Postpartum Hemorrhage

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Postpartum Hemorrhage

• Pongsun Puntachai , MD
• OB GYN Department
• Sanpasittiprasong hospital , Ubon Ratchathani

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Definition

1. Blood loss gt 500 ml after 3rd stage of labor
   after vaginal delivery
2. Blood loss gt 1000 ml after cesarean section

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Classification

1. Early PPH ? ???????????? 24 ???????????????
2. Late PPH ? ???????????? 24 ???????????? 12
   ??????? ????????

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Etiology

• Early PPH
• - Uterine atony
• - Retained placental fragments
• - Retained placenta
• - Genital tract lacerations
• - Placental adherence
• - Uterine inversion

• 2. Late PPH
• - Endometritis
• - Retained placental
• fragments
• - Disorders of coagulation

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• Uterine atony

The most common cause of early PPH

• Normally, contraction of the uterine muscle
  compresses the vessels and reduces flow

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• Definition
• A condition in which the uterine corpus does not
  constrict properly
• Continued blood loss from the placental site

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Risk factors

• Overdistended uterus ? multiple pregnancy,
  hydramnios, macrosomia
• Fatiqued uterus ? precipitated labor, prolonged
  labor, multiparity, drug eg. Oxytocin
• Intrauterine infection ? prolonged PROM
• Abnormal uterus ? myoma uteri, uterine anomaly

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Diagnosis

• ???????????????????????? ?????????????????
• ???????????????????????????? 3

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• Management

1. Uterine massage 2. Medical treatment
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?? ???? ?????????? ?????????????? ??????????
Oxytocin (syntocinon) -20 ?????/???????? 1 ??????????????? 60 ???/???? -10 ?????????????? ?????????????? oxytocin ?????????? 3 ???? ????????? ????????????????? ???????? ??????? ?????
Methylergometrine maleate (Methergine) 0.2 ?????????????????????????????????? 0.1 ????????? ( 5 ?????) ????????????????????????? ??????????????? ???????? ??????? ??????????????? ?????
Sulprostone (Nalador) 500 ??????????????????? 1 ??????? 1500 ????????? ?? 24 ??????? ???????? ??????? ??????? ???????? ????? ???????? ??????????? ???????? ?????????? ?????? ????????????????? ?????????? ?????? ????? ????? ?????? ???????????????
Misoprostol (Cytotec) 800 ???????????????????? - ???????? ????? ?????????? prostaglandin
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• 3. ????????????????? ?????????????????????????????
  ?????????????? ??????????????????? ??????
• 3.1 ????????????????????????
• 3.2 ??????????????????????????????
  ????????????????????????????????????????????
  crystalloid ??? oxytocin
• 3.3 ????????
• 3.4 ?????????????????????????????
  ?????????????????????????????? ?????????????????
• 3.5 ?????????????? ????????????????
• 3.6 ??????????????????????? ????????????????????
  ???????????????? shock

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• 4. Resuscitation
• 5. Bimanual
• uterine
• compression

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• 6. Surgery e.g.
• 6.1 ?????????????
• - internal iliac artery ligation
• (hypogastric ligation)

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• - uterine artery ligation

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• - Selective arterial embolization

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• - Uterine compression suture (B-Lynch)

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• 6.2 ????????????????
• - Hysterectomy

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• Retain placenta
• Definition ???????????????????????????????????
• Normally after the placenta is delivered, uterus
  contracts down to close off all the blood vessels
  inside the uterus.
• But in retained placenta, the uterus cannot
  contract properly, so the blood vessels inside
  will continue to bleed

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• Etiology
• 1.Retained placental fragments
• - ????????????????????????????
• - ???????????? (placenta succenturiata)
• - ?????? placenta adherence

2.Retained placenta - ?????? placenta
adherence - ?? Constriction Ring ,cervical clamp

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• Retained placental fragments

Diagnosis - Ultrasound - ????????????????????
?
Treatment - Uterine curettage
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• Retained placenta

Diagnosis ?????????????? 30 ????
Treatment - Manual removing
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• Manual removing
• Blood,Fluid
• Empty bladder
• Antibiotic (Ampicillin Metronidazole)
• ??????????? (manual removal under anaesthetic)

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2.????????????????????????????????????????????????
1.??????????????????????
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3.????????????????????????????????????? fixed
????????
4.?????????? ??????????????????????????
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• Genital tract lacration
• Etiology

• Precipitated labor
• OB procedures
• Breech delivery
• Inappropriate episiotomy

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• Diagnosis
• ????????????
• ??????????????????? ???????????????????????
• ???????????????

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Vaginal tear

• Usually longitudinal
• Forceps or vacuum operation, but they may even
  develop with spontaneous delivery
• Lacerations of the anterior vaginal wall in close
  proximity to the urethra are relatively common

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• Management
• They are often superficial with little to no
  bleeding,and repair is usually not indicated
• If lacerations are large enough to require
  extensive repair, difficulty in voiding can be
  anticipated and an indwelling catheter placed

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• Cervical tear

• Usually, less than 0.5 cm. and upper third of
  the vagina ? no need for repair
• - Deep cervical tears require surgical repair

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• Placenta adherence
• Definition
• ?????????????????????????????????????????????????
  ???????? trophoblast cell ???????????????
  decidual basalis ?????????? fibrinoid

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• Classification
• Placenta accreta ???????????????????????????????
  ???
• Placenta increta ????????????????????????????????
  ????????
• Placenta percreta ???????????????????????????????
  ?????????????????? serosa ????????

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• Risk factors
• -Placenta previa
• -Previous cesarean section
• -Previous curettage
• -Multiparity

Diagnosis -Ultrasound -MRI
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Management

• 1. Supportive therapy
• - Blood replacement therapy
• - Intravenous fluid
• 2. ??????????????????????????? placenta accreta
  ??????????????????????????????????
• 3. Hysterectomy

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• 4. Alternative treatment
• - Uterine artery embolization
• - Uterine artery or internal iliac artery
  ligation

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• Uterine inversion

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• Definition
• ??????????????????????????????????????????????
• Risk factors
• 1.??????????????????
• 2.??????????????????????
• 3.?????????????? ????????????????? ???? placenta
  accreta
• 4.???????????????????????????
• 5.???????????????? ??????????????????

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• Classification
• 1.First degree ????????????????????????????????
  ????????????
• 2.Second degree ????????????????????????????????
  ????????????????????????
• 3.Third degree ?????????????????????????????????
  ?(complete version)
• 4.Fourth degree ??????????????????????????????

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• Diagnosis
• 1.??????????????????
• 2.???????????????????????????????????????????
• ( cup-like defect )
• 3.????????????
• 4.????? ultrasound

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• Management
• Conservative treatment
• IV fluid , blood transfusion
• Anesthesia (halothane) and push
• Remove the retained placenta then push back the
  uterus
• Oxytocin and stop halothane immediately
• Observation for hemorrhage and recurrent uterine
  inversion
• If failed conservative treatment, surgery may be
  indicated

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• Surgical treatment
• Huntington maneuver ?????????????????????????
  Allis ???? Babcock forceps ??? round ligament
  ????????????????????????????
• Haultian maneuver ????????????????????
  ???????????????????????????????? midline
  ??????????????????????????????????????????????????
  ???????? ??????????????????????

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• Huntington maneuver

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• Haultian maneuver

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• Late PPH
• Etiology
• - Endometritis
• - Retained placental
• fragments
• - Disorders of coagulation

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• Diagnosis
• - ??????????
• - ????????????????????????????
• - ????????????????????????????
• - ????????????
• - ?????????
• - ????????????????????????

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• Initial treatment
• ????????????????????????????????????
• ????????????????????????????
• ??????????????

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Endometritis

• Gram-negative enteric bacteria
  E.coli,Klebsiella,Enterobacter,Pseudomonas,Serrati
  a
• Gram-negative anaerobes Bacteroides
• Gram-positive bacteria S. pyogenes
• Viruses Varicella
• - Fungal infection

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Disseminated intravascular coagulopathy(DIC)

• ?????

??? Coagulating factor
Coagulating factor
Hemorrhage
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• Risk factors

• Cesarean delivery
• Prolonged rupture of membrane gt24 hrs.
• Prolonged labor with multiple vaginal
  examinations
• Prolonged internal fetal monitoring
• Maternal anemia

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• Sign and symptom

- ??????????????????????? ??????? 2 ??????? -
????????????????????? - ??? - ????????????????????
? - ?????
Lab investigation - Increased WBC
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• Management
• 1. Ampicillin 2 gm iv q 6 hrs
• Gentamicin 5 mg/kg iv q 24 hrs
• Metronidazole 500 mg iv q 8 hrs
• 2. Clindamycin 600 mg iv q 6 hrs
• Gentamicin 5 mg/kg iv q 24 hrs

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• ?????????????????????
• ????????????????????????????????????????????????
  ????????????????????????????????????
• ????????????????????
• - ????????????????????????????????
• - ???????????????????????????????????
• - Gas gangrene ????????
• - ????????????????????????????????????

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• Retained placental fragments
• - Curettage

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• Uncontrolled late PPH
• - Uterine vessel ligation
• - Internal iliac artery ligation
• - Hysterectomy

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• ???????????????????????????
• - ???????????????
• - ?????????????????? 2-3 ???????
• - ???????????????????? Sheehan syndrome

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• Active management
• of the third stage of labour

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• 1.??? oxytocin 10 unit im. ????????????????????
  ????????????????????????????? ????????????????????
  ???????????????????????????????????????????
• 2. ??? Clamps ???????????? ??????????????????
• 3. ??????????????? controlled cord traction
  ?????????????????????????? ???????????????????????
  ???????
• 4. ?????????????????????????????????? ?????????
  counter traction ????????????????????????????
  ??????????????????????

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• 5. ??????????????????????????????
  ?????????????????????????????
• ????????????????????
• 6. ?????????????????? ????????????????????????????
  ?? ?????????????????????????????
• 7. ??????????????????????????????????? ?????????
  15 ???????????????????
• 8. ???????????????????????? ???????????????

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• ??????????????????????????????????
  ??????????????????????????

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Thank you

• Pongsun Puntachai , MD
• OB GYN Department
• Sanpasittiprasong hospital , Ubon Ratchathani