PPH

Post-partum haemorrhage

(PPT)
2015-2016


Primary PPH..loss of blood estimated to be > 500 ml in NVD & > 1000 ml in CS within 24 hr of delivery.
Secondary PPH..abnormal vaginal bleeding from 24 hrs-6 wks after delivery.

Brasss-V drape

Primary PPH

Aetiology....4 T.s


Tone
Tissue
Trauma
Thrombosis

Assessment

• History & Examination
• ...continious bleeding after delivery of placenta
• ...feeling unwell &/or fainting
• ...pallor, cold extremities
• ...hypotension, tachycardia
• ...agitation &/or confusion
• ...exam of lower genital tract.

Management

1-recognition
2-communication
3-resuscitation
4-monitoring & investigations
5-treatment


3-resuscitation
*immidiate call for help
*assessment of airway & breathing initially
*wide bore IV line with bl sent for cross match
*rapid IV infusion
*give blood, colloid & crystalloid
*keep the patient warm & lying flat
*IV antibiotics

4-monitoring & investigations

*monitoring of pulse rate, bl.p, urine output & O2 saturation.
*CVP monitoring

5-treatment

A-mechanical & medical
• a-Tone
...mechanical uterine message
...bimanual uterine compression
...non-pnematic anti-shock garment (NASG).

...Oxytocin (syntocinon)

...Ergometrine
...Dinoprost & Carboprost.

NASG

• b-Trauma of genital tract
...pressure & repaire

• c-Tissue

...oxytocin
...empty the bladder
...transfer to the theater.

• d-Thrombin

B-Surgical treatment
• a-balloon tamponade
• b-hemostatic uterine bracing suture (B-Lynch)
• c-bilateral ligation of uterine arteries.
• d-bilateral ligation of internal iliac arteries.
• e-selective arterial embolization
• f-hysterectomy.

catheter

Bakri balloon
. Sengstaken Blakmore.

B-Lynch suture

Complications

-Shock
-Collapse
-DIC
-Sheehan syndrome.
-Maternal mortality.

Prevention

*be aware of risk factors
*treat anemia antenatally
*active management of 3rd stage of labour
*prophylactic oxytocin or syntometrine
*nipple stimulation & breast feeding.


Secondary PPH
Aetiology
• 1-subinvolution of uterus (retained tissue, endometritis).
• 2-lower genital tract laceration
• 3-surgical injury
• 4-dehiscence of CS
• 5-coagulopathy & bleeding disorders

Endometritis risk factors

-CS
-prolong rupture of membranes
-sever meconium stained liquor
-long labour with multiple pelvic examination
-manual removal of placenta
-at extremes of maternal age
-low socio-echonomic state
-maternal anemia
-prolonged surgery
-internal fetal monitoring.

Assessment

History & Examination
...offensive lochia & abdominal cramp.
...fever, rigor, tachycardia
...uterine tenderness
...enlarged uterus
...open cervical os


Investigations
...FBC
...blood culture
...C-reactive protein
...high vaginal swab
...USG
...duplex color doppler.

Management

...patient observation + antibiotics
...oxytocine &/or ergometrine
...misoprostol
...retained tissue should removed by forceps.
...ellective curettage with antibiotics.
...iron supplementation
...packing of uterus
...laprotomy & tie the uterus or internal iliac A.s
...hysterectomy (rarly).