Postpartum Hemorrhage

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Postpartum Hemorrhage

• Pramote Srikaew MD.
• Dip.Thai Broad of OB-GYN,
• Dip.Thai Broad of preventive medicine

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Postpartum hemorrhage

• Definition loss 500 ml or more of blood after
  vaginal delivery or 1000 ml or more after
  cesarean delivery
• Normal pregnancy-induced hypervolumia 30-60 or
  1-2 L
• Normal control of hemorrhage of placenta site
  contraction and retraction of myometrium to
  compress the vessels

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Cause of PPH

• Uterine atony
• overdistended uterus-large fetus, twins,
• hydramnios
• prolong labor
• very rapid labor
• Oxytocin-induced or augmented labor
• choriamnionitis
• some general anesthesia-halogenated
• hydrocarbon

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Uterine Atony
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Cases of PPH

• Retained Placental tissue
• avulsion cotyledon
• Succenturiated lobe
• Abnormally adherrent-accreta,
• increta,percreta

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Causes of PPH

• Uterine Inversion
• Rupture uterus
• Lacerations and hematoma
• Episiotomy extensions
• Lacerations of perineum, vagina
• or cervix

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Uterine Atony

• Atonic uterus is flaccid and not firm to
  palpation
• If bleeding persists despite a firm,
  well-contracted uterus, the cause of hemorrhage
  in most likely from laceration

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Oxytocin

• If uterus is not firm, vigorous fundal massage is
  indicated
• 20 U of oxytocin in 1000 mL of RLS or NSS I.V. 10
  mL/min(200 mU/min) with uterine massage
• Oxytocin should never be given undiluted bolus
  dose as serious hypotension or cardiac
  arrhythmias

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Ergot Derivatives

• Methylergonovine(Methergine), 0.2 mg, I.M. or
  I.V.
• If give i.v. may cause dangerous hypertension
  especially in the woman with preeclampsia

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Prostaglandins

• 15-methyl derivative of PGF2alpha (Hemabate)
• Initial dose 250 mcg(0.25mg) i.m.
• Repeat if necessary at 15-90 minute interval
• Maximum of eight dose
• Pulmonary airway and vascular constriction, side
  effects include diarrhea, hypertension, vomiting,
  fever, and tachycardia

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Management of bleeding Unresponsive to Oxytocin

• Employ bimanual uterine compression
• Obtain help
• Begin blood transfusion,
• Explore the uterine cavity manually for retained
  placental fragment or laceration
• Thoroughly inspect the cervix and vagina after
  adequate exposure
• Add second large-bore I.V. catheter
• Foley catheter is inserted to monitor urine output

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Uterine temponade
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Bimanual compression
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B-Lynch uterine compression
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B-Lynch ligation at BKLH
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Postpartum hysterectomy
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???????????????????? ??????

• ??????????????????????????????????????????
  ????????
• ??????
• ?????????????????????????
• ??????????????????????
• ??????????????????????
• Blood Bank ???????
• ??????????????????????????????????????????????

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ANC

• Identify risk for PPH
• Uterine atony macrosomia , twins, hydramnios
• Rupture uterus previous C/S, myomectomy
• Abnormal adherent Previous C/S, D_at_C
• Placenta previa
• Should be take blood for blood group, counseling
  for risk of PPH

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Labor Room

• admit check ??? identify ??????????????? PPH
• ???????????????? lab ????? confirm ??????? blood
  bank ?? group ??????????
• ???????????????? PPH ?????????????????
• ?????????????????????????????
• ??????????????????????????????????
• ?????????????? induction of labor ??????
• ?? case prolong labor
• ?? case ???????????(precipitate labor)
• ?????????
• ?????????????????????????????????

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????????????????

• ??????????????? ??? oxytocin 10 U im.
  ???????????????? controlled cord traction
• ???? ??? methergin .2 mg im. ???? iv.??????????
• ??????????????????????????????????????????????????
  ???????????????????????? ????? ??????????????? 30
  ????
• ?????????????????????????????? ??????????????
  ???????????????????? 15 ????
• ??????????????????? uterine massage
  ??????????????? uterine massage ?????

21
????????????????

• ???????????????????????????????????????????
  methergin 1 dose ???? ??? dose ??? 2 ???
• ???????????????? ???????????? ????? x-macth
  ?????? i.v. catheter ???? RLS ??? oxytocin 20 U
  i.v. 10 mL/min ?????????????????
• ?????????????????????????????????????????????
  explored vagina, cervix ??? uterine cavity
• ????????????????? ????? Cytotec 2-4 tablets
  rectal suppository ????????????????
• ????????????????????? Nalador 1amp NSS 100 cc
  i.v. ?? 30 ???? ??? retained foley cath. ????
  i.v.??????? 2 ???? RLS ???? NSS

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?????????????

• ???????????? PPH ??case ??? set C/S indication
  previous C/S, placenta previa, abruptio placenta,
  CPD , ????????? preeclampsia, failed induction,
  twins, high parity, chrioamnionitis
• ?????? oxytocin, methergin, ??? naladol ????????
• ???????????? hypogastic artery ligation
  ????cesarean hysterectomy ????????

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????????

• Observed uterine atony ??????????????? 24 ???????
  ????????????????????????????? detect uterine
  atony ??? 15 ???? ????????????????? detect
  uterine contraction ??? 1-2 ??.???????????????????
  ???
• Blood for HCT ??????????????? 4 ??.
  ???????????????
• ??????????????? prepereal infection
• ????????????????? Sheehan syndrome failure of
  lactation

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????????????????????????????????????????

• ?????????????? Sheehan syndrome ??????????
  ??????????????? breast atrophy, loss of pubic and
  auxiliary hair, hypothyroidism ??? adrenal
  cortical insufficiency