMENT OF THE HEALTH STATUS OF THE PATIENT AND TO

KEEP THE HAEMOGLOBIN LEVEL NORMAL

•HIGH RISK PATIENTS (TWINS, HYDRAMINOS, GRAND MULTIPARA, APH, H/O PREVIOUS THIRD STAGE COMPLICATIONS, SEVERE ANAEMIA) TO BE SCREENED

•BLOOD GROUPING

•INTRANATAL:• SLOW DELIVERY OF THE BABY

•C-SECTION

•ACTIVE MANAGEMENT OF THE THIRD STAGE

• EXAMINATION OF THE PLACENTA

• EXPLORATION OF THE UTERO-VAGINAL CANAL FOR EVIDENCE OF TRAUMA

• TO OBSERVE THE PATIENT FOR ABOUT TWO HOURS

MANAGEMENT OF III STAGE BLEEDING.•OBJECTIVE:

• EMPTY THE UTERUS OF ITS CONTENTS AND MAKE IT CORRECT

• REPLACE THE BLOOD.

• ENSURE EFFECTIVE HAEMOSTASIS

PLACENTAL SITE BLEEDING• PALPATE THE FUNDUS AND MASSAGE THE UTERUS TO MAKE IT HARD

• IF STILL BLEEDING CONTINUOUS, SUGGESTIVE OF GENITAL TRACT INJURY

• DEXTROSE SALINE DRIP STARTED AND ARRANGE BLOOD TRANSFUSION IF NECESSARY

• CATHETERISE THE BLADDER IF FOUND FULL

• SEDATION MAY BE GIVEN WITH MORPHINE INTRAMUSCULARLY.

SECONDARY POSTPARTUM

HAEMORRHAGE

CAUSES…• RETAINED BITS OF COTYLEDONS OR MEMBRANES

• INFECTION

• ENDOMETRITIS AND SUBINVOLUTION OF THE PLACENTAL SITE

• CHORION EPITHELIOMA

• CA CERVIX

• PLACENTALPOLYP

• INFECTED FIBROID

• PUERPERAL INVERSION OF UTERUS

RARE

DIAGNOSIS• BRIGHT RED BLEEDING OF VARYING AMOUNT

• VARYING DEGREE OF ANEMIA

• EVIDENCE OF SEPSIS PRESENT

• O/E:

• EVIDENCE OF SEPSIS

• SUBINVOLUTION

• USG: BITS OF PLACENTA INSIDE UTERINE CAVITY

MANAGEMENT

•OBJECTIVES: • TO ASSESS THE AMOUNT OF BLOOD LOSS AND TO REPLACE THE

LOST BLOOD

• TO FIND OUT THE CAUSE AND TO TAKE APPROPRIATE STEPS TO RECTIFY IT.

•SUPPORTIVE THERAPY:•BLOOD TRANSFUSION

•CONSERVATIVE:• IF SLIGHT AND NO APPARENT CAUSE IS DETECTED, CAREFUL

WATCH FOR A PERIOD OF 24 HRS OR SO IN THE HOSPITAL

•ACTIVE TREATMENT:

•EXPLORE THE UTERUS UNDER GA.

•PRODUCTS REMOVED WITH OVUM FORCEPS.

•MATERIALS REMOVED SENT FOR HISTOLOGICAL EXAMINATION.