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POST PARTUM HEMORRHAGE

By Dr. Rajabu Nyangara MtillyMD (UDSM), MMED-OBGY (IMTU)

18thDec.2014


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Introduction

Outlines

Definitions

Epidemiology

Classification

Etiological risk factors

Pathophysiology

Clinical presentation

Management

Complications

Preventions Challenges

References


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Definitions

Postpartum hemorrhage (PPH) as an OBSTETRICEMERGENCY is loss of blood

> 500mls following vaginal delivery

>1000mls following caesarean birth.Another way 10% drop in hematocrit is PPH

Normally blood loss following vaginal delivery

ranges btn 300-500mlsNB, Clinical estimation of amount of blood loss

following delivery is greatly inacurate.


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Defincont..

Hemorrhage following delivery is from

excessive bleeding from placental

implantation site, trauma to genital tract and

adjacent structures or both.

So PPH is a description of an event rather than

a diagnosis, therefore when encountered a

cause must be determined.


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Epidemiology

As a major cause of maternal deaths in high

and low income countries respectively

accounts 1:100,000 and 1:1000

A systematic review reported highest rates of

PPH in Africa (27.5%) while Europe and North

America pointing to 13%.

In Tanzania it accounts 18% of maternal death


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Classification

1. Primary PPH-when PPH occurs in the first 24

hours post delivery.

2. Secondary PPH occurs after 24hours post

delivery.


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Etiology and risk factors

Etiology can be simplified as four Ts and

others

A. Tone-uterine atony accounts 80% of PPH

B. Trauma-trauma to uterus, cervix, vaginal and

perineum

C. Tissue-Retained POC or clotsD. Thrombin-coagulation disorders

E. Others-eg complications of placenta previa


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Etiolog.cont..

A. Uterine atony as a major cause results from

the following risks;

Overdistended uterus due to large

fetus,multiple gestation, hydramnios etc

High parity

Hypotonic myometrium

Some general anaetheticseg halogenated

hydrocarbons


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Etiolog.cont..

Poorly perfused myometrium

Following prolonged labour

Following excessive oxytocin-augmentedlabour

Misuse of tocolytics

Chorioamnionitis


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Etiolog.cont..

B. Tissue

Can be due to avulsed cotyledon, retained

placenta

Clots may accumulate in endometium


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Etiolog.cont..

C. Trauma

Ruptured uterus

Lacerations of cervix

Large episiotomies including extensions

Laceration of perineum, vaginal etc

Iatrogenic procedures leading to trauma


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Etiolog.cont..

D. Coagulation

This intensifies all above and can becongenital defects eg. von willbrand dseor

acquired defects eg. Pathologies that ends up with DIC eg Abruptio

placenta and other consumptive coagulopathy

disorders. Dilusional coagulopathy disorders

Iatrogenic blood thinning agents


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Etiolog.cont..

E.Others

abnormally adherent placenta-accreta,

increta and percreta

Placenta previa complications

Uterine myoma esp. submucous and prev

surgeries

Uterine inversion, placenta abruption


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Pathophysiology anatomy


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Pathophysiolcont..

Myometrium has a peculiar character ofcontraction and retraction.

This means when contractions end, theirrelaxation will never allow myofibrils to regaintheir prior length.

So progressively myofibrils shortens ascontractions continues repetitively.

This retraction behavior enhances theirtourniquet effect to spiral arteries and hence aidsachieving hemostasis post partum.

The same mechanism supports labor progress.


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Pathophysiolcont..

When above characters lack the uterine atony

is encountered and hence hemorrhage per

placental implantation site.

Lack of immediate speculation of cause of

continuing bleeding post delivery and

appropriate interventions may end up with

PPH.


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Clinical presentations

A post delivery or C/S woman presenting withprofuse bleeding

Hypovolemic shock signs and symptoms

Diziness, blurring of vision, fainting andlethargy

Pallor, cold with or without sweaty

extremities, tachycardia, thready weak pulses,hypotension and dyspnea, sometimes withdry cough.


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Clinical presentcont..

Presence of shock in the absence of visible

blood loss should rise concern on;

uterine rupture, broad ligament hematoma,

amniotic fluid embolism, anaphylactic shock

or thromboembolism and other diferrentials.


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Mangement

In any Emergency SHOUT call for HELP

NB. Consider ABCs, Use few secs to identify the

cause of bleeding and resurcitate the pt.

As DELAY MEANS DEATH, DONT LEAVE PT ALONE

Quickly Remind; Has the uterus well contracted?

Has placenta been delivered completely?

Is bleeding due to trauma?

Are there known risks of PPH?


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Mn..cont Imediately after call for help.

Ensure airway is patent, patient is breathing and controlany active bleeding if possible.

Insert bilateral wide bore (14G) cannular and runing ivcrystalloids as fast as possible guided with pt vitals.

Crystalloid(normal saline or ringer lactate) are usually givenin ratio of 3:1 ie 3mls in every 1mls of blood loss.

Draw blood sample for grouping and xmatching, Hb,hematocrit,bed side clotting time, trace 4units of blood.Also check RBG, BP and oxygen saturation consider ICUcare for close vital monitoring .

Blood transfusion should be considered in any woman withpostpartum hemorrhage in whom abdominal uterinemassage and oxytocic agents fail to control the bleeding.

In extreme emergency blood group 0-ve may be used


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Mn..cont Transfuse as soon as possible.

Insert urethra cather for output monitoring. Do other investigations, RFT, FBP etc

Consider referral immediately if facility doesnt fit requirementsof management.

1.CONSERVATIVE MANAGEMENT

A.Uterine atony Before considering it as diagnosis try to rule out genital

tract trauma ie inspect vagina and cervix forlacerations.

Explore uterine cavity if is empty massage uterus perabdomen and,

Give oxytocin at least 20IU in IV infusion of crystalloidsdont prefer bolus administration.

Prostaglandings up to 1000mcg rectally and 600mcgorally can also be used.


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Mn..cont During administration of uterotonic agents

bimanual compression may control

hemorrhage.


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Mn..cont This technique is usually appllied when

bleeding is unresponsive to oxytocics.

Another way is baloon tamponade.(Bakri

baloon)


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Mn..cont

This is not effective if uterus has retained

products

Baloon is inflated with 250-500mls of warm

saline, till uterus is firm and minimal blood loss.

Continue oxy. Infusion and commence broad

spectrum antibiotics.

When successful remove baloon after 12-24hrs,gradually deflate baloon by 100mls per hour.


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Mn..cont

Fundal compression suture by B-lynch suture


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Mn..cont

B.genital tract lacerations

It usually from spontaneous or precipitatous

delivery, size, presentation and contracted pelves.

It suspected by bright red bleeding where there is

steady trickle of blood and uterus remains firm.

Treated by suturing any bleeders, vaginal pack

and assess bleeding after removal

If too serious consider blood replacement.


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Mn..cont

C. Retained tissue

Occurs when there is incomplete separation ofthe placenta.

Presents with bogy relaxed uterus and dark-redbleeding

Treted D &C, oxytocics and prophylactic

antibioticsHematoma-presents with deep severe unrelivedevacuate clots.


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Mn..cont

D. Coagulation disorders

If bleeding is difficult to control considercoagulopathy-consumptive or dilusional.

Usually blood transfusion is whole fresh bloodNot available consider bloody products

Fresh frozen plasma, correcting DIC

cryoprecipitate(when fibrinogen


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Mn..cont

E. Uterine rupture

Can be complete, incomplete or dehiscence

Risks increases with prev C/S also when there isprevious myomectomy or mult-para in obstructedlabour.

Surgery should not be delayed owing tohypovolemic shock because it may not be easilyreversible until the hemorrhage is controlled.

At this point, a decision must be made to performhysterectomy or to repair the rupture site. In mostcases, hysterectomy should be performed.


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Mn..cont

F. retained placenta

When controlled cord traction fails, manual

removal of placenta necessitates


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Mn..cont

In some other situation manual removal fails,and if forced bleeding becomes extreme thatleads to non-conservative mnx, where

hysterectomyis done. For example placentapercreta,increta etc

uterine artery embolization or ligature ofinternal iliac arteries may be applied to control

intractable PPH.

NB. If surgery is of beneficial mnx, decisionshould not be delayed.


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Mn..cont

Hysterectomy. Final option, it is warranted

earlier if hemodynamic condition of the

patient is unstable and other management

options have failed. Two types

Subtotal ( may no be effective for lower segment

bleeding) Total hysterectomy


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Complications

Shockwhich leads to end organ injuries like

Acute kidney injury if pt not resuscitated well

and immediately.

Multiple organ failure from

hemorrhagic/hypovolemic shock ends into

Death


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Preventions

The use of AMTSL Prenatal screening of risk pts eg those with APH, multiple

gestations, multipara etc

Advice them to deliver at capacitated hospital

Correction of anemia early in pregnancy by advising dietand hematenics plus deworming

Encourage hospital delivery and emphasis on education toboth clients and health workers targeting recognition ofsigns and sy with early referral.

Correcting delay model. Home-infrastructure-hospital-healthprovider.

Educating community about PPH


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Challenges

Lack of facilities and human resource

immediately available for serving life.

Disproportion of client to physician ratio

Poor unavailable diagnostic and treatment

material


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References

William obstetrics 22ed 2005-obstetrichemorrhage

Gynecology by ten teachers-postpartum

hemorrhage Handout notes on PPH by Dr. Rajab, OBGY

specialist

Internet handouts on PPH Postpartum hemorrhage - Wikipedia, the free

encyclopedia.htm/2014

pph by dr. rajabu nyangara mtilly.ppt

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