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1、Post Partum Hemorrhage,District I ACOG Medical Student Teaching Module 2010,Post Partum Hemorrhage-Definition,Commonly defined as.SVD 500cc blood lossC/S 1000cc blood loss*PPH generally refers to GA 20wks,Other Definitions,Hematocrit Change defined as change 10%but not useful in acute settingNeed fo
2、r Transfusion variable practiceHemodynamic stabilityTiming early or lateSymptomatic,Relevance,One of top five causes of maternal mortality anywhere#1 cause maternal mortality worldwideDeveloped countries 1/100 000 births compared to 1/1000 births in developing countriesIncidence 5%-10%deliveries(dep
3、ends on defn),Physiologic Adaptations of Pregnancy,plasma volume 40-50%RBC 20-30%*in severe PIH-hemoconcentration,Normal Mechanism of Hemostasis,Living ligatures Baskett 2000Intrinsic vasospasmLocal decidual hemostatic factors including tissue factor&type 1 plasminogen activator inhibitor clotting f
4、actors(except I and XI),Blood Loss Estimation,All studies show gross underestimation of blood loss at deliveryVisual estimation especially unreliable for small and large amounts of blood lossPrasertcheroensuk et al(2000)-228 women in 3rd stage-500cc:visual(5.7%)actual(27.63%)-1000cc:visual(.44%)actu
5、al(3.51%)*Incidence underestimated 90%,Primary,Early or Acute PPH,Delivery-24h PP90%PPH casesAssociated with more bleeding,Secondary or Late PPH,24h 12 weeks postpartumAffects 1-3%of all deliveriesCommon causes include:-infection-RPOC-Abnormal uterine involution,Etiology,4 Ts-Tone-Tissue-Trauma-Thro
6、mbin,Uterine Atony,75-90%PPHMostly associated with 10 PPH6%after c/sRisk factors after c/s incl multiples,Hispanic ethnicity,induced/augmented labor,macrosomia,and chorioamnionitis,Tissue,Retained placenta 10%PPH cases10%placentas have fundal implantationPlacenta accreta 0.005%of all deliveries90%of
7、 accretas have PPH and 50%of these have hyst,Trauma,10 cause PPH in 20%casesInjury to genital tract during delv OR 1.765%uterine inversions have PPH48%uterine inversions have bld transfusion,Thrombin,1%cases of PPHKnown association with coagulation failure-abruption-PIH-sepsis-IUFD-incompatible bloo
8、d-abortion,Risk Factors in PPH,Factors Associated With PPH,Retained Placenta(OR 3.5)Failure to Progress 2nd Stage(OR 3.4)Placenta Accreta(OR 3.3)Lacerations(OR 2.4)Instrumental Delivery(OR 2.3)Large For GA Newborn(OR 1.9)Hypertensive Disorders(OR 1.7)Induction of Labor(OR 1.4)Augmentation of Labor W
9、ith Oxytocin(OR 1.4),Factors Associated With PPH,DM 30-35%compared to 5-10%Inherited coagulopathies most common is VWB(1-3%prevalence)-70%have type 1(factor VIII,vW Ag,vW factor activity)-risk PPH 22%with vWD&18%hemophilia,Additional Risk Factors,Age 35yAsian or Hispanic ethnicityObesityPost dates 4
10、2 wksPrevious PPHPlacenta Previa,Key Management Issues,PreventionEarly RecognitionImmediate Appropriate Intervention,Blood Loss Signs&Symptoms,2500cc blood loss 50%mortality if not managed urgently&appropriately,Initial Management,ABCsCall for helpMobilize team(staff,anesthesia,blood bank etc)IV acc
11、essFluid resuscitationExamine patient including fundal massage,dx trauma/inversion/other etiologies,and fundal massageFoley catheterBlood work(CBC,coag profile,cross match)Reverse coagulation abnormality,Uterotonic Medications,OxytocinErgotHemabateMisoprostolVasopressin,Drug Therapy For PPH,Surgical
12、 Management,CurettageEmbolizationTamponade(Balloon,packing etc)Compression suturesVessel ligationHysterectomy,Tamponade,Bakri Balloon-Silicone balloon-500cc capacityFoley catheter with 30cc balloonSengstaken-Blakemore BalloonVaginal packingSaline filled glove,B-Lynch Suture,Vessel Ligation,Vessel Li
13、gation,Uterine-OLeary Stitch-Chromic 0 passed through lateral aspect of lower segment as close to cervix as possible and then through broad ligament lateral to vesselsOvarian-distal to cornua by passing suture through myometrium medial to vessels,Recombinant Activated Factor VIIa,Tx of bleeding diso
14、rdersDose up to 120mcg/kg q2h until hemostasisPromising but needs more studies$10,000/mgRisk thromboembolism,Step 1 Initial Assessment,ResuscitationLarge bore ivsO2Vitalsfoley catheter,Dx Etiology-explore uterus(tone/tissue)-explore genital tract(trauma)-review history(thrombin)-observe clots,Labs-C
15、BC-coag profile-cross match,Step 2 Directed Therapy,Tone-massage-compress-drugs,Tissue-manual removal-curettage,Trauma-correct inversion-repair laceration-identify rupture,Thrombin-reverse anticoagulation-replace factors,Step 3 Intractable PPH,Get Help-OB/Surgery-Anesthesia-Lab/Blood Bank-ICU,Local
16、Control-manual compression-pack uterus-vasopressin-embolization,BP and Coagulation-crystalloids-blood products,Step 4-Surgery,Repair Lacerations,Ligate Vessels-uterines-ovarian-internal iliac,Hysterectomy,Step 5 Post Hysterectomy Bleeding,Abdominal Packing,Embolization,Secondary PPH,Generally less bleedingMostly related to infection or RPOCNo RCTsAbx/uterotonics as appropriateEvacuation,
