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POSTPARTUM

HEMORRHAGE
DEFINITION

• Traditionally, loss of 500 mL of blood


or more after completion of the third
stage of labor
• Hemorrhage after the first 24 hours
is designated late postpartum
hemorrhage
HEMOSTASIS AT THE
PLACENTAL SITE
• Near term, it is estimated that approximately 600
mL/min of blood flows through the intervillous
space. With separation of the placenta, there is
also separation of the many uterine arteries and
veins that carry blood to and from the placenta.
Usually, hemostasis in the absence of surgical
ligation depends on intrinsic vasospasm and
formation of blood clot locally.
HEMOSTASIS AT THE
PLACENTAL SITE
• At the placental implantation site, most
important for achieving hemostasis are
contraction and retraction of the myometrium
to compress the formidable number of
relatively large vessels and obliterate their
lumens.
• Adherent pieces of placenta or large blood clots
prevent effective contraction and retraction of
the myometrium and thereby impair
hemostasis at the implantation site.
SHEEHAN SYNDROME
• classical case is characterized by failure of lactation,
amenorrhea, breast atrophy, loss of pubic and axillary
hair, hypothyroidism, and adrenal cortical insufficiency
• do not develop in most women who hemorrhage
severely
• varying degrees of anterior pituitary necrosis with
impaired secretion of one or more trophic hormones
account for the endocrine abnormalities. In all of these,
the appearance of the pituitary was abnormal and the
sella turcica was either totally or partially empty.
UTERINE ATONY
• the overdistended uterus is prone to be hypotonic after
delivery
• woman with a large fetus, multiple fetuses, or hydramnios
is prone to hemorrhage from uterine atony.
• woman of high parity may be at increased risk for uterine
atony.
• mismanagement of the third stage of labor involves an
attempt to hasten delivery of the placenta short of
manual removal.
• constant kneading and squeezing of the uterus that
already is contracted likely impedes the physiological
mechanism of placental detachment, causing incomplete
placental separation and increased blood loss.
MANAGEMENT AFTER
DELIVERY OF PLACENTA
• The fundus should always be palpated to make
certain that the uterus is well contracted. If it is
not firm, vigorous fundal massage is indicated.
• 20 U of oxytocin in 1000 mL of lactated Ringer
or normal saline proves effective when
administered intravenously at approximately
10 mL/min (200 mU of oxytocin per minute)
simultaneously with effective uterine massage.
MANAGEMENT AFTER
DELIVERY OF PLACENTA
• Ergot Derivatives, intramuscular
methylergonovine (0.2 mg), may stimulate the
uterus to contract sufficiently to control
hemorrhage. May cause dangerous
hypertension, especially in women with
preeclampsia.
• Prostaglandins such as the rectally
administered prostaglandin E2 20-mg
suppositories have been used for uterine atony
BLEEDING UNRESPONSIVE TO
OXYTOCICS
• Use bimanual uterine compression
• Obtain help!
• Add a second large-bore intravenous catheter so
that crystalloid with oxytocin may be continued
at the same time blood is given.
• Begin blood transfusions.
• Explore the uterine cavity manually for retained
placental fragments or lacerations.
• Thoroughly inspect the cervix and vagina after
adequate exposure.
• Insert a Foley catheter to monitor urine output,
which is a good measure of renal perfusion.
Bimanual compression
HEMORRHAGE FROM
RETAINED PLACENTAL
FRAGMENTS
• Placenta Acreta - placental villi is
attached to the myometrium
• Placenta Increta - placental villi
invade the myometrium
• Placenta Percreta - placental villi
penetrate the myometrium
ETIOLOGY
• Abnormal placental adherence is
found when decidual formation is
defective.
• Placenta previa
• Prior cesarean delivery.
• Undergone curettage.
• Gravida 6 or more
CLINICAL COURSE AND
DIAGNOSIS
• Early in pregnancy, the maternal serum alpha-
fetoprotein level may be increased
• Antepartum hemorrhage is common, but in the great
majority of women bleeding before delivery is the
consequence of coexisting placenta previa.
• Myometrial invasion by placental villi at the site of a
previous cesarean scar may lead to uterine rupture
before labor
• Ultrasound Doppler color flow mapping
– (1) a distance less than 1 mm between the uterine serosal
bladder interface and the retroplacental vessels
– (2) the presence of large intraplacental lakes
MANAGEMENT
• immediate blood replacement therapy
• prompt hysterectomy
• uterine or internal iliac artery ligation or
angiographic embolization
• "conservative" management was manual
removal of as much placenta as possible
and then packing of the uterus
• weekly methotrexate therapy was given
postpartum
UTERINE INVERSION
• always the consequence of strong traction
on an umbilical cord attached to a placenta
implanted in the fundus
DIAGNOSIS
• abdominal palpation of the crater-like
depression and vaginal palpation of the
fundal wall in the lower segment and cervix
TREATMENT
• Assistance, including an anesthesiologist, is
summoned immediately.
• The freshly inverted uterus with placenta already
separated from it may often be replaced simply by
immediately pushing up on the fundus with the palm
of the hand and fingers in the direction of the long
axis of the vagina.
• Preferably two intravenous infusion systems are
made operational, and lactated Ringer solution and
blood are given to treat hypovolemia.
TREATMENT
• Tocolytic drugs such as terbutaline, ritodrine, or
magnesium sulfate have been used successfully
for uterine relaxation and repositioning
• After removing the placenta, the palm of the hand
is placed on the center of the fundus with the
fingers extended to identify the margins of the
cervix. Pressure is then applied with the hand so
as to push the fundus upward through the cervix.
• Oxytocin is started to contract the uterus while
the operator maintains the fundus in normal
relationship.
GENITAL TRACT
LACERATIONS
ETIOLOGY DIAGNOSTIC AID MANAGEMENT
Perineal lacerations Injury to the lower portion of Thorough examination Suturing of the external
the vagina integument without
approximation of underlying
perineal & vaginal fascia

Vaginal lacerations Isolated laceration involving Thorough inspection of the Extensive repair of the
the middle or upper third of upper vagina laceration
the vagina but unassociated
with lacerations of the
perineum or cervix are
observed less commonly

Levator ani Overdistention of the birth Thorough inspection Extensive repair of the
canal may result in laceration
separation of muscle fibers
if the injury involves the
pubococcygeus muscle

Injuries to the cervix Difficult forcep rotation or Laparotomy in the Surgical repair
deliveries performed presence of damage of this
through an incompletely severity, intrauterine
dilated cervix exploration
PUERPERAL HEMATOMAS
• 1 in 300 to 1 in 1000 deliveries
• Risk factors
– Nulliparity, episiotomy, and forceps delivery
– hematomas may develop following injury to a blood
vessel without laceration of the superficial tissues
• Classification of hematomas
– Vulvar  often involve branches of the pudendal
artery, including the posterior rectal, transverse
perineal, or posterior labial artery
– Vulvovaginal
– Paravaginal involve the descending branch of the
uterine artery
– Retroperitoneal
• In its early stages, the hematoma forms a
rounded swelling that projects into the upper
portion of the vaginal canal and may almost
occlude its lumen
• If the bleeding continues, it dissects
retroperitoneally, and thus may form a tumor
palpable above the Poupart ligament, or it may
dissect upward, eventually reaching the lower
margin of the diaphragm
• Branches of the uterine artery may be involved
with these types of hematomas.
VULVAR HEMATOMAS
DIAGNOSIS
• severe perineal pain and usually rapid appearance of a
tense, fluctuant, and sensitive tumor of varying size
covered by discolored skin
• Symptoms of pressure, if not pain or inability to void,
should prompt a vaginal examination with discovery of
a round, fluctuant tumor encroaching on the lumen
• When the hematoma extends upward between the
folds of the broad ligament, it may escape detection
unless a portion of the tumor can be felt on abdominal
palpation or unless hypovolemia develops
TREATMENT
• Smaller vulvar hematomas identified after leaving
the delivery room may be treated expectantly
• if the pain is severe or the hematoma continues to
enlarge, the best treatment is prompt incision
• done at the point of maximal distention along with
evacuation of blood and clots and ligation of
bleeding points
• The cavity may then be obliterated with mattress
sutures. Often, no sites of bleeding are identified
after the hematoma has been drained.
• In such cases, the vagina, not the hematoma cavity,
is packed for 12 to 24 hours
• With hematomas of the genital tract, blood
loss is nearly always considerably more than
the clinical estimate
• Hypovolemia and severe anemia should be
prevented by adequate blood replacement
• Subperitoneal and supravaginal hematomas are
more difficult to treat
• They can be evacuated by incision of the perineum;
but unless there is complete hemostasis, which is
difficult to achieve by this route, laparotomy is
advisable.
UTERINE RUPTURE
• Complete uterine rupture - all layers
of the uterine wall separated
• Incomplete uterine rupture - uterine
muscle separated but visceral
peritoneum is intact. Incomplete
rupture is also commonly referred to
as uterine dehiscence
DIAGNOSIS OF UTERINE
RUPTURE
• hemoperitoneum from a ruptured uterus may result
in irritation of the diaphragm with pain referred to the
chest uterine
• electronic fetal monitoring finding tends to be
sudden, severe heart rate decelerations that may
evolve into late decelerations, bradycardia, and
undetectable fetal heart action
• occasionally, maternal hypovolemia from concealed
hemorrhage.
• cessation of contractions following uterine rupture
• loss of station may be detected by pelvic examination
MANAGEMENT
• In cases of scar separation without
bleeding following VBAC, exploratory
laparotomy is not indicated.
• With frank rupture during a trial of labor,
however, hysterectomy may be required.
• In selected cases, suture repair with
uterine preservation may be performed
Classification of Causes of Uterine Rupture
Uterine Injury or Anomaly Sustained Before Uterine Injury or Abnormality During Current
Current Pregnancy Pregnancy
1. Surgery involving the myometrium 1. Before delivery
Cesarean delivery or hysterotomy Persistent, intense, spontaneous contractions
Previously repaired uterine rupture Labor stimulation—oxytocin or prostaglandins
Myomectomy incision through or to the Intra-amnionic instillation—saline or
endometrium prostaglandins
Deep cornual resection of interstitial oviduct Perforation by internal uterine pressure catheter
Metroplasty External trauma—sharp or blunt
2. Coincidental uterine trauma External version
Abortion with instrumentation—curette, sound Uterine overdistention—hydramnios, multifetal
pregnancy
Sharp or blunt trauma—accidents, bullets, knives 2. During delivery
Silent rupture in previous pregnancy Internal version
3. Congenital anomaly Difficult forceps delivery
Pregnancy in undeveloped uterine horn Breech extraction
Fetal anomaly distending lower segment
Vigorous uterine pressure during delivery
Difficult manual removal of placenta
3. Acquired
Placenta increta or percreta
Gestational trophoblastic neoplasia
Adenomyosis
Sacculation of entrapped retroverted uterus