POSTPARTUM HAEMORRHAGE

Dr. Ahmed Al Harbi Consultant Obstetrician & Gynecologist

POSTPARTUM HAEMORRHAGE
Definition Excess blood loss after delivery (>500ml ) (>500ml Types - Primary PPH in the first 24 hours -Secondary PPH up to 6 weeks. weeks. Massive PPh may be truly terrifying and its management requires experience and a clam sense of purpose that is best obtained by a thorough knowledge of protocols and participation in obstetric haemorrhage practice drills. drills.

POSTPARTUM HAEMORRHAGE
Aetiology and management The most important cause of massive PPH is uterine atony when the uterus is not contracted. Steps to stop bleeding
1. Massaging the uterus to cause it to contract 2. Bimanual compression 3. Uterine contraction is maintained by ergometrine and high dose intravenous Syntocinon 4. The bladder should be emptied 5. Prostaglandin F2-alpha (Haemabate) may be injected systemically or directly into the myometrium through the anterior abdominal wall.

POSTPARTUM HAEMORRHAGE
Fibrin degradation products, which are increased in disseminated intravascular coagulation, may themselves act to relax the uterus. uterus. When bleeding persists despite uterine contraction, look for genital tract trauma and repair it. If the patient's haemodynamic status is it. not improving, or is deteriorating despite apparent control of revealed bleeding, consider hidden bleeding such as broad ligament or paravaginal bleeding or even uterine rupture. rupture. If conservative measures are not succeeding, move to surgical solutions sooner rather than later. Is the uterus empty? Can later. tamponade be effected by the use of intrauterine balloons such as the Rusch urological catheter? Rarely, bilateral internal iliac artery ligation or hysterectomy may be necessary. necessary.

POSTPARTUM HAEMORRHAGE
Secondary PPH
1. Retained products or conception 2. Uterine infection

Massive haemorrhage

Summon senior multidisciplinary help

- Resuscitate - Replace and maintain fluid volume - Investigate status and cause of bleeding - Arrest blood loss

RETAINED PLACENTA
Incidence
Retained placenta is found in 2% of deliveries. deliveries. The frequency of retained placenta is markedly increased (twenty-fold) at gestation <26 weeks, (twentyand even up to 37 weeks it remains tree times more common than at term. At term, 90% of term. 90% placentas will be delivered within 15 minutes. minutes. Once the third stage exceeds 30 minutes, there is a ten-fold increase in the risk of haemorrhage. tenhaemorrhage.

RETAINED PLACENTA
Management When the placenta is delivered, it should be inspected for completeness. completeness. Manual exploration of the uterine cavity is required. required. This will need to be undertaken under anaesthesia. anaesthesia. If the placenta is retained as a whole, if it is within the uterus, the operator (wearing a gauntlet glove) should use the fingers of one hand, held as a 'spatula' to lift the placenta, whilst the hand on the abdomen balances these movements with downward pressure on the uterus. A uterus. gauze swab around the exploring fingers. Curettage with fingers. a blunt instrument. instrument. Antibiotics should be routinely administered. administered.

PLACENTA ACCRETA
Definition
Placenta accreta is a retained placenta that is morbidly adherent to the uterine wall. wall.

Epidemiology
Placenta accreta is a serious cause of haemorrhage. haemorrhage. Lower segment Caesarean section appears to increase the risk of subsequent placenta praevia, and there is a wellwell-documented associated between placenta praevia and previous Caesarean section and placenta accreta. accreta.

PLACENTA ACCRETA
Management 1. Hysterectomy 2. Simple excision of the site of trophoblast invasion with over sewing of the area to the uterine 3. Internal iliac artery ligation

RETAINED PLACENTA
Key points

Anticipate haemorrhage, insert an intravenous infusion line, take blood for full count, group, save and catheterize - Check that the placenta is not in the cervical canal or vagina prior to giving anaesthetic - Give prophylactic antibiotics - Carry out manual removal call senior help if there is accrete and/or heavy bleeding
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HAEMATOMAS
Vulval and paravaginal haematomas
Definition 1. Infralevator haematomas include those of the vulva and perineum, as well as paravaginal haematomas and those occurring in the ischiorectal fossa 2. Supralevator haematomas spread upwards and outwards beneath the broad ligament or partly downwards to bulge into the walls of the upper vagina. These haematomas can also track backwards into the retroperitoneal space.

VULVAL & PARAVAGINAL HAEMATOMAS

(a) Vulval

(b) Para vaginal haematomas

VULVAL & PARAVAGINAL HAEMATOMAS

Incidence and associations

An acceptable definition would be any haematoma >4cm in diameter. The incidence of these is approximately 1:1000 deliveries. The injury if frequently related to episiotomy Intact perineum

VULVAL & PARAVAGINAL HAEMATOMAS

Diagnosis Although a vulval haematoma is usually obvious, a paravaginal haematoma may be missed, with no symptoms until shock develops. develops. In general, the symptoms depend upon the size and rate of haematoma formation. formation. Some genital haematomas may be up to 15cm diameter. 15cm in diameter. Management 1. Resuscitative measure 2. Surgical evacuation of the haematoma - haematoma is <5cm in diameter <5 - not expanding

VULVAL & PARAVAGINAL HAEMATOMAS

Observation to limit haematomas

1. Ice packs 2. Pressure dressings 3. Appropriate analgesia

Need for surgical interventions

1. Haematomas >5cm in diameter 2. Rapidly expanding

VULVAL & PARAVAGINAL HAEMATOMAS

Technique The incision should be made via the vagina. vagina. If a figure of eight suture does not achieve haemostasis, either a drain or haemostasis, a pack can be used. used.

MANAGEMENT OF HAEMATOMAS
 A trap for the unwary beware occult haemorrhage in a 'collapsed' postpartum patient  Large vulval haematomas benefit from drainage: - leave the wound open - leave a drain  Broad ligament haematomas are usually managed conservatively

SUBPERITONEAL HAEMATOMAS
Incidence and associations Subperitoneal haematomas (broad ligament) are much less common than genital haematomas: 1 in 20,000 haematomas: 20, deliveries. deliveries. Spontaneous vaginal delivery, Caesarean section or forceps operations. operations. Patients presenting immediately tend to show signs of lower abdominal pain and haemorrhage. haemorrhage. Management A conservative approach is recommended. If It is not recommended. possible to maintain a stable haemodynamic state, prompt surgical exploration is recommended and a hysterectomy may be indicated. indicated.

INJURIES TO THE CERVIX

After a vaginal delivery, the majority of women will have lacerations and/or bruising of the cervix. cervix. Bleeding does not appear to be arising from the vagina or perineum and which continues despite a well-contracted uterus is an indication for wellexamining the cervix. cervix. Deep lacerations, and particularly those that involve the vaginal vault, need to be managed in theatre under anaesthesia. anaesthesia. A laceration into the vault could extend forward to the bladder or laterally towards the uterine artery at the base of the broad ligament. ligament.

INJURIES TO THE CERVIX

Management Prompt recognition of the injury and action to control the bleeding are essential Repair For repairing a cervical tear, good visibility using rightright-angle retractors is essential. Using two essential. pairs of ring forceps applied to the cervix at any one time, it is possible to inspect the whole circumference accurately. Identification of the accurately. apex of the tear is essential before commencing repair. repair.

INJURIES TO THE CERVIX

Key Points

 The cervix often looks damaged but is very rarely associated with bleeding  Ventouse prior to full dilation has been implicated in injury to the cervix

UTERINE RUPTURE
Rupture, or tearing, of the uterus occurs most commonly in association with a previous scar, uterus, typically previous Caesarean section. Unrecognized perforation of section. the uterus in a previous termination of pregnancy. pregnancy. Almost all cases occur in labour. labour.

Patients Complain
1. 2. 3. 4. Continuous abdominal pain Vaginal blood loss Contractions cease The fetal heart rate pattern becomes abnormal

UTERINE RUPTURE
If rupture occurs in the second stage of labour, labour, it is frequently not recognized. The fetus is recognized. usually delivered by ventouse or forceps for 'fetal distress'. distress'. The mother will bleed internally and start to show signs of circulatory collapse whilst complaining of abdominal discomfort. discomfort. Immediate laparotomy is necessary when uterine rupture is suspected. Sometimes it is suspected. possible to repair the uterus, but frequently the only safe way forward is hysterectomy. hysterectomy.

UTERINE INVERSION

UTERINE INVERSION
Descent of the uterine fundus into the cavity, through the cervix or even though the vulva is a very rare event. event. The inverted uterus may be seen at the vulva, felt in the vagina or in lesser cases, identified as a dimpling of the uterine fundus on abdominal examination. examination. The patient may be shocked out of all proportion to visible blood loss. Do not remove the placenta if it is still loss. attached; attached; this will increase the bleeding. Immediately bleeding. replace the uterus through the cervix by manual compression. compression.

END OF PRESENTATION THANK YOU