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OBSTETRICAL HAEMORRAGE

PUJA AGUNG ANTONIUS


OBGYN DEPT
FACULTY OF MEDICINE
ANDALAS UNIVERSITY
Postpartum Hemorrhage

Objectives
Definition
Etiology
Risk Factors
Prevention
Management
Puddles on the floor
Revealed bleeding.
Postpartum Hemorrhage

Traditional Definition
blood loss of > 500 mL following vaginal delivery
blood loss of > 1000 mL following cesarean
delivery
Functional Definition
any blood loss that has the potential to produce or
produces hemodynamic instability
Incidence
about 5% of all deliveries
Postpartum Hemorrhage

Early less than 24 hours


Late more than 24 hours 1%
Postpartum Hemorrhage

Etiology of Postpartum
Hemorrhage
Tone - uterine atony
Tissue - retained tissue/clots
Trauma - laceration, rupture,
inversion
Thrombin - coagulopathy
Postpartum Hemorrhage

Risk Factors for PPH - Antepartum


previous PPH or manual removal
placental abruption, especially if concealed
intrauterine fetal demise
placenta previa
gestational hypertension with proteinuria
overdistended uterus (e.g. twins,
polyhydramnios)
pre-existing maternal bleeding disorder
(e.g. ITP)
Postpartum Hemorrhage

Risk Factors for PPH - Intrapartum


operative delivery - cesarean or assisted
vaginal
prolonged labour
rapid labour
induction or augmentation
chorioamnionitis
shoulder dystocia
internal podalic version and extraction of
second twin
acquired coagulopathy (e.g. HELLP, DIC)
Postpartum Hemorrhage

Risk Factors for PPH -


Postpartum
lacerations or episiotomy
retained placenta/placental
abnormalities
uterine rupture
uterine inversion
acquired coagulopathy (e.g. DIC)
UTERINE ATONY
Atony is identified by a boggy, soft uterus
during bimanual examination and by
expression of clots and hemorrhage during
uterine massage.
The most frequent cause of obstetrical
hemorrhage is failure of the uterus to
contract sufficiently after delivery and to
arrest bleeding from vessels at the
placental implantation site
Risk Factors
Up to half of women who had atony after
cesarean delivery were found to have no
risk factors (Rouse, 2006)
Primiparity

High parity 0.3 percent in women of


low parity to 1.9 percent with parity of 4
or greater. It was 2.7 percent with parity
of 7 or greater (Babinszki, 1999).
Risk Factors
Overdistended uterus
Labor abnormalities predispose to atony
and include hyper or hypotonic labor.
Labor induction or augmentation with
either prostaglandins or oxytocin
Prior postpartum hemorrhage
Uterine Atony after Placental
Delivery
Vigorous fundal massage usually prevents
postpartum hemorrhage from atony
(Hofmeyr, 2008)
Simultaneously, 20 units of oxytocin in
1000 mL of crystalloid solution will often
be effective given intravenously at 10
mL/min for a dose of 200 mU/min.
Uterotonic Agents
Ergot derivativesmethylergonovine
Methergineand ergonovine.
These drugs rapidly stimulate tetanic
uterine contractions and act for
approximately 45 minutes parenteral
Regimen is 0.2 mg of either drug given
intramuscularly.
Uterotonic Agents
E- and F-series prostaglandins
Carboprost tromethamine Hemabateis
the 15-methyl derivative of pros-
taglandin F2 250 g (0.25 mg) given
intramuscularly
E-series prostaglandins dinoprostone
prostaglandin E2is given as a 20-mg
suppository per rectum or per vaginam
every 2 hours
Uterotonic Agents
MisoprostolCytotecis a synthetic
prostaglandin E1 analogue that has also
been evaluated for both prevention and
treatment of atony and postpartum
hemorrhage
Bleeding Unresponsive to
Uterotonic Agents
Begin bimanual uterine compression
Immediately mobilize the emergent care
obstetrical team to the delivery room and
call for whole blood or packed red cells
Request urgent help from the anesthesia
team.
Two large-bore intravenous catheters

Indwelling Foley catheter


Bleeding Unresponsive to
Uterotonic Agents
Begin volume resuscitation with rapid
intravenous infusion of crystalloid
Manually explore the uterine cavity for
retained placental fragments and for uter
ine abnormalities, including lacerations or
rupture
Inspect the cervix and vagina again for
lacerations
Blood transfusions
Uterine Packing or Balloon
Tamponade
24F Foley catheter with a 30-mL balloon
is guided into the uterine cavity and filled
with 60 to 80 mL of saline.
Segstaken-Blakemore

Rusch balloons

Condom catheters

Gauze
Surgical Procedures

Uterine compression sutures


Pelvic vessel ligation

Angiographic embolization

Hysterectomy
Rupture of the Uterus
Primary occurring in a previously intact
or unscarred uterus
Secondary reexisting myometrial inci-
sion, injury, or anomaly
Complete when all layers of the uterine
wall are separated
Incomplete when the uterine muscle is
separated but the visceral peritoneum is
intact
Diagnosis
Hypovolemic shock
Diaphragmatic irritation with pain referred
to the chest
Nonreassuring fetal heart rate

Cessation of contractions

Loss of station

Felt alongside the fetus.


Pathogenesis.
Rupture of the previously intact uterus
during labor most often involves the
thinned-out lower uterine segment
Inherent weakness in the myometrium in
which the rupture takes place
anatomical anomalies, adenomyosis, and
connective- tissue defects such as Ehlers-
Danlos syndrome
Management and Outcomes
Uterine rupture accounted for 14 percent
of deaths caused by hemorrhage
Hysterectomy that may be necessary to
control hemorrhage.
Hysteroraphy conservative
Traumatic Uterine Rupture
Blunt trauma
Internal podalic version extraction

Difficult forceps delivery

Breech extraction

Unusual fetal enlargement such as with


hydrocephaly.
Postpartum Hemorrhage

Prevention
be prepared
active management of the third stage
prophylactic oxytocin with delivery or with
delivery of anterior shoulder
10 U IM or 5 U IV bolus
20 U/L N/S IV run rapidly
early cord clamping and cutting
gentle cord traction with suprapubic
countertraction
Postpartum Hemorrhage

Active v.s Expectant Third Stage


Outcome
Management
(subjects)
PPH > 500 mL (n=4636)
PPH > 1000 mL (n=4636)
Maternal Hb < 91 (n=4256)
Blood transfusion (n=4829)
Therapeutic oxytocin (n=4829)
Nausea (n=3407)
Manual removal (n=4829)
0.1 1 10
Cochrane Library
Issue 1, 2000 Odds Ratio (95% Confidence Interval)
Postpartum Hemorrhage

Diagnosis - Is this a PPH?


consider risk factors
observe vaginal loss
express blood from vagina following C/S
REMEMBER
blood loss is consistently underestimated
ongoing trickling can lead to significant blood
loss
blood loss is generally well tolerated to a
point
Postpartum Hemorrhage

Diagnosis - What is the


cause?
assess the fundus
inspect the lower genital tract
explore the uterus
retained placental fragments
uterine rupture
uterine inversion
assess coagulation
PostpartumHemorrhag
e

A = airway

A B CB

C
=
=
breathing
circulation
Postpartum Hemorrhage

Management - ABCs
talk to and observe patient
large bore IV access (16
gauge)
crystalloid - lots!
CBC
cross-match and type
get HELP!
AIRWAY

Eddy Rahardjo
Estimasi BB : ... 60 kg
Estimasi Blood Volume : ... 70 ml/kg x 60 = 4200 ml
Estimasi Blood Loss : .... % EBV = ..... ml

Tsyst 120 100 < 90 < 60-70


Nadi 80 100 > 120 > 140 - ttb
Perf hangat pucat dingin basah

-- 15% EBV
NORMO -- 30% EBV
VOLEMIA -- 50% EBV

EBL = perdarahan 600 1200 2000 ml


Infus RL 1200-2000 2500-5000 4000-8000 ml
Kristaloid vs Koloid sebagai Cairan
Pengganti: Hasil-hasil
Kristaloid Koloid

Manfaat Merembes ke komponen Tetap berada di komponen


ekstraselular intravaskular
Mengurangi peningkatan cairan volume yang diperlukan
paru lebih sedikit
Meningkatkan fungsi organ Meningkatkan transpor
setelah operasi oksigen ke jaringan,
Reaksi anafilaktik minimal kontraktilitas jantung dan
keluarannya
Kemungkinan dapat mengurangi
angka kematian
Lebih murah
Predisposisi untuk terjadinya
Resiko Mahal
edema pulmonal
Choi et al 1999.
Kristaloid vs Koloid sebagai Cairan
Pengganti: Kesimpulan
Kristaloid
merupakan pilihan pertama
untuk digunakan, karena:
Lebih aman
Lebih murah
Lebih mudah didapatkan
Postpartum Hemorrhage

Management - Assess the


fundus
simultaneous with ABC s
atony is the leading cause of PPH
if boggy bimanual massage
rules out uterine inversion
may feel lower tract injury
evacuate clot from vagina and/or cervix
may consider manual exploration at this
time
Postpartum Hemorrhage

Management - Bimanual Massage


Postpartum Hemorrhage

Management - Oxytocin
5 units IV bolus
20 units per L N/S IV wide open
10 units intramyometrial given
transabdominally
Postpartum Hemorrhage

Management -ManualExploration
if no response to bimanual massage
and oxytocin then proceed to
exploration
manual exploration will:
rule out uterine inversion
palpate cervical injury
remove retained placenta or clot from
uterus
rule out uterine rupture or dehiscence
Postpartum Hemorrhage

Management - Additional Uterotonics


ergotamine - caution in hypertension
0.25 mg IM or 0.125 mg IV
maximum dose 1.25 mg
Hemabate (carboprost) - asthma is relative
contraindication
15 methyl-prostaglandin F2
0.25 mg IM or intramyometrial
Maximum dose 2 mg
Cytotec (misoprostol) - caution in asthma
400 mg pr or po
Postpartum Hemorrhage

Management - Bleeding with firm


uterus
explore the lower genital tract
requirements - appropriate analgesia
- good exposure and lighting
appropriate surgical repair
- may temporize with packing
Postpartum Hemorrhage

Management - Continued uterine bleeding

possible coagulopathy - INR, PTT, TCT, fibrinogen


if coagulation is abnormal:
correct with clotting factors, platelets

if coagulation is normal:
prepare for O.R. (may consider embolization)

rule out uterine rupture, inadequate incision repair

consider uterine/hypogastric ligation, hysterectomy


Masase fundus uteri
Segera sesudah plasenta lahir
(maksimal 15 detik)

Uterus kontraksi ? Ya Evaluasi rutin

Tidak

Evaluasi / bersihkan bekuan


darah / selaput ketuban
Kompresi Bimanual Interna
(KBI) maks. 5 menit
Pertahankan KBI selama 1-2 menit
Uterus kontraksi ? Ya Keluarkan tangan secara hati-hati
Lakukan pengawasan kala IV
Tidak

Ajarkan keluarga melakukan Kompresi


Bimanual Eksterna (KBE)
Keluarkan tangan (KBI) secara hati-hati
Suntikan Methyl ergometrin 0,2 mg i.m
Pasang infus RL + 20 IU Oksitosin, guyur
Lakukan lagi KBI
Uterus kontraksi ? Ya Pengawasan
kala IV
Tidak RUJUK
siapkan laparotomi
Lanjutkan pemberian infus + 20 IU Oksitosin
minimal 500 cc/jam
Selama menunggu operasi dapat dilakukan
Kompresi Aorta Abdominalis atau pemasangan
balon/ kassa intrauterin

Ligasi arteri uterina dan/atau hipogastrika Perdarahan Pertahankan


B-Lynch method berhenti uterus

Perdarahan berlanjut

Histerektomi
Postpartum Hemorrhage

Management - ABC s

ENSURE that you are always


ahead with your
resuscitation!!!!
consider need for Foley catheter, CVP, arterial
line, etc
consider need for more expert help
B-Lynch
methode
b-lynch_technique.exe
B-Lynch
Medical Anti Schock Trouser & Penekan
Infus
Postpartum Hemorrhage

Conclusions
be prepared
practice prevention
assess the loss
assess maternal status
resuscitate vigorously and
appropriately
diagnose the cause
treat the cause
Postpartum Hemorrhage

Management - Evolution

Panic
Panic
Hysterectomy

Pitocin
Prostaglandins
Happiness
Postpartum
Hemorrhage

Thank You

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