3. POSTPARTUM HAEMORRHAGE.pptx

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• Obstetrics
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PRIMARY POSTPARTUM HAEMORRHAGE

• Blood loss per vagina of more than 500 ml within 24 hours after vaginal delivery OR

• Blood loss per vagina of more than 1000 ml within 24 hours after C/S OR

• Any bleeding per vagina within the first 24 hours after delivery resulting in hypovolemia or otherwise causing a woman to become symptomatic due to the blood loss.
  

CAUSES OF PRIMARY PPH

• TONE – Uterine atony

• TRAUMA – Tears in the genital tract

• TISSUE – Retained placenta or pieces of placenta

• THROMBIN – clotting abnormalities

UTERINE ATONY

• Uterine atony is a loss of tone in the uterine musculature. Normally, contraction of the uterine muscle compresses the vessels and reduces flow. Thus, lack of uterine muscle contraction can cause an acute hemorrhage.

• Clinically, ≥ 80% of postpartum hemorrhages are due to uterine atony.

UTERINE ATONY BY ABNORMALLY LARGE UTERUS

• Big Baby

• Multiple pregnancy

• Polyhydramnios

• Fetal abnormalities e.g. severe hydrocephalus

MANAGEMENT

• Call for help

• Resuscitation - adequate blood volume replacement

• Treatment

INITIAL RESUSCITATION

• Two wide bore canulae

• Take blood for grouping and cross matching and for FBC and Clotting Profile

• Rapid infusion of IV fluids

• Passage of urethral catheter

Treatment

• The first step in management of uterine atony is uterine massage

• The next step is pharmacological therapies, the first of which is oxytocin

• The next step in the pharmacological management is the use of ergometrine & Misoprostol (Cytotec).

• Surgery if the above measures fail

PHARMACOLOGICAL THERAPIES

• Initial pharmacological therapy - Intravenous infusion of 20 units oxytocin in 500 ml of normal saline

• The next pharmacological management is the use of ergometrine 0.5 mg IV and IM & Misoprostol (Cytotec) 600-800mcg rectally

Ergometrine is contraindicated if the BP is high

FAILURE OF MEDICAL MANAGEMENT

• Examination under anaesthesia (EUA)

Retained placenta – Manual removal

Genital tract lacerations - Suture

Retained placenta tissue – E.O.U

Clotting Abnormality – FFP, Platelet conc. etc

Failure of medical Mg. of Atony – Surgical Mg

• Surgical management

SURGICAL MANAGEMENT OF PPH

• Tamponade (balloon) or uterine packing

• Apply compression sutures

• Systematic pelvic de-vascularisation - Uterine artery ligation, The tubal branches of both ovarian arteries, Internal iliac artery ligation

• Interventional radiologist—if appropriate, ‘uterine artery embolization

• Subtotal or total abdominal hysterectomy

Balloon Tamponades

• The balloon inserted in the uterus and inflated with saline exerts pressure on the uterine vessels to stop bleeding

• A positive tamponade test can occur within 5 to 15 minutes

• Very effective (≥85%)

• Easy to use

• Is being effectively used in low resource settings

• Safer alternative to uterine packing

Innovative Uterine Balloon Tamponade Devices

Using gloves

Condom Balloon Tamponade

Surgery: Compression Sutures. E.g. B-Lynch Suture

RISK REDUCTION

• An intravenous infusion should be started during the active phase of the first stage of labour.

• Twenty units of oxytocin in 500 ml of normal saline should be given by rapid infusion after the placenta has been delivered.

• Make sure that the uterus is well contracted during the first hour after the delivery of the placenta and make sure that the patient empties her bladder frequently.

THE END