Case Presentation

Andalas University

Management of Post Partum Hemorrhage Caused by Uterine Atony

By : Sri G. Bahertry
With guidance of

H. Mahjoeddin Soeleman, M.D.

CONSULTANT OF OBSTETRIC AND GYNECOLOGY

DEPARTEMENT OF OBSTETRIC AND GYNECOLOGY FACULTY OF MEDICINE ANDALAS UNIVERSITY DR. M. DJAMIL HOSPITAL PADANG 2004

Chapter I INTRODUCTION

Obstetrics is bloody business even though the maternal mortality rate has been reduced dramatically by hospitslization for delivery and the availability of blood for transfusion, death from hemorrhage remains prominent in the majority of mortality reports. ( Cunningham, 2001) Traditionally post partum hemorrhage has been defined as the loss of 500 ml or more of blood after completion of the third stage of labor. Nonerheless, nearly a half of all women who are delivered vaginally shed that amount of blood or more, when measure quantitatively. ( Arias F, 1993) Pospartum hemorrhage is the consequence of excessive bleeding from placental implantation site trauma to the genital tract and adjacent structures or both. Uterine atony, degrees retained placenta including placenta accreta and its variants, and genital tract lacerations account for most cases of postpartum hemorrhhage. ( Cunningham, 2001) Obstetricians usually resort to hysterectomy when the classic

conservative measures fail to control nontraurnatic postpartum hemorrhage. Hysterectomy is a radical prosedure that carries the undesirable side effect to reproductive sterillity, secondary amenorrhea, and physical and psychologic trauma. (AbdRabbo. SA, 1994) In this paper, we will discuss a case of 28 years old patient, diagnosed with postpartum hemorrhage caused by uterine atony. Before that the patient was diagnosed with post partum hemorrhage which cause of residual plasenta. Then the patient have been curretage, Oxytocin had been given and massage of uterine and bimanual compression were performed, the blood still flew from the cervical canal but all manuver were failed. Laparatomy was done. Uterine artery ligation was performed, the blood couldnt be controlled. So decided Supravaginal Hysterectomy.

Chapter II CASE PRESENTATION

ANAMNESIS Patients identity Name : Fidyawati Age Occupation Address MR No : 28 years : Housewife : Palinggam No. 3 : 388730 Husbands identity Name : Afrizal Age Occupation Address : 30 years : Private employee : Palinggam

A 28 year old patient was admitted to the emergency room of Dr. M. Djamil Hospital on November 3rd, 2004 at 21.15, accompanied by midwife with the chief complaining of massive vaginal bleeding since one hour ago. Present Illnes History : Massive vaginal bleeding since one hour ago. Before that she has been delivering the health male baby spontaneously, 3200 gram in weight, and 50 cm in height. The baby cried spontaneously. After delivering baby, the placenta had not delivered then the midwife performed manual removal of the placenta. The vaginal bleeding still continued then the patient reffered to the M. Djamil Hospital by the midwife in intravenous line. There was no history of fever . There was no history of injury. History of Previous Diseases : No history of heart, lung , liver, kidney, diabetes nor hypertension diseases. History of Familial Disorders : None of family member ever had hystory of contagious, hereditary nor psychiatric disorders Marietal history : Once, in 1998

History of pregnancies/abortions/deliveries : 1. 1996, female, 2.800 gram, term, midwife, spontaneous, alive 2. 1998, female, 2.500 gram, term, midwife, spontaneous, alive 3. Present, male, 3.200 gram, term, midwife, spontaneous, alive PHYSICAL EXAMINATION General Condition Consciousness Blood Pressure Pulse Rate Respiratory Rate Temperature Eyes Neck Thorax Abdomen Genital Extremities : Poor : Conscious : 90/60 mmHg : 132 x/minute : 28 x/minute : 37 OC : Conjunctiva was anemic, sclera was not icteric : JVP 5-2 cm H2O, thyroid glands were not enlarged : Heart and lungs were in normal condition : Obstetrical Record : Obstetrical Record : Edema -/-, Physiological reflexes +/+, Pathological reflexes -/-

OBSTETRICAL RECORD Abdomen Inspection Palpation : Seen of few enlarged : Uterine fundal was palpable at umbilical, contraction was weak Abdominal tenderness was (-), release pain (-) and no muscle rigidity Auscultation Genital Examination Inspection : Vulva and urethra was normal, seen the blood flew from the introitus vagina, dark red in color. Speculum examination - Vagina : Fluxus was (+), dark red, no tumor, no laceration Seen the blood collected at the posterior fornix : Bowel sound was (+) normal

- Portio

: Normal size, no tumor, no laceration, fluxus was (+). OUE was opened about 3 cm, seen blood flew from the OUE, dark red in color.

VT/ bimanual : - Vagina - Portio - CUT - AP - CD Laboratory Hb Leucocyte Trombocyte CT DIAGNOSIS : : 5,7 gr% : 19.700 : 270.000 /mm : 4 : P3A0A3, post outside spontaneous delivery + early post partum hemorrhage caused by residual placenta with severe anemia MANAGEMENT : Improve general condition, uterotonic Prepare whole blood Antibiotics : Consultation with anesthesiologist Preparing for curattage in general anasthesia PLAN : Curattage in general anasthesia Consult to the consultant : agree to perform curattage On Nov 4th ,2004 at 22.15 Performed curattage in general anasthesia, Took out the residual placenta about 100 gram : no tumor : normal size, OUE was opened about 3 fingers, it was palpable residual tissues in cervical canal : size equal to term babys head, the weak contraction : rigidless both sides : not protruded, pressure pain was negative

DIAGNOSIS

: P3A0A3 post outside spontaneous delivery + post curattage on indication early post partum hemorrhage caused by residual plasenta with severe anemia

MANAGEMENT

: Control of general condition, vital sign, vaginal bleeding, and uterine contraction

At 22.30 The patient was still in anasthesia PHYSICAL EXAMINATION Blood Pressure Pulse Rate Respiratory Rate Temperature DIAGNOSIS MANAGEMENT : 100/60 mmHg : 128 x/minute : 24 x/minute : 37 OC : P3A0A3 post outside spontaneous delivery + early post partum hemorrhage caused by uterine atony : control of general condition, vital sign, vaginal bleeding, and uterine contraction Uterotonica and uterine massage Bimanual compression At 22.45 The blood still flew from the vagina about 200 cc, the uterine contraction was still weak PHYSICAL EXAMINATION Blood Pressure Pulse Rate Respiratory Rate Temperature DIAGNOSIS : 90/60 mmHg : 128 x/minute : 28 x/minute : 37 OC : P3A0A3 post outside spontaneous delivery + early post partum hemorrhage caused by uterine atony + failure of uterine massage and bimanual compression. MANAGEMENT PLAN : Control of general condition, vital sign, vaginal bleeding, and uterine contraction : Laparatomy

The blood still flew from the vagina. The uterine contraction was weak

At 22.50 Consult to the consultant : agree to perform laparotomy At 23.00 Performed laparotomy Done ligation of right and left uterine arteries and ovarian artery Performed the bleeding observation The blood still flew from the cervical canal about 300 cc Impression : Uterine atony + failure of uterine and ovarian arteries ligation Plan : Supravaginal hysterectomy At 23.15 Performed supravaginal hysterectomy

Chapter III LITERATURE REVIEW

3.1. Definition Postpartum Hemorrhage complicates approximately 3.9 % of vaginal and 6.4 % of cesarean deliveries. Postpartum bleeding has serious consequences and account by bleeding during pregnancy. (Arias F. 1993) Traditionally post partum hemorrhage has been defined as the loss of 500 ml or more of blood after completion of the third stage of labor. Nonetheless nearly a half of all women who are delivered vaginally shed that amount of blood or more, when measuured quatitatively. This compares with 1000 ml blood loss for cessarean section, 1400 ml for elective cessarean hysterectomy.( Cunningham, 2001) Martohoesodo and Abdullah divided postpartum hemorrhage as primary hemorrhage which begin at the first 24 hours, and secondary hemorrhage after 24 hours. While the other author categorized as early postpartum hemorrhage and late postpartum hemorrhage. (Cunningham FG 2001, . Martohoesodo S, Abdullah MN, 1999)

3.2.

Etiology Excessive bleeding affects approximately 5 to 15 percent of women after

giving birth. The etiologies of early postpartum hemorrhage era most easily understood as abnormalities of one or more of four basic processes (four T's) namely; Tone, Tissue, Trauma and Thrombin. bleeding will occur if for some reason the uterus is not able to contract well enough to arrest the bleeding at the placental site. Retained products of conception or blood clots, or genital tract trauma may cause large blood losses postpartum, especially if not promptly identified. Coagulation abnormalities can cause excessive blood loss alone or when combined with one of the other processes. (Schuurmans N, at al. 2000) bleeding will occur if for some reason the uterus is not able to contract well enough to arrest the bleeding at the placental site. Retained products of conception or blood clots, or genital tract trauma may cause large blood losses postpartum, especially if not promptly identified. Coagulation abnormalities can cause excessive blood loss alone or when combined with one of the other processes. (Schuurmans N, at al. 2000)

Uterine atony, degree of retained placental, including placental accreta and its variants and genital tract lacerations account for most case of Postpartum Hemorrhage. (Cunningham FG, 2001) In certain situations, there is a distrubance in this mechanism, leading to uterine atony.The following is a list of factors that predispose to uterine bleeding : Trauma to the Genital Tract Large episiotmy, including extensions Lacerations of perineum, vagina or cervix Ruptured uterus Bleeding from placental implantation site Hypotonic myometrium uterine atony Some general anasthetic halogenated hydrocarbones Poorly perfused myometrium hypotension Hemorrhage Conduction analgesia Overdistended uterus large fetus, twins, hydramnions Following prolonged labor Following oxytocin induced or augmented labor High parity Uterine atony in previous pregnancy Chorioamnitis Retained placental tissue Avulsed cotyledon, succenturiate lobe Abnormally adherent accreta, increta, percreta Coagulation defects Intensify of the above 3.3. Diagnosis Sometimes bleeding may caused by both atony and trauma, especially after major operative delivery. In general, inspection of the cervix and vagina should be performed after every delivery to identify hemorrhage from lacerations. Anesthesia should be adequate to prevent discomfort during such an examination. Examination of the uterine capacity, the cervix and all of the vagina essential after breech extraction, after internal podalic version and following vaginal delivery in a woman who previously underwent cessarean section. The
( Cunningham, 2001 )

same is true when unusual bleeding is identifed during the seconf stage of labor..
( Cunningham, 2001 )

3.4.

Uterine Atony Metabolic factors contribute to uterine atony. For effective contraction to

be maintained, it is necessary to have an adequate supply of oxygen and fuel to support the aerobic metabolism of myometrial cells. Hypoxia or acidosis from any cause, including acute respiratory insufficiency, diabetic ketoacidosis, and sepsis, may disturb myometrial metabolism. Patients who deliver after difficult or obstructed labor may suffer from uterine atony. The mechanism of uterine in these case is complex, and muscle exhaustion, lactate buildup, and glycogen depletion may be implicated. Because calcium is an important regulator of smooth muscle tone, hypocalcemia can be implicated in some case of uterine atony. (Arias F, 1993) There are many reasons why the uterus may fail to adequately contract in the immediate postpartum period. Mechanical factors include inability of the uterus to contract because of an intrauterine object, usually placental fragments or blood clots. Also it has been observed that extreme uterine distention before labor, as in multiple gestation or polyhydramnions, is accompanied by poor uterine tone postpartum. 3.5 Management Management of postpartum hemorrhage begins before excessive blood loss has occurred by carefully observing for rate of bleeding immediately following delivery. Although spontaneus placental delivery is preferable to attempts to express the placenta, a sudden increasi in vaginal bleeding may be an indication for manual removal of the placenta. Immeditely after placenta delivery, bimanual massage of the uterine promotes uterine contraction and homeostasis. The placenta should be examined, as described above, for completeness. If uterine bleeding does not promptly diminish, the obstetrician should proceed in serial fashion to consider possible causes of bleeding and institute therapeutic measure. If manuver is unsuccesful in stoppping hemorrhage, an alternative should be attempted. When less invasive measure are not initially succesful, it is usually fruitless to repeat them while the patient continues to bleed. ( Andersen HF 1992 )

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Clinicians should assess each woman's risk for Postpartum Hemorrhage and make appropriate arrangements for her care. Routine prophylactic oxytocin after delivery of the shoulder reduces the risk of Postpartum Hemorrhage. Administration of oxytocin before delivery of placental is associated with a reduction in length of the third stage of labor (mean 5 minutes) and low incidence of manual removal of placenta (2 percent) compared with physiologic management of third stage labor (15 minutes and 2.5 %).(Benedetti,1996, Schuurmans N, et al, 2000) Drugs may have important effects on postpartum uterine tone. The use of large dosages of oxytocin to stimulate desultory or obstructed Iabor may result in relative oxytocin insensitivity. It is not clear whether this tachyphylactic effect of exogenously administered oxytocin results from down regulation of oxytocin receptor or simply from individual variability of oxytocin effect. Simultaneously, pharmacologic methods should be employed to control uterine bleeding. Initial therapy includes the administration of dilute solution of oxytocin usually 10 to 20 units of oxytocin in 1000 ml of physiologic saline solution. The solution can be administrated in rates as high as 500 ml in 10 minutes without cardiovascular complications. (Benedetti TJ, 1996, Chan PD. Johnson SM, 2003) The second step in the management of Postpartum Hemorrhage involves attention to the specific cause; proceed with massage, compression and medication for atony, evacuation of the uterus for retained blood clots or products of conception, physical repair of any trauma and reversal of coagulation defects.
(Schuurmans N, at al, 2000)

If retained blood clots or products of conception are identified, they should be carefully removed, including complete manual removal of the placenta if necessary. After the uterus is empty, massage, compression and medication should be used to combat atony. Initial exploration may also reveal trauma including uterine inversion or rupture and laceration of the cervix or lower genital tract. If uterine inversion is identified, prompt replacement should be undertaken prior to administration of further oxytocic drugs. Laceration must be carefully and completely visualized and repaired. If uterine rupture has occurred, arrangements for laparatomy should be initiated. If a coagulation abnormality is known or suspected, direct pressure at the bleeding site should be employed to minimize losses until specific therapy has taken effect. (Schuurmans N, et al, 2000)

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The approach to intractable Postpartum Hemorrhage will be individualized depending on the clinical situation and the skills and technology available. Continued monitoring and fluid and blood component replacement and use of all available expertise are essential. (Schuurmans N. et al, 2000) Schuurmans N, et al, 2000 recommended 1. Uterine vessel ligation may be effective in controlling Postpartum Hemorrhage 2. Internal illiac artery ligation has been reported for use in Postpartum Hemorrhage, however its effectiveness is not yet proven. This procedure requires more extensive surgical skills and the situation may deteriorate if the illiac veins are injured. 3. Peripartum hysterectomy can be life saving in Postpartum Hemorrhage A clamp, cut and drop technique should be used to gain control of bleeding as rapidly as possible. 4. Diffuse post hysterectomy bleeding may be controlled by abdominal packing to allow time for normalization of the woman's haemodynamic and coagulation status. Specific vessels which hemorrhage persistently may be controlled with embolization procedures.

If bilateral uterovarian vessel ligation does not stop the bleeding, temporary occlusion of the infundibulopelvic ligamen vessels may be attempted. It may be an especially usefull technique if the patient is low of parity and future child bearing is importance. If this appears to control hemorrhage, ligation infundibulopelvic ligament can be performed by passing an absorbable suture from anterior to posterior through the avascular area inferior to and including the ovarian vessel. (Benedetti TJ, 1996) If bleeding continues, attention should next be paid to interrupting the blood flow to the uterus from the infundibulopelvic ligament . There are a number of techniques to accomplish this. The easiest involves ligation of the anastomosis of the ovarian and uterine artery, high on the fundus, just below the uterovarian ligament. (Benedetti TJ, 1996) During pregnancy the blood supply to the uterus comes mainly from uterine artery (90%) and from ovarian, cervical and vagina] vessels. Occlusion of the uterine arteries reduces most of the uterine blood flow and produce uterine

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ischemia. Occlusion of the ovarian vessels results in additional deprivation of uterine blood supply. this vascular occlusion is a temporary procedure, because recanalization appears to be the rule, and normal uterine circulation will be established. (AbdRabbo, SA, 1994) 3.6 Emergency Peripartum Hysterectomy Emergency hysterectomy is the most common treatment modality when massive postpartum hemorrhage requires surgical intervention. The incidence of emergency peripartum hysterectomy reported in the literature varies from 7 to 13 peritoneum 10,000 births, and is much higher after caesarean section than vaginal delivery. (Schuurmans N, et al. 2000) The advantages of emergency hysterectomy in the situation of massive hemorrhage are the ability to remove the source of bleeding and the familiarity of the obstetrician with the procedure of hysterectomy, which, albeit more technically difficult in this situation, is still a familiar operation to any obstetrician/ gynecologist. The disadvantage of hysterectomy may include the loss of uterus in a woman who wishes to continue childbearing. Hysterectomy is associated with more blood loss and longer operative time but this may reflect the fact that hysterectomy is reserved for the worst cases of PPH. (Schuurmans N. et al, 2000) Subtotal hysterectomy has been advocated to reduce operative time and blood loss. It is hard to find data which will support this as subtotal hysterectomy is often performed in the worst cases which already have larger blood loses and longer operating times. Leaving the cervix in place would appear to be a reasonable option if the bleeding secondary to uterine atony. If the bleeding site is in the lower uterine segment or cervix, as occurs with placenta previa or with abnormal placentation, bleeding will not be controlled as it is supplied by the cervical branches of the uterine arteries. (Schuurmans N. et al, 2000)

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CHAPTER IV DISCUSSION A patient was referred by vaginal bleeding a midwife with complaining of a massive

after delivery. The cause of bleeding after performing

examination was placenta residual. The bleeding was still continuing even had performed curratage and uterotonica. Found there was inadequate of uterine contraction. Uterine massage had also performed but unsuccessfully. Then bimanual compression was performed according to literature that stated in the management of Postpartum Hemorrhage involves attention to the specific cause ; proceed with massage, compression and medication for atony,
( Schuurmans N, et al,

evacuation of the uterus for retained blood clots or products of conception, physical repair of any trauma and reversal of coagulation defects.
2000)

Performed of uterine and ovarian arteries ligation to avoid the bleeding, but after performing of observation the bleeding was still continuing so that is unclear. Metabolic factors suggested to be performed of supravaginal hysterectomy. (Schurrmans N, et al 2000) The cause of uterine atony in this case contribute to uterine atony. For effective to be maintained, it is necessary to have an adequate supply of oxygen and fuel to support the aerobic metabolism of myometrial cells. Hypoxia or acidosis from any cause including acut respiratory insufficiency, metabolism. diabetic ketoacidosis and sepsis may disturb myometrial
(Arias F, 1993)

CHAPTER V CONCLUSION

1. Diagnose of Postpartum Hemorrhage that caused of uterine atony is right 2. Management of uterine atony until performed supravaginal hysterectomy in this case is true according to standard procedure.

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3. The cause of uterine atony is unclear, many factors contribute it.

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REFERENCES

1. Cunningham FG, Obstetrical Hemorrhage, In Williams Obstetrics 21th Ed. The Mc Graw-Hill Companies. New York, 2001; 1184-6. 2. Arias F, Postpartum Complications, In practical Guide to High Risk Pregnancy and Delivery, 2nd Ed, Mosby Year Book, Boston USA, 1993; 433422. 3. AbdRabbo, SA, Stepwise Uterine Devascularazation, In American Journal Obsterics and Gynecology, 1994; 171. 4. Martodohoesodo, S, Abdullah MN, Gangguan dalam Kala III Persalinan, Dalam Ilmu Kebidanan Ed Ketiga, cetakan Kelima. Yayasan Bina Pustaka Sarwono Prawirohardjo. Jakarta, 1999; 653-663. 5. Andersen HF, Hopkins M: Post partum Hemorrhage Gynecology and Obstetric volume 2, revised edition, JB lippincott Copmpany, Philadelphia , 1992, chap 80, 1-9 6. Schuurmans, et al. Prevention and Management of Postpartum Hemorrhage, in Journal SOGC Clinical Partice Guidelines, 88; 2000: 1-11. 7. Benedetti, TJ, Obstetric Hemorrhage, In Obstetrics Normal and Problem Pregnancies, Churchill Livingstone, USA, 1996; 517-526. 8. Johnson SM, Postpartum Hemorrhage, Current Clinical Strategies

Gynecology and Obstetrics, 2004 Ed, 2002; 162-164.

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