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Postpartum bleeding (perinatal bleeding) (causes (Uterine atony risk…
Postpartum bleeding (perinatal bleeding)
Blood loss of:
over 500ml in vaginal delivery,
over 1000ml in cesarean section.
Early postpartum bleeding – blood loss up to 24 hours after delivery
Late postpartum bleeding – blood loss from 24 hours to 6 weeks after delivery
Definition of massive (severe) haemorrhage
blood loss with velocity over 150ml/min (loss of over 50% of circulating blood during 20 minutes)
sudden loss of over 1500-2000ml of blood (uterine atony; loss of 25-35% of blood volume).
Two mangement protocols
Basic (A): at blood loss 500-1000ml, without shock symptoms.
Full (B): at blood loss over 1000-1500ml or shock symptoms presence (tachycardia/bradycardia, hypotension, oliguria)
causes
Obstetric coagulopathies:
HELLP, von Willebrand, PIH, DIC, preterm placental abruption.
Birth canal lacerations
Uterine atony (up to 75-90% of all haemorrhages):
polyhydramnios, macrosomy, multiple gestation, medications, prolonged delivey, vaginal operative delivery, chorioamnionitis, abnormal placentation, leyomyomas, placental remains
Uterine atony risk factors
excessive uterine distention
prolonged, operative, quick, induced labor
cesarean section, placental remains
tocolysis, obesity
age >35 years, leyomyomas
uterine malformations, atony in history
Placental remains
atony and bleeding in 4th stage of delivery
puerperial infection
possibility of neoplasmatical transformation of placetnal tissue
Treatment
uterine cavity emptying (manual or instrumental placental separation, curettage, massage of uterine muscle and cavity)
uterotonics – oxytocin, carbetocin, ergometrin, PGF (karboprost, dinoprost, misoprostol)
surgical treatment
uterine tamponade (Bakri baloon or gauze)
uterine arteries embolisation – 30-60 minutes
hemostatis sutures
uterine arteries
tubal branches of ovarian arteries
internal iliac artery
B-Lynch suture – on anterior and posterior uterine wall, should induce contraction
Hayman suture – modification of B-Lynch
Hysterectomy
Indications
urgent: haemorrhage, uterine muscle rupturę, hematoma, atony, uterine inversion, abnormal placentation, placenta praevia, placental abruptio, endometritis
not urgent: layomyomas, neoplasms (cervix, overies)
elective: previous cesareans section, endometriosis, patient’s request