Management of obstetric hemorrhage - PowerPoint Presentation

Slide1

Management of obstetric hemorrhage

(

PPH)

done by

mayar

alatrash

Slide2

Recall..

Definition

Significant blood loss after getting birth , >500 ml after vaginal delivery

>1000 ml after cesarean section

( if you can determine the amount of bleeding precisely )

Or

- Decrease 10% or more in hematocrit baseline

Or

- Need blood transfusion

Or

- Change of mother’s vitals (hypotension, tachycardia) , oliguria , lightheadedness ,dizziness , syncope.

Causes

: 4 T (

Tone, Tissue ,Trauma ,Thrombin)

Slide3

PPh

according to the time of onset

Primary

Within 24 hours following delivery

Secondary

After the first 24 hours following delivery up to 12 weeks

Slide4

Slide5

It’s an important issue

- Affect 2% of all women get birth.

- One quarter of maternal death globally.

- Leading cause of maternal death in low income countries. - Not affect mortality only but also interfere with maternal morbidity , while blood loss may cause shock and organ dysfunction.

Slide6

EMERGENCY !!

Risk factors

Prevention

PPH

Treatment

Complications

Death!

Delivery

Slide7

Risk factors are the first step in the way of PPH causes

Welcome to PPH

Slide8

Tone(uterine atony)

1-

uterine

over distention,

so anything that makes the uterus stretch out too

much:

- multiple pregnancy - more than 4 previous deliveries -

hydramnios

- baby >4 kg - maternal obesity - previous PPH - induction of labor

2-

uterine muscles fatigue during the delivery

process

-

prolonged

labor > 12 h - prolonged 3rd

stage

3-

prior C-sections or uterine

surgery

4-

full bladder (develop in females that are unable to pass urine following

anesthesia)

5-

some

obstetric medications like

anesthetics

- especially

halothane

, as well as

magnesium sulfate

,

nifedipine

, and

terbutaline

can all increase the risk of uterine atony.

Slide9

Trauma

any kind of injuries to the birth

canal:

cervical or vaginal lacerations

or hematomas , perineal tears or uterine rupture.

- large fetus.

- hasty deliveries.

-

and iatrogenic causes like an episiotomy

Slide10

Tissue

Retained products

of conception

(especially placenta)

- prior uterine surgery, especially when the placenta implants itself near a scar from the previous surgery.

Slide11

Thrombin (coagulation disorder)

Primary : hemophilia

Secondary to obs. condition : preeclampsia , placental abruption , amniotic fluid embolism.

Slide12

Prevention

Efficient prevention >> efficient outcomes >>lower mortality and morbidity

Achieved by :

1- access to appropriate

medications2- trained health care workers in procedures relevant to the management of

PPH

3-countries need

evidence-based guidance to

inform their

health policies and

improve their

health outcomes.

Slide13

active management of the

third stage of

labour

-- package

of interventions performed during the third stage of labor-- cornerstone

for the prevention

of PPH

-- Include:

the administration of

a prophylactic

uterotonic

after the delivery of a baby, early cord clamping

and cutting,

the controlled traction of the umbilical cord, Uterine massage

Slide14

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Uterotonics

agents

1-

syntocinon

(synthetic oxytocin ) 2- misoprostol (prostaglandin E1 analogues )3-

carboprost

tromethamine

(15-methyl prostaglandin F2 alpha

derivative)

4-

ergometrine

/

ergonovine or methylergonovine (ergot alkaloids )5- carbetocin (longer acting relative of oxytocin)

In females with no risk factors or at low risk for uterine atony

, any single

one of these agents is recommended.

In females at

high risk

for uterine atony,

combinations

like oxytocin and misoprostol or oxytocin and

methylergonovine

are recommended.

Slide16

PPH

life-threatening life saving supportive management definitive management

Slide17

Supportive management

1-

call for help

2-

A B C A stands for airway, so you’ll want to protect the airway, especially when there’s loss of consciousness.

B

stands for breathing, so you’ll want to administer Oxygen through a non-rebreather mask

.

C

stands for circulation - meaning measuring vital signs and establishing the degree of

hypovolemia

3-

inserting two large caliber peripheral IV catheters - of at least 14 gauge or even

larger. And starting fluid resuscitation immediately, with 500 milliliters of normal saline or lactated Ringer’s solution given over 30 minutes

then adjusted accordingly 4- blood sample for CBC , blood group , cross match and clotting profile

5- apply Foley's catheter to empty bladder 6- empty uterus and vagina from clots

7- Cross match 4-6 units of blood

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Definitive management

(underlying cause )

Uterine atony Dx : palpation

 soft , boggy and enlarged

Vaginal examination  bleeding not from vaginal or cervical laceration

Mx

:

1-

uterotonic

medication

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2- bimanual uterine compression

https://

www.youtube.com/watch?v=onyPC943cWs3- if (1+2) fall to stop bleeding + patient is hemodynamically stable

intrauterine balloon tamponade can be done (Bakri Postpartum balloon )

https://

www.youtube.com/watch?v=S1tRfMy0coI

4- Another technique is

uterine artery

embolization

( not sever bleeding + stable patient ) // interventional

radiology

technique

5- bleeding

not stop , surgical ligation of the uterine

arteries6-

B- lynch suture

7-

hysterectomy

 ( refractive atony /

placental invasion /Irreparable uterine rupture/vessel

lacerations)

Slide20

Trauma

-

Cervical

and vaginal lacerations Dx

: speculum examination. MX : surgically suturing the laceration under local anesthesia.- Hematomas : symptoms include labial, rectal, or pelvic pressure or pain.

For

small

hematomas in hemodynamically stable females

, IV fluids

are given and the hematoma typically

resorbs on its own

.

For

rapidly

expanding hematomas, or in hemodynamically unstable females, IV fluids and blood transfusions, along with incision and drainage of the hematoma may be required

.- Perineal tears can be seen on

inspectionMX : perineal tears may be sutured under local or general anesthesia.(depending on degree )

Uterine rupture :

DX : sudden

and severe abdominal pain./ ultrasound is needed to see the accumulation of blood.

Mx

: emergency surgery to repair or remove the uterus

.

Slide21

Slide22

Tissue

(

placenta

accreta or related disorders, or when there’s an accessory placental lobe.)placenta

accreta

per se,

placenta

is burrowed deep into the endometrium, but doesn’t reach the myometrium

.

placenta

increta

,

placenta has invaded the myometrium, but doesn’t go all the way through.

placenta percreta, placenta

invades all the way through the myometrium, and may extend to neighboring organs.DX: closely inspecting the placenta after delivery

On palpation, the uterus feels firm

ultrasound

will show the retained placental tissue as a

hyperechoic mass.

Slide23

MX

: depends on the depth of

invasion

- Small, focal accreta can usually be removed with

curettage- Burrowed more deeply into a large portion of the uterine wall hysterectomy

(manual removal of placenta

accreta

should not be

attempted)

Slide24

Thrombin

* Can progress to DIC

 normal

hemostasis can’t occur

. DX: lab abnormalities like a high INR, prolonged PT, PTT, low platelets, or low levels of deficient clotting factors.

**

Fibrinogen may be low, or normal, but bear in mind that a normal fibrinogen level, between 150 and 400 milligrams per deciliter, is low for a postpartum female, since fibrinogen levels usually increase during pregnancy

.**

MX

:

blood transfusions - red blood cells, platelets, fresh frozen plasma or cryoprecipitate.

Slide25

uterine inversion

can also cause postpartum hemorrhage.

With uterine inversion, the uterine fundus descends through the cervix and into the vagina -

kinda like turning a bag inside out.

DX: on palpation - empty pelvis, the uterine fundus is missing from the pelvis.

MX

:

- administering

uterine relaxants like magnesium sulfate, halogenated anesthetics, and

nifedipine

.

- Then

, the uterus can be manually put back in place

.- If unsuccessful, surgery may be required to put the uterus back in place.

Slide26

Complications of PPH

• Sheehan’s syndrome : Pituitary ischemic injury

(necrosis of the anterior lobe of the pituitary gland

)

• Postpartum infection• DIC• Anemia

• Transfusion

hepatitis

•

Asherman’s

syndrome (Intrauterine adhesion )

Slide27

Secondary PPH

Causes of Secondary PPH

• Endometritis

• Retained placental tissue

• Sub-involution of placental site• Ruptured pseudo-aneurysms and arteriovenousmalformations (rare)

Slide28

Endometritis

• Combination of ampicillin (clindamycin if penicillin

allergic) and metronidazole

• In cases of endomyometritis

(tender uterus) or overt sepsis, add gentamicinRetained tissuesSurgical measures (Evacuation of retained tissues)

o If excessive or continuing bleeding, irrespective of USS

findings

o Carries a high risk for uterine perforation

Slide29

Thank You