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Postpartum Hemorrhage(PPH)

Major causes of death for


pregnancy women
maternal mortality)

Postpartum hemorrhage28%)
heart diseases
pregnancy-induced hypertension
(or Amniotic fluid embolism )
infection
Definition of PPH
be defined as a blood loss exceeding 500ml
after delivery of the infant

PPH: occurs in 24 hour of delivery


the late PPH: occurs after 24 hour of delivery
to 6 weeks
Major causes
Uterine atony (90%)
lacerations of the genital tract(6%)
retained placenta(3%-4%)
coagulation defects (blood dyscrasia)

(4T: tone, tissue,trauma,thrombin)


1. Uterine atony
Local factors
overdistention of the uterine
(hydramnios, multiple pregnancy,
macrosomia )
condition that interfere with
contraction(leiomyomas)
complications(PIH,anaemia, placenta
praevia
Systemic factors:
nervous
drugs(magnesium sulfate,sedative)
abnormal labor(prolonged,precipitous)
History of previous PPH
Preeclampsia, abnormal placentation,
pathology
Contraction constricting the spiral
arteries
preventing the excessive bleeding from
the placenta implantation site
the uterine atony give rise to PPH
when no contraction occur
Prevention and therapeutic of
uterine atony
Administration of medicine:
promotes contraction of the uterine corpus
decreases the likelihood of uterine atony

Oxytocin agents
Methegine
prostaglandin
Mechanical stimulation of uterine contraction:

Massage of uterus through the abdomen and


bimanual compression

intrauterine packing
Surgical methods
If massage and agents are unsuccessful:
Ligation of the uterine arteries
ligation of the hypogastric arteries
selective arterial embolization
hysterectomy
taking into account the degree of
hemorrhage,the overall status of patient,her
future childbearing desires
2. Lacerations of the genital
tract
Causes:
Instrumented delivery (forceps)
manipulative delivery(breech
extraction,precipitous labor, macrosomia)
Types:
perineum laceration
vaginal laceration
cervical laceration
perineum and vaginal laceration

The first degree tear:


involves only skin and a minor part of the
perineal body
the second degree tear:
involves the perineal body and vagina
the third degree tear:
involves the anal sphincter and anal canal
management
Vaginal examination soon after delivery

repair:
cervical laceration >2cm in length and be
actively bleeding
laceration of vaginal and perineum
3. Retained placenta

Separation and explosion of placenta is


caused by strong uterine contraction

Placenta tissue remaining in the uterus


prevent adequate contraction and predispose
to excessive bleeding
causes:
adherence of placenta (previous cesarean
delivery,prior uterine curettage)

succenturiate placenta

placenta accreta (into the decidua)


placenta increta(into the myometrium)
placenta pericreta(through the myometrium
to the peritoneal)
Prevention and treatment
The placenta should be examined to see that it
is complete or not
part of placenta is missing, removed digitally
not separated, manual removal of placenta is
done
hysterectomy is required for placenta
increta(percreta,accreta)
uterine contraction drugs
4. Coagulation defects
Acquired abnormality in blood clotting:
abruptio placenta,
amniotic fluid embolism
severe preclampsia
congenital abnormality in blood clotting:
thrombocytopenia
severe hepatic diseases
leukemia
disseminated intravascular
coagulopathy(DIC)
if bleeding persists in spite of all other
treatment described, DIC should be
suspected
the blood passing from the genital tract is
not clotting
shock: reduction of effective circulation
inadequate perfusion of all tissues
oxygen depletion
depression of functions
Record:
pulse
blood pressure
maternal heart rate
central venous pressure
urine output

Lab tests:
Hb,
BT(bleeding time), CT( clotting time),
platelets count
fibrinogen
prothrombin time and patial thromboplastin
time
FDP
womens group and cross-matching
Treatment:
the key is correcting the coagulation defect
resuscitation must be started as soon as possible
infusion of crystalloid(saline) and Dextran is
started firstly while arranging the blood
transfusion
blood transfusion is essential
infusion of platelets, fresh frozen plasma, FDP ,
clotting factors,
Potential complications of PPH:
Postpartum infection
Anemia
Transfusion hepatitis,
Sheehans syndrome
Ashermans syndrome

The best management of PPH is prevention


Key words

the definitio n of HHP


The causes of HHP
treatment methods of Uterine atony
the types of retained placenta
the degrees of the perineal and vaginal
laceration

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