Definition of postpartum hemorrhage
Decline in Hct 10%
Est blood loss >500ml vaginal
>1000 ml C-section
Primary PPH causes
REtained placenta - placenta accreta
Defects in coagulation
Clinical thing behind postpartum hemorrhage
Msot common cause - uterine atony ---> Bimanual exam for soft, poorly contracted uterus --> atony as a caustiave factor
Compression or massag eof uterine corpus can diminish bleeding, explel blood and clots, and allow time for other interventions.
Atony not a factor for PPH, what now
Other causes --> lacerations
Gential tract hematomas - enlarging mass
POC retention --> US can help, normal stripe can help r/o, should be done before instrumentation
Risk factors for PPH
Hx of PPH
Episiotomy, esp mediolateral
Overdistnded uterus (macrosomia, twins, hydramnios)
Asian or hispanic ethnicity
Surgical mgmt of PPH
Bilateral uterine artery ligation
B-Lynch technique --> to the corpus
Hypogastric artery ligation (old)
Repair of rupture
Risk factors for placenta accreta
Previoucs palcenta previa
Who gets arterial embolization in PPH
Persistent bleeding esp if rate of loss is not excessive
RAdiographic identification --> gelfoam, coils, or glue... Balloon occlusion
Can also be used for bleeding post hysterectomy, or as an alternative for hysterectomy.
Mgmt approach for hemorrhage due to ruptured uterus
Rutpure --> previous c-delivery or otehr surgical procedure involving the uterine wall.. or from congenital malformation
Mgmt of uterine rupture of previous C-delivery scar
Revision of edges of prior incision with primary closure.. in adddition, cosnideration must be givent o neugboring structures such as the broad ligament, paramterial vessels, ureters, and bladder.
PE findings that suggest inversion
Firm mass belwo or near the cervix, coupled with absence of identification of uterine corpus...
Placenta still attached to an inverted uterine corpus... how to manage
Do not attempt to detachor remove placenta... this will lead to additional rupture.. replacement of the uterine corpus involves placing the palm of yout hand against he fundus as if holding a tennis ball with teh ingertips exerting upward pressure circumferentially....
Medical mgmt of uterine inversion
Relaxation may be necessary --> terbutaline, mag sulfate, halogenated general anestehteics, and nitroglcyerin...
If manual replacement of uterine prolapse is not sucessful..
Two approaches: Huntington procedure, with progressive upward traction on the inverted corpus using Babcock or Allis forceps
Haultain procedure --> incision of cervical ring posterioruly... subsequent repair
Treatment for 2/ PPH
Curettage - often removal of tissue is minimal yet bleeding subsides promptly...
How to avoid complication of uterine perforation during D&C
Counsel on possibility of hysterectomy before procedure!!1
Once patient is stable and blood is gone, mgmt of PPH
Prenatal vitamin (60mg of elemental iron)
Additional iron tablets (300mg --> 60mg of elemental iron)
Consider EPO (but not approved)
When uterotonics fail..
Tamponade, but usually exp lap..
If C-delivery is done for uterine atony, there should be documentation of other attempts!!!
PPH other def
>500 ml vaginal.... but actual measured blood loss during uncomplicated vag deliveries averages 700ml... blood loss may often be underestimated...
Hemorrhage as a cause of maternal mortality
Developing world: Top cause!
3rd in teh US, direclty responsible for 1/6 of maternal deaths.
Cause of PPH
Uterine atony (50% !)
Obstetric lacerations (20%)
Retained placental tissue
Predisposing causes of PPH
Excessive manipulation of uterus
General anesthesia (halogenated compounds!)
Uterine overdistention (twins, polyhydramnios)
Op delivery and intrauterine manipulation
oxytoxinc induction or augmentation
Previous hemorrhage in the third stage
Extravasation of blood into the myometrium (Couvelaire uterus)
Intrinsic myometrial dysfunction
Life threatening. Loosing of placenta --> bleeding that penetrates into the uterine myometrium --> peritoneal cavity
Risk factors for spontaneous rupture
Previous uterine surgery
Oxytocin induction of labor
Rupture after C-delivery
How often is retained placental tissue a cause of bleeding
5-10%, usually in placenta accreta (increaseing in freq due to c-deliveries)
Also in manual removal of placenta, mismanagement of third stage of labor, and in unrecognized succenturiate placenta.
Imaging findings of retained placental prodcuts
U/S findings of echogenic uterine mass
usually U/S used in hemorrhage occuring a few hours after delivery or in late postpartum hemorrhage
Coagulopathies in pregnancy may be associated with what
Excess thromboplastin from retained dead fetus
Amniotic fluid embolism
may present as hypofibrongenemia, thrombocytopenia
How to evaluate a patient of risk of PPH
Blood transfusions during previous pregnancy
Anemia during labor
Oxytocin induction or augmentation
Rapid or tumultuous labor
Severe preeclampsia or eclampsia
Vaginal delivery after prev C--delivery
General anesthesia for deliery
Delay in placental delivery after vaginal delivery of infant
Complications of hemorrhage
Partial or total necrosis of anterior pituitary --> Sheehan syndrome
Failure to lactate
Decreased breast size
Loss of pubic and axillary hair
Prevalence of Sheehan
Rare <1 / 10,000
Hypotensive post partum with normal lactation, probably does not have this.
Predelivery prep for PPH
Type and screen
Type and cross match for at risk, with reservation for up to 24h post deliverty
Large bore IV cath
Alert to risk of hemorrhage
Spontaneous placental separation, signs?
Uterus becomes roudn and firm
Sudden gush of blood
Uterus seens it rise in abdomen
Umbilical cord moves down and out of vagina
Hemorrhage with the placenta?
Opinion divided.... a placenta that has not delivered by 18 mintue sshould be removed...
Active bleeding/hemorrhage --> manual removal right away.
Steps to take in the immediate postpartum period to lower incidence of PPH
Oxytocin during delviery of anterior shoulder, with controlled cord traction (instead of around placental delivery). Recues by 40%
Potential risk of entrapment of undiagnosed second twin, thus not to be done in people without U/S screening.
What may be just as effective as IV oxytocin for prevention of PPH
Sublingual misoprostol, useful for low resource areas because misoprostol does not have to be refrigerated or require specialized equipment for administration.... but still a useful adjucnt everywhere...
Ergot alkaloids for PPH, problems?
Not more effective than oxytocin, and can pose more risk because they rarely cause marked hypertension (usually with IV or when regional anesthesia is used)..
Do NOT use in hypertensive women or in women with cardiac disease.
Cardinal principles of vaginal laceration repair
Begin repair above the highest extent of the laceration. This is because the tendency of bleeding vessels to retract from the laceration site. Highest suture is also used to provide gental traction to bring the laceration site closer to the introitus
Post delivery and repair of vaginal uterine lacerations and hematomas
Recovery room attendants should frequently massage the uterus and check for vaginal bleeding.
Vaginal bleeding is persisting after placental delivery, what steps need to be taken?
1. Manually compress the uterus
2. Obtain assistance
3. If not already done, obtain blood for typing and cross matching
4. Observe blood for clotting to rule out coagulopathy
5. Begin fluid or blood replacement
6. Explore uterine cavity carefully
7. Inspect cervix and vagina
8. Insert second IV cath
When should manual exploration of the uterus be considered
Intrauterine manipulation such as version and extraction
Malpresentation has occurred during L&D
Premature infant has been delivered
Abnormal uterine contour prior to delivery
Possibility of undiagnosed multiple pregnancy to r/o twins
Most important first step in controlling atonic postpartum hemorrhage
Bimanual uterine compression --> 20-30 minutes or more
T&S blood is given when available
Manual compression of uterus will controlm most causes of hemorrhage due to uterine atony, retained POCs, coagulopathies
Technique for bimanual massage
With one hand, grasp uterine fundus and bring it down over symphysis pubis
With other hand, place first and second finers on either side of the cervix and push it cephalad and anteriorly. Pulsating uterine arteries should be felt by the fingertips. Massage the uterus with both hands while maintaining compression. Prolonged compression may be required but is almost always successful in controlling bleeding.
usually you need a foley too.
Alternative to uterine packing
Bakri balloon. Inflatable balloon that inflates up to 800ml. Double lumen port so drainage of blood can still occur so that concealed hemorrhage does not occur...
Delayed PPH >=2 weeks almost always due to what
Subinvolution of placental bed or retained placental fragments.
Involution of placental site is normally delayed, but for weird reasons, subivolution of adjacent endometrium and the decidua basalis