Postpartum hemorrhage, PPH

Notes
  • This is defined as a blood loss of 500 ml or more within 24 hours after birth.
  • PPH is the leading cause of maternal mortality in low-income countries
  • Most deaths resulting from PPH occur during the first 24 hours after birth
  • There are two categories of postpartum hemorrhage: Primary postpartum hemorrhage (bleeding volume of ≥ 500mL (estimated empirically) within the first 24hrs postpartum and Secondary postpartum hemorrhage ( 6wks <bleeding period postpartum > 24hrs)

##Predisposing factors for postpartum hemorrhage include the following:

  • Grand multiparity (past delivery of ≥ 5 infants who have achieved a gestational age of ≥ 24wks)
  • History of postpartum hemorrhage
  • History of retained placenta
  • Multiple pregnancy
  • Polyhydramnios (excess of amniotic fluid in the amniotic sac)
  • Prolonged or obstructed labor

##Causes of postpartum hemorrhage are:

  • Uterine atony
  • Prolonged or obstructed labor
  • Placenta praevia (partial or complete blocking of the neck of the uterus by the placenta that may interfere with normal delivery)
  • Placental abruption or abruptio placentae (partial or complete separation of placenta from the uterus before the baby is born)
  • Genital tract lacerations
  • Episiotomy
  • Fibroids
  • Oxytocin hyper-stimulation
  • Use of halothane in general anesthesia
  • Vulvar /vaginal/subperitoneal hematomas
  • Uterine rupture (especially when the scar from the previous caesarean section tears open)
  • Retained placental fragments of which 80% is due to placenta accreta (adhered to myometrium) as opposed to few cases of placenta increta (invasion of myometrium) and placenta percreta (penetration of myometrium).
  • Uterine inversion (due to the failure of detachment of placenta from the uterus as it exits and subsequent pulling on its inside surface and turning it inside out)
  • Blood Coagulation disorders especially disseminated intravascular coagulation (DIC)
  • Subinvolution (failure of the uterus to heal or return to the normal size), infections and retained placenta are the major causes of secondary postpartum hemorrhage.

##Uterine atony (the most common cause of primary postpartum hemorrhage) is associated with the following:

  • Prolonged labor (especially 3rd stage)
  • Polyhydramnios
  • Multiparity
  • Fetal macrosomia (a newborn who's significantly larger than average i.e. > 4,000gm)
  • Preeclampsia
  • Operative birth (assisted vaginal delivery with forceps or a vacuum device with or without the assistance of maternal pushing)
  • Use anesthesia
  • Use of magnesium sulphate
  • Use of terbutaline
  • Human race (it is more common in Asians, Hispanics and native Americans)
  • Statistics: PPH is also the primary cause of about 25% of all maternal deaths globally.
Symptoms
  • Blood loss of 500 ml or more within 24 hours after birth.
Diagnosis
  • Monitoring of Lochia (vaginal discharge after giving birth that is categorized into Lochia rubra that lasts for up to 3 to 5th day, Lochia serosa that lasts for up to 10th day and Lochia alba that may last up to 6th week, which is the end of postpartum period). Any Lochia after 6wks should raise concerns.
  • HB and PCV
  • Bleeding time
  • Clotting time
  • Coagulation factors
  • Blood grouping
Differential
  • Endometritis
Prevention

 

  • Prophylactic uterotonics during the third stage of labor

_Oxytocin (most preferred)

_Misoprostol

_Ergometrine or the fixed drug combination of oxytocin and ergometrine

  • Timely and appropriate management of PPH
  • Improving health care for women during childbirth
  • Surveillance of uterine tonus through abdominal palpation
Management
  • Fundal massage to promote uterine contractions and express clots
  • Removal of retained uterus

_Controlled Cord Traction (CCT)

_Manual removal with the hand

_Curettage

_Methotrexate  (if small in size)

 Avoiding bladder distension

  • Proper perineal care
  • Oxytocin therapy (most preferred): IV inf., 20 Units in 500mL dextrose or normal saline at the rate of 20 drops per minute for about 2hrs after the delivery. OR
  • Misoprostol 600ug orally or Misoprostol per rectum
  • Surgery:

_Subtotal hysterectomy in case of failure of other measures

_In case of invasive placenta

_Suturing of lacerations

_Manual replacement of inverted uterus

  • Manual removal of retained placenta

_Administer Morphine 10mg IM STAT and Diazepam 10mg IV

_Attempt to remove the placenta manually with the right hand while the left hand is supporting the uterus

  • Clotting factor replacement in case of coagulopathies
  • IV fluids, blood transfusion, oxygen when required
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