POSTPARTUM HEMORRHAGE

DEFINITION:

Bleeding from the genital tract after delivery of the fetus till the end of puerperium more than 500ml blood.

This definition is critisized as:

-It is difficult to estimate blood loss in terms of quantity accuretly.

-Effect of blood loss varies according to maternal health.

-Effect of blood loss varies according to rate of loss.

So other definitions are proposed to standardize amount of blood loss to:

- > 1% of body wt.

- Leading to 10% drop in H.V

- Affecting maternal general condition.

Incidence: 5-8%

TYPES OF POSTPARTUM HEMORRHAGE

Primary postpartum hemorrhage Within 1st 24 hours postpartum	Secondary postpartum hge After 1st 24 hours till end of puerperium
-Retained placenta -Uterine atony.[Atonic] -Trauma to genital tract -Acute inversion of the uterus -Coagulation defects		-Retained placental part or membranes [most common] -Subinvolution of the uterus -Puerperal sepsis. -Subaute uterine inversion -Tumours e.g Fibroid or Choriocarcinoma [most serious]

I.PRIMARY POSTPARTUM HEMORRHAGE

Postpartum hemorrhage within the first 24 hrs after fetal delivery.

AETIOLOGY:

I.Atonic postpartum hge:[Uterine atony & Failure of retraction]

1.Anatomically abnormal muscle:

CUMF,Fibroid ut.,Scarred ut.,Dissecting Htoma in couvlaire uterus, Retained placenata {Mechanical}

2.Functionally abnormal muscle:

Multiparity,Ms of LUS,Anemia , PET (Blood vessel defect)

3.Overstrech of uterine muscle :

Polyhydramnious.,Twin , macrosomic fetus.

4.Exhausted & Relaxed uterine muscle:

Precipitate&Prolonged labor,Abuse of ecbolics.Oversedation,Deep anesthesia,full bladder&rectum

5.Infected muscle: Chorioamnionitis.

II.Retained Placenta: Failure to deliver the placenta for 30minutes.

A-Retained Separated placenta due to:

Uterine inertia, Contraction ring , Rupture uterus.

B-Retained non separated placenta due to:

Uterine inertia, Abnormally adherent placenta.

Accreta vera,Increta, or Percreta .

Adherence may be focal,partial or total adherence.

Abnormal adherence may be due to :

-Implantation over septum, fibroid or scar

-Previous endometritis

-Previous excessive D&C

-Previous manual placental separation ]

C-Retained placental parts due to:

Bad managment of the third stage, especially in presence of abnormal placenta(succenturiata,Bilobate&bipartite,...), Focal abnormal adherence.

III.Traumatic postpartum hge:

IV.Coagulation defect

usually due to DIC or patient on anticoagulant therapy.

V.Acute uterine inversion : faulty management of the third stage.

CLINICAL PICTURE OF PRIMARY POSTPARTUM HGE:

1.History:

-History of aetiology or previous PPH or Retained placenta.

-Severe vaginal bleeding & collapse :

-Placenta not delivered = Retained placenta

-After placental delivery =...................................

-Severe pain + fullness of vag.+/-protruding mass[grade III inversion] = Inversion of the uterus

.

2.Examination:

-General examination :

Shock hypovolemic & neurogenic.

May not be proportional to amount of vaginal bleeding if : Traumatic PPH with internal Hge e.g RU, or severe neurogenic shock as with Acute inversion.

-Abdominal examination:

-Retained placenta: +ve or -ve signs of Separation?

-Atonic: Lax,extremely soft,enlarged uterus

-Traumatic: Uterus contracted&hard

-Acute inversion:Cup shaped fundus[I],or ut.not felt[III]

-Local P/V ex: Vaginal bleeding and :

-Retained placenta:Cord present +/- signs of separation.

-Atonic:Blood is dark in color with blood clots filling uterus.

-Traumatic:Fresh bright red continuous bleeding.+/- tears & lacerations can be seen or felt.

-Acute inversion:

-Depressed fundus inside the uterus [GradeI]

-Cx forming a collar around fundus [GradeII]

-Fundus outside vulva[GradeIII or complete inversion]

-DIC: Fluid blood ,no blood clots.

MANAGMENT

I.Prophylactic managment:

1.Hospital delivery & careful managment of patients liable for PPH.

2.Proper active managment of all stages of labor esp. 2nd&3rd stages.

3.Examination of the cx.&vagina after placental delivery for tears & lacerations

4.Evacuation of the bladder regularly during & after labor.

5.Following labor proper uterine massage & observation for early detection of cases while still in good general condition.

II.ACTIVE MANAGMENT

AT HOME

1)Call the ambulance for rapid transfer to hospital.

2)Arrest the bleeding by:

-If placenta retained: only Brandt Andrew's method is attempted

-Massaging the uterus + Ergometrine 0.5mg I.V.

-In severe cases Bimanual compression is done till transport to hospital.

-Firm hemostatic pack if traumatic tears or lacerations of perin. or vag.

3)Initiate I.V drip of saline or ringer or plasma expanders+I.V morphia.

IN HOSPITAL:

I.Rapid Resuscitation : Antishock measures + monitoring

.

					A. If placenta not yet delivered
	Stimulation of the uterus to contract by evacuation of the bladder,uterine massage & I.V ergometrine
	Try to deliver the placenta under anesthesia by Brandt Andrew method ,if still retained Crede's method is then attempted.
Sucessful							Failed
	Manual separation of the placenta under anesthesia 1.Introduce the right hand guided by the UC till the placenta 2.feel placental edge-->take a fold of memb.& pass through the cleavage line (bet.placenta & uterus) 3.Pull on the cord to deliver the placenta while the hand in the uterus explores the uterine cavity while still inside.
Successful									Failed
		RU		Constriction ring				Placenta adherent no cleavage line
Laparotomy						treatment of CR				Standard ttt supravaginal hysterectomy
			If young patient in desperate need for future fertility--> Piece meal removal of placenta + Methotrexate,AB,Ecbolics.Or cut the Cord & leave the placenta + Methotrexate, AB, Ecbolics.

Complications of manual separation:

Infection, Rupture uterus(How?), Retained parts, Failure.

			B.If Placenta has been delivered
		Examine the placenta carefully for retained parts
uterus is lax then Stimulate contraction							uterus is contracted
	If bleeding continues and one more attack occurs inspite of ecbolics and massage
	Exploration of the genital tract under anesthesia Asepsis,Sterilization,catheterization &toweling then: -UUS palpated while abdominal hand pushing the fundus to be in reach. -LUS palpated while the abd. hand streches the LUS. -Cervix&Fornices examined by 4 ring forceps. -Vagina & Perineum carefully inspected via speculum.
Traumatic he				Retained parts						Atony of the uterus
ttt accordingly				Manual Separation					Bimanual compression : Uterus compressed between fist in anterior fornix and abdominal hand
										Still bleeding
	Old lines of ttt not commonly used now: a)I.U douching by warm antiseptic using Bouzman double way catheter--> Wash blood clots & stimulate the uterus to contract. b)Tight uterovaginal pack + AB-->Mechanical compression& stimulate the uterus to contract.[Disadv.: Conceals bleeding if not tight enough, Shocky,introduces Infection, Rupture uterus
								Still bleeding
Patient completed her family-->Supravaginal hysterectomy					Patient need future fertility the one or more of the following procedures are done: B - Lynch sutures, bilateral uterine/ovarian aretery ligation, Bilateral internal iliac artery ligation. If failed => Hysterectomy
						Still bleeding -Why?-

C.Bleeding due to Acute inversion of the uterus:

1.General anesthesia to abolish the severe neurogenic shock.

2.Reposition of the uterus under general anesthesia +/- Relaxing infusions.

3.After reposition keep your hand inside the uterus & start ecbolics till the uterus firmly contracts.Then remove your hand.

4.Pack,Ecbolics&AB at least for 1 week.

D.Bleeding due to DIC--->Managment of DIC

1. Treatment of the cause

2. Antishock measures with replacment by fresh blood,FFP, Cryoppt, Fibrinogen

3.Antfibrinolytic drugs:Trasylol,EACA,Tranexamic acid.

Secondary Postpartum Hemorrhage

PPH after 24hrs from fetal delivery till end of puerperium

DIAGNOSIS:

-Delivery more than 24 hrs ago.

-Vaginal bleeding.

-Picture of the cause.

TREATMENT:

Prophylactic of the cause.

Active: 1.Must perform D&C for every case to exclude Choriocarcinoma.

2.Specific ttt according to cause.

TTT of complications.

Remeber that complications of the third stage of labor may be:

I.Short term:

1.Retained placenta.

2.Primary PPH.(all its causes)

3.Embolism (A.F or thrombotic)

4.Obstetric Shock & its complications.[ARF,DIC,Sheehan synd.]

5.Complications of ttt [e.g hysterectomy,bl.transfusion)

6.Complications of anesthesia.

II.Long term:

1.On Puerperium 3S

2.Subfertility & infertility ,why?

3.Prolapse & stress incontinence(repeated Crede's method)

4.In subsequent preg.: Retained placenta(esp.after manual removal),PlPr.

Disseminated Intravascular Coagulopathy [DIC]

Definition: A coagulopathy in which both thrombotic&fibrinolytic systems are activated simultaneously.

Pathophysiology: -DIC is a 2ry effect to a primary disease.

Tissue destruction: Concealed Acc.Hge,IUFD,Missed ab.,PIH,A.F emb.,V.M.					Infection: Septic abortion, Chorioamninitis			Prolonged Shock state.			Massive old blood transfusion.
			Passage of fluid rich in thromboplastin into the maternal circulation & activation of the extrinsic pathway.
				Intrvascular thrombus formation
		Activation of the fibrinolytic system with lysis of the thrombus
Consumption of platelets, clotting factors& fibrin						Increased level of FDP			Microthrombi formation
	Bleeding tendency						-Anticoaguant -Tocolytic			-Ischemic organ damage -Acute Renal Failure

Diagnosis

-Suspected in every case of primary cause & must be excluded .

-Picture of bleeding tendency in late cases :

Symptom: Ecchymotic patches, bleeding gums & teeth, epist. etc.

Sign : Bed side clotting test: 5ml blood in a standing dry test tube

Investigation:

1.Coagulation profile:[N]

Prolonged Bleeding time [2-4min]

Clotting time [6-12min],

Prothrombin time PT [10-14sec],

Partial thromboplastin time PTT [35-45sec].

Decreased platelet [250,000/ml]

Decreased fibrinogen level.

2.Increased level of FDP [N; 10 microgm%]

COMPLICATIONS: of the cause +

1.Massive hge.

2.Thromboembolic manifestations.

TREATMENT:

PROPHYLACTIC : Very important.

ACTIVE:

1.Essentially ttt of the cause.

2.If no bleeding site[intact vascular tree]-->Heparin may be given together with replacement of fibrinogen

3.If there is bleeding:

a)Antishock measures

b)Replacment by Fresh blood ,FFP, Cryoppt, Fibrinogen .

c)Antifibrinolytics may be used but not preferred as they ppt thrombosis.

Maternal Birth Tract Injuries

1.Perineal tears

Traumatic injury of the perineal body.[?]

AETIOLOGY: (= indications of episiotomy):

1.Passage:

-Rigid perineum,Perineal scar,Perineal edema[friable] as in PIH.

-Narrow subpubic angle.

2.Passenger:-Macrosomia, Malpresentation e.g D.O.P,Face presentation .Why?, delivery of aftercoming head of breech.

3.Power: -Precipitate Labor (tissues tear rather than distend)

4.Attendent fault: -Head delivered during contraction

-Inefficient Perineal support.

-Head allowed to extend before crowning.

-Operative instrumental delivery without episiotomy.

TYPES & DEGREES:

1st degree: Frochette,post.vag.wall,Perineal skin.

2nd degree: First +Perineal body tear but not external anal sphincter

3rd degree: Second +External anal Sphincter.[Complete perineal tear].

4th degree: Third +Rectal mucosa.

N.B Grade 0 is hidden perineal tear due to overstrech-->Patulous vagina.

CLINICAL PICTURE & COMPLICATIONS

			SYMPTOMS
Immediate		During Puerperium		Late = Healed perineal tear
1mary PPH		Infection (P.S)				Repeated Vaginitis.
					IncompleteTear => Prolapse
	Complete tear-->Incontinence to stool&flatus then to flatus only.

				SIGNS
	Early				Late
Tear is evident			Incomplete tear-Absent or reduced perineum.
		Complete perineal tear -Absent corrugations around the rectum,2 lateral dimples -Bright red MM of anal canal seen through the vagina. -P/R -->absent sphincteric tone & voluntary control

TREATMENT

1.Prophylactic:

Proper managment of the second stage , controlled head delivery, properly timed episiotomy when indicated.

2.Curative:

-Immediate repair within the first 24hrs, if after 24hrs repair is delayed 3-6 months for edema to resolve & infection decreases.

IMMEDIATE REPAIR OF PERINEAL TEARS:

1-Complete perineal tear:

-Under General anesthesia.

A-Suturing the tear in layers:

1-Anorectal wall is closed from above downwards in 2 layers not involving the mucosa.

2-The torn ends of the External anal sphincter are identified and sutured

3-The Levator ani muscles are approximated infront of the rectum

4-The vaginal wall is closed from above downwards.

5-The deep then superficial tranverse perineal muscles are then sutured

6-Lastly the perineal skin wound is closed.

Chromic catgut is used for all layers, interrupted sutures.

B-Postoperative care:

1-Perineal wound is kept dry and clean

2-Low residue diet.

3-Antibiotics to avoid wound infection.

4-Intestinal antiseptics

5-No sexual intercourse for 2 months.

2-Incomplete perineal teal

-Under Local infilteration anesthesia

A-Suturing the torn layers are sutured as above.

B-Post-operative care:

1-Perineal wound is kept dry and clean

2-Antibiotics to avoid wound infection.

2-Repair of healed perineal tears : Lawson Tait operation - see recto-vaginal fistula repair.

2.Vulval,Vaginal, Cervical tears:

AETIOLOGY:

as perineal tears

+ Vaginal tears may occur in obstructed labor (Pressure necrosis)

TYPES OF VAGINAL TEARS:

-Lacerations -Tears -Spiral tear -Colporrhexis

TYPES OF CERVICAL TEARS:

-Uni or bi lateral cervical tears.

-Stellate tears.

-Annular detachment. -Button hole tear. -Endocervical lacerations.

CLINICAL PRESENTATION AND COMPLICATIONS

	EARLY		LATE
1.PPH 1ry 2.Puerperal Sepsis 3.Extension of cervical tear--> Ruptured uterus.		4.Vaginal tears--->Prolapse 5.Chronic cervicitis (Cx. tears) 6.Repeated vaginitis (Vag tears) 7.Cervical tears--->Incompetent cervix. 8.Fistula formation

TREATMENT:

1.Prophylactic

2.Curative:

A-Immediate:

-EUA (for PPH) Immediate repair of tears.

-If the urinary bladder is involved an indwelling urinary catheter is inserted for 2 wks after repair.

B-Late:

-Cervical tears if diagnosed later are ttt be tracheolorrhaphy or cerclage in susequent pregnancy.

-Treatment of complications (Prolaps, fistula.........etc)

3.RUPTURE OF THE UTERUS

Incidence:Variable according to standards of Obstetric care 1/1000-1/8000.

Most cases are MP because:

1.Previous pregnancy & labor: False sense of security.

2.Passage: CP due to Osteomalacia

3.Passenger: MP-->Macrosomia, Also increased incidence of D.M

4.Power: Weak uterine&abdominal ms.-->Malpresentations&position.

& Maldirection of uterine axis.

Uterus of MP responds to obstruction by uterine overactivity.

AETIOLOGY OF RUPTURE UTERUS

		I.RUPTURE DURING PREGNANCY
	A.Spontaneous			B.Traumatic
1.Rupture of uterine scar. 2.Rupture of intrauterine ectopic pregnancy 3.Rupture of anterior or posterior sacculation. 4.Concealed accidental hge. 5.Invasive vesicular mole.			1.Abdominal trauma. 2.Iatrogenic: Forceful ECV, EPV.
		II.RUPTURE DURING LABOR
	A.Spontaneous			B.Traumatic

1.Presence of uterine scar 2.Obstructed labor esp.in MP. 3.Abuse of Oxytocin,or Methergin given before fetal delivery 4.Abruptio-placentae

1.Forceps,Ventouse or breech extraction,esp.if cx not fully dil. 2.Destructive operations. 3.Intruterine manipulations

PATHOLOGY OF RUPTURE UTERUS

1.Type Of Rupture:

-Complete:All layers + Peritoneum.[usually UUS]

-Incomplete: Intact peritoneum [ LUS.why?]

2.Site Of Rupture:

-Fundus-->Site of previous perforation.

-UUS-->Site of previous scar.[USCS]

-Between UUS&LUS-->Retraction ring.

-LUS-->Instrumental delivery or extending cervical tear.

Site of LSCS ruptured scar.

Incidence of rupture of USCS is 5% while LSCS 0.5%.

3.Severity Of Bleeding : variable-

-If the uterine artery or one of its main branches are torn , severe bleeding occurs.

-With dehescience of a scar, bleeding usually is minimal.

-If the fetus and placenta escape into the peritoneal cavity or are delivered, the uterus retracts and so bleeding is not excessive, unless the uterine artery or one of its main branches are torn

DIAGNOSIS OF RUPTURE UTERUS

I.RUPTURE DURING PREGNANCY

May give the C/P of acute abdomen or may be a silent rupture.

AN AETIOLOGICAL FACTOR FOR ANTEPARTUM HEMORRHAGE

A.Acute abdomen:

History: -OF a cause e.g ...............

-In case of ruptured scar symtoms the preceed rupture may be

noted: mild lower abdominal pain ± vaginal spotting ± tender scar.

-Collapse + nausea + vomiting

-Sudden Severe abdominal pain + Shoulder pain.

-Vaginal bleeding. [ = APH ]

Examination:

General examination:

Hypovolemic & Neurogenic shock = Shock not proportionate to vaginal bleeding

Abdominal examination:

T, R, RTCullen signShifting dullness = Intraperitoneal Hge.

-If the fetus escapes into peritoneal cavity:

Fetal parts easily felt, abnormal lie, No FHS.

Uterus felt away from the fetus.[remember abd.preg.!?]

-If the fetus is still in the uterus:

FHS show severe fetal distress.

P/V: Contraindicated if diagnosis of placenta previa is not ruled out [this is a case of APH. Ok!!] Otherwise it reveals that no PP is felt.

B.Silent rupture:

Usually due to slow gradual dehiscence of a previous scar,so symptoms are mild at first & bleeding is minimal due to fibrosis of the gapped edges.

II.RUPTURE DURING LABOR

A.Picture of ruptured uterus due to obstructed labor:

1.C/P of obstructed labor & impending uterine rupture.[mention]

2.The C/P suddenly becomes replaced by C/P of rupture uterus:

*History:

-Irritable noisy patient suddenly collapses.

-Pain:

-Severe labor pain replaced by continuous severe bursting abd.pain

-Feeling of obstruction suddenly replaced by feeling of giving way

-Uterine contractions suddenly cease.

-Vaginal bleeding starts.

*Examination:

General --->Shock

Abdominal--->As any rupture uterus.

P/V: As obstructed labor +

PP receeds & becomes freely mobile.

Vaginal bleeding feeling tear Hematuria.

B.Picture of ruptured uterus due to obstetric trauma:

-Suspected in cases of labor with one of the aetiologic factors of trauma & should always be ruled out

The patient may present as follows:

1.Primary PPH & shock following labor.

2.Discovered during trial of manual separation of a retained separated placenta.

3.Discovered later on where the patient develops paralytic ileus or puerperal sepsis and peritonitis.

COMPLICATIONS OF RUPTURE UTERUS:

1.MMR 10 - 40% due to : Hge&shock,ARF,Infection,AF embolism, DIC,Anesthetic.

2.Maternal morbidity:

Infertility,Injury to UB,Intestine,Ureters.,Sheehan's synd.,RU in subsequent preg. if repair was done [commonest scar to rupture]

3.PNMR: Complete RU-->100%. Incomplete RU-->60%

TREATMENT OF RUPTURE OF THE UTERUS:

I.Prophylactic ttt: -Rupture uterus should not be seen in modern obstetrics-

1.During pregnancy:........................

2.During labor: ...........................

II.Active ttt:

1.Resuscitation & Antishock measures.

2.Immediate laparotomy and:

1)Extract the fetus & placenta

2)Supravaginal hysterectomy ± Bilateral internal iliac artery ligation.

In rare cases if the patient is in desperate need for future fertility + Clean cut small rupture ,repair of rupture may be attempted.[But this should never be considered a standard line of ttt] The patient should not get pregnant for at least 2 years, Hospitalized all through pregnancy & delivered by C.S with the earliest sign of fetal maturity.

3)Explore abdominal viscera for tears or lacerations.

4)Inspection for vagina and perineum for tears especially in case of traumatic rupture of the uterus.