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POSTPARTUM HEMORRHAGE (PPH)

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Definition 

loss of > 500 mL of blood after delivery (most women probably lose > 500 mL, often underestimated)

Etiology (4 T’s)

  1. Tone: uterine atony (most common cause of PPH)

    • occurs within first 24 hours
    • labour (prolonged, precipitous)
    • uterus (infection, over-distension)
    • placenta (abruption, previa)
    • maternal factors (grand multiparity, GA)
    • halothane anesthesia

  2. Tissue: retained placenta (see above)
  3. Trauma: laceration (vagina, cervix, uterus), episiotomy, hematoma, uterine rupture, uterine inversion (see above)  
  4. Thrombin: coagulopathy

    • most identified prior to delivery (low platelets increases risk)
    • includes hemophilia, DIC, aspirin use, ITP, TTP, VWD (most common)
    • maintain fibrinogen > 1000 mg/mL, platelets > 50 000
Management

determine cause, call for help
supportive  :ABC's, fluid, +- transfusions, +/- other blood products

Examination
  1. reexamine patient, ensure complete delivery of placenta,check for uterine atony and drain bladder
  2. check for cervical and vaginal lacerations
  3. elevate the uterus and massage through patient's abdomen

Investigations : pelvic U/S if indicated to look for cause 

Medical

  1. oxytocin (5 U IV push then 40 u/L NS drip)
  2. methylergonavine maleate (ergotamine; 0.2 mg PO or 0.25 mg IM) (normotensive patients only; must explore uterus before giving ergotamine)
  3. prostaglandins (PGF-2 alpha intrauterine or IM)
  4. hemabate (prostaglandin; 0.25-1.00 mg intramyometrium every 15 minutes)
  5. uterine packing (3-4 five yard Kerlex rolls tied together and soaked in betadine and removed in 12-24 hours; controversial)

surgical
  1. seek and suture lower genital gract lacerataions
  2. D&C (beware of vigorous scraping which may cause Asherman)
  3. hypogastric, ovarian artery or uterine artery ligation
  4. arterial embolization
  5. hysterectomy (last option) complications: Sheehan syndrome (pituitary necrosis)

POSTPARTUM HEMORRHAGE (PPH) POSTPARTUM HEMORRHAGE (PPH) Reviewed by Radiology Madeeasy on September 08, 2010 Rating: 5
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