post partum hemorrhage
DESCRIPTION
a complete explanation about pphTRANSCRIPT
POST PARTUM HEMORRHAGE
Recognition Referral
General Measures
• Call for extra help.• Start resuscitation.• Two bore wide I.V. canula must be sited• Blood grouping and cross matching• Investigation like Hb estimation(usually normal),
PCV, coagulation profile carried out by the side• Urinary catheterization is started• Monitoring of the vitals every 15 mins
Management of Third Stage
• Inj methergin 0.2mg IV• Oxytocin infusion with normal saline• Delivery of placenta by modified Brandt –
Andrews technique• Separation of placenta occurs• By controlled cord traction the placenta is
expressed out.
• If placenta doesn’t separate out , manual removal of placenta under GA is done.
• If still bleeding continues, cause for PPH is diagnosed and managed accordingly
Manual Removal of Placenta
Prevention of PPH• Improvement of health status during antenatal
period• High risk patients are screened and delivered in
hospital • Active management of third stage of labour reduces
PPH by 60%• Oxytocin infusion for women delivered by caesaren
section and cases with augmented labour• Examination of placenta• Active management of fourth stage of labour and
careful observation.
Management of Atonic Uterus
Medical management• Uterotonic agents are the first line of
management in PPHS.No Drugs Dosage Contraindications
1. Oxytocin 10 units I M, 20 – 40 units / L
Do not give as I V bolus
2. Methyl ergometrine 0.25 mg I.M./I.V.Repeat every 5 – 15 mins(max. 5 doses)
HypertensionCardiac disease
3. 15 methyl PGF2α0.25 mgRepeat every 15 mins(max. 8 doses)
Hepatic insufficiencyAsthmatic patientsCardiac and renal problems
4. Misoprostol 400- 600 µg PO800 – 1000 µg per rectal
Uterine scar
Stepwise Management of Atonic PPHStep I - Bleeding continues
- 15 methyl PGF2 250g every 15-30 mins
Step II - a) Bimanual compression
b) Aortic compression
Step III - Transvaginal options
- Uterine packing
- Tamponade
Step IV - Compression sutures
B.Lynch, Hayman, Cho Square
Step V -Other surgical measures
- stepwise uterine devascularisation
Step VI - Hysterectomy
Transvaginal options• Uterine tamponade by tight intrauterine packing
with gauze under general anaesthesiaUseful in cases of uncontrolled PPH where medical
treatment has failed and the patient is prepared for transport to tertiary care centre.
• Balloon tamponadeThis is feasible in atonic PPH following vaginal
delivery which is unresponsive to medical treatment and before surgical interventions
Simple, easy and cost effective measure
SURGICAL METHODS
Step-Wise Devascularisation Of The Uterus
• Effective in controlling PPH in 80% of cases
Steps:• Unilateral uterine artery ligation • Bilateral uterine artery ligation at the upper part of the lower
uterine segment• Low uterine vessels ligation after mobilization of the bladder • Unilateral ovarian vessel ligation • Bilateral ovarian vessel ligation
• 90% of the blood supply for uterus comes from uterine artery
• Ligation of uterine arteries result into significant reduction in blood flow to the uterus
• But complete devascularization would not be achieved.
• Can be done for both vaginal delivery and LSCS
Following vaginal delivery – ligation of uterine artery
B – lynch sutureLigature material:chromic catgut 2.0
Hayman suture – modified B lynch suture
Transverse compression suture
Cho suture
Multiple square sutures are used to cover the whole body of uterus
Internal iliac artery - anatomy
Internal iliac artery ligation• INDICATIONS:Atonic uterus refractory
to other treatmentAbruptio placenta with
atonic uterusFor therapeutic purposes,
before or after hystrectomy for PPH
• Reducing the blood supply to the uterus decreases the pulse pressure of the artery, thus PPH is controlled
• Internal iliac artery ligation also used in patients with traumatic causes of PPH – more beneficial than atonic PPH.
Uterine artery embolization
• Highly feasible, safe & beneficial procedure• Done under USG guidance• can avoid hystrectomy surgery in uncontrolled
PPH patients• Preserves the function of uterus, tubes and
ovaries
Hystrectomy
Indications:• Uterine rupture secondary to obstructed labor• Previous Caesarean section• If rupture is extensive & hemorrhage cannot
be contained by suture of ruptured area
• Saving life of the one giving birth to a new life…