Postpartum Hemorrhage
Definition, etiology & classification
Etiology
Classification
Definition
defined as greater than 500 mL estimated blood loss in a vaginal delivery or greater than 1000 mL estimated blood loss at the time of cesarean delivery. Cumulative blood loss greater than 1000 mL with signs and symptoms hypovolemia within 24 hours of the birth process, regardless of the route of delivery.
Trauma
Tissue
Tone
Thrombin
Uterine atony
Laceration
Ruptur
Hematoma
Inversion
Retained placenta
Invasive placenta
Coagulopathy
Early postpartum hemorrhage
: <24 hours of delivery,
Late postpartum hemorrhage
: >24 hours - 6 weeks after delivery.
Normal Labor
Seven discrete cardinal movements of the fetus occur over the course of labor and delivery: engagement, descent, flexion, internal rotation, extension, external rotation or restitution, and expulsion.
Risk Factor
Antepartum hemorrhage
Augmented labor
Chorioamnionitis
Fetal macrosomia
Maternal anemia
Maternal obesity
Multifetal gestation
Preeclampsia
Primiparity
Prolonged labor
Pathophysiology
Management & Education
Uterine atony is a failure of the uterine myometrial fibers to contract and retract. Trauma to the genital tract in pregnancy results in significantly more bleeding . The trauma specifically related to the delivery of the baby, either vaginally in a spontaneous or assisted manner or by cesarean delivery, can also be substantial and can lead to significant disruption of soft tissue and tearing of blood vessels.
Diagnostic Approach
Retained Placenta
Trauma
Uterine atony
Clinical findings
- Uterus feels relaxed
- Boggy & soft
Investigations
- Full blood count
- Coagulation profile
- Urea & electrolytes
- Abdominal USG (Uterine rupture or intraperitoneal bleeding)
Clinical findings
- Bleeding from trauma area
- Extension of uterine angles
- Tears during CS
- Uterine rupture
Investigations
- Inspection
- USG
Clinical findings
- Retained placenta and membranes
Investigations
- Examination under anaesthesia
Coagulapathy
Clinical findings
- Continuing bleeding
- Contracted uterus
Investigations
- Full blood count
- Urea and electrolytes
- Coagulotion profile
Shock managements
- Resusitation
- Transfusion
- Provide oxygen by mask
- Crossmatch
Trauma
Tissue
Uterine atony
Thrombin
- Oxytocint 20-40 IU in 1L normal saline
- Carboprost (Hemabate) 250 mcg IM (2 mg total)
- Methylergonovine (Methergine) 0,2 mg IM every two hours- four hours
- Misoprostol 800-1000 mcg rectally or 600-800 mcg sublingually/orally
- Suture lacerations
- Drain expanding hematoma
- Replace inverted uterus
- Inspect placenta
- Explore uterus
- Manual removal of placenta
- Curettage
- Observe clotting
- Check coagulation studies
- Replace clotting factors, platelets
- Supply fresh frozen plasma
Refers to Sp.OG
Complication & prognosis
Prognosis
Complications
Anemia
Anterior pituitary ischemia with delay or failure of lactation (i.e., Sheehan syndrome or postpartum pituitary necrosis)
Blood transfusion
Death
Dilutional coagulopathy
Fatigue
Myocardial ischemia
Orthostatic hypotension
Postpartum depression
Depends on its duration, the amount of blood loss, comorbid conditions, and eh effectiveness of treatment
Anggraini Barus
1808260110