Postpartum Hemorrhage

Posted: July 15, 2010 by gerardloh in O & G

Estimation of blood lost:

  • Tampon: 80 ml
  • Sarong: 500 ml
  • Abdominal pack: 250 ml
  • Gauze: 30 – 50 ml
  • Pad: 100 ml
  • Linen: 300 – 5—ml
  • Kidney dish: (portex) 700 ml

( plastic) 300 ml – small

500 ml – big

  • Gully pot – 100 ml

Postpartum Hemorrhage

Postpartum Hemorrhage – >500ml blood lost

Early ( 1°) PPH  – in 1st 24 hours

Late ( 2°) PPH – up to 6 m.o

Risk factor:

PIH

GDM

Patients on coagulation therapy

Multiple gestation

Multiple parity

Obese patients

Patients with anemia

Etiology:

1° PPH – uterine atony (90%), genital tract trauma, coagulopathy, uterine rupture, uterine inversion

2° PPH – retained product of conception, uterine infection

Clinical signs of PPH

  • External hemarhage – visible vaginal bleeding  + anemic syndrome, severe → HYPOVOLEMIC SHOCK!!
  • Internal hemorrhage – x visible bllod lost, but present signs and symptoms of anemia
Genital tract trauma

Perineum tear

1° – perineal skin and mucosa

2° – 1° + muscles

3° – 2° + external anal sphincter

4° – 3° + rectal wall

Paravaginal hematoma

Supralevator – spreads upwards and outwards beneath the broad ligament or partly downwards to bulge into the walls of the upper vagina. Not visible externally, only can be detected by digital examination and laparotomy.

Infralevator – includes those of vulva and perineum, as well as those occurring in ischiorectal fossa. Massive swelling and ecchymosis of the labia, perineum and lower vagina on the affected side, and may extend to the buttock. Anorectal tenesmus may result from extension into ischiorectal fossa, and urinary retention may succeed spread ventrally into the paravesical fossa.

Management!!

Determine the cause and treat it!!

  1. FBC + cross matching of blood group
  2. Massage the uterus
  3. Set 2 lines (large gauge – 14 – 16 Fr) on both wrist
  4. Ergometrine
  5. Empty bladder
  6. Check for trauma of the genital tract

According to cause:

  • Genital tract trauma
  1. Cervical tear – stitch from apex
  2. Vaginal tear – s/f tear: stitch  from the apex

Deep tear – EUA, packed –remove after 24 hours and stitching is done

  1. Paravaginal hematoma –

supralevator: laparotomy, CT, TAH (total abdominal hysterectomy)

infralevator: if <5cm and is not expanding → ice packed, vaginal packing and analgesics,

If >5cm and is expanding → xplore and evacuate hematoma, ligate vessels,

drain, packed and CBD for 24hours.

  • Coagulopathy – correction by transfusion with O- blood, FFP,  and anticoagulant therapy should be reversed: aspirin with platlets, LMW heparin with protamine and warfarin with vit K or FFP. In DIC – 6 cryopercipitate + 4 FFP + 2 platlet
  • Uterine rupture – incomplete type: repair;  complete type: TAH
  • Uterine inversion – immediately replace the uterus through the cervix by manual compression using as much of the hand as possible and maintain uterine contraction with an oxytocin.
  • Retained product of conception – early: manual extraction of the placenta under anaesthesia; late – blunt curettage
  • Uterine infection – antibiotics, uterotonics and antipyretics.

List of drugs available for hamostasis in PPH

  1. Syntometrine (i/m) : oxytocin 5 units + ergometrine 0.5 mg (long acting)

c/i: HPT and cardiopathy

  1. Syntocinon (i/v) : oxytocin 10 units (short acting)

40 units in 1 pint over 4 hours, 125 ml/hr

  1. Hemabate (i/m) : PGF2α

If 3 times syntometrine (fail) → give hemabate up to max 8 times, every 15 min (fail) → tamponade or balckmore tube/rusch catheter (fail) → hysterectomy

ALWAYS MONITOR VITAL SIGNS & SIGNS INDICATING

Active 3rd stage management to prevent PPH

  1. Indentify risk factors.
  2. Early cord clamping.
  3. Control cord traction.
  4. Administration of syntometrine (i/m)
  5. i/v syntocinon.
  6. Massage uterus.
  7. Set 2 lines (large bore).
Comments
  1. lulu says:

    good summary,but i think it is better its better if we have a list, from a-z what u should do, when u were called in ta midnight, where ur mo is sleeping nicely, and ta midwife telling u: DOctor, patient bleeding!!
    tats wat we need during housemanship in m’sia, right?

  2. Very good post. I will be going through some of these issues as well.
    .

  3. My brother recommended I would possibly like this blog.
    He used to be entirely right. This post actually made my day.
    You cann’t imagine simply how so much time I had spent
    for this information! Thank you!

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