PPH & COAGULATION DISORDERS

Postpartum Hemorrhage
Definition
Loss of 500 ml or more of blood following vaginal delivery. (Hg. may occur before, during or after delivery of the placenta ) Or 1000 ml of blood loss for cesarean section Early PPH Blood lost during the first 24 hrs after delivery Late PPH Blood lost between 24hr6weeks after delivery

Postpartum Hemorrhage
Incidence

5-8% It is the most common cause of excessive blood loss in pregnancy Hemorrhage (including APH, PPH, abortion & ectopic) is the leading obstetric cause of maternal mortality in Saudi Arabia & underdeveloped countries It is the third leading cause of MM in USA

Morbidity & Mortality

Women compromised by anemia or intercurrent illness are at increased risk of complications Anemia Morbidity related to blood transfusion hepatitis, HIV, transfusion rection Morbidity related to hypovolemic shock Renal failure (acute tubular necrosis)

Morbidity & Mortality

Shehans syndrome postpartum hypotension partial or complete necrosis of the anterior pituitary panhypopituitrism -Characterized by failure to lactate, amenorrhea, hypothyroidism, adrenal insufficiency & breast size & loss of pubic & axillary hair. -Incidence 1:10000 deliveries

Sterility resulting from Hysterectomy performed to control severe Hg

Etiology of PPH
1-Uterine atony

With separation of the placenta many uterine blood vessels are severed abruptly the bleeding that results is controlled by contraction & retraction of the myometrium to compress the blood vessels
Uterine atony results when there is failure of the myometrium to contract It accounts for 50% of the cases of PPH

1-Uterine Atony
Predisposing causes:

Uterine over distension twins, polyhydramnious or large infant

Grandmultiparity Prolonged labor

Dysfunctional labor
Oxytocin induction or augmentation of labor

Contd/Uterine Atony Predisposing Causes

Instrumental deliveries Uterine infections General anesthesia with halogenated compounds Previous HG or blood transfusion Uterine lieomyoma Intrauterine manipulation Abruptio placenta with couvelaire uterus

Etiology of PPH
2-Obstetric lacerations

20%of PPH
It may involve the vagina, vulva, cervix or uterus Predisposing causes : Precipitate delivery, operative delivery & large infant

Hematomas laceration of blood vessels underneath vaginal or vulvar epithelium

Etiology of PPH
contd/Obstetric lacerations

Excessive bleeding from the episiotomy if it involves varicosities or arteries, if the episiotomy is large, early episiotomy or delayed repair

Rupture uterus risk factors: CS or uterine surgery, IOL with PG or oxytocin, grandmultiparity & malpresentation

Etiology of PPH
3-Retained placental tissue

5-10% of PPH

Predisposing causes: placenta accreta, mismanegement of the 3rd stage of labor, succenturiate placenta U/S or sonohysterography are helpful in the DX of pt. with retained placental tissue

Etiology of PPH
4-Low laying placenta as the lower segment is less contractile excessive bleeding from the placental site after delivery 5-Inversion of the uterus Due to strong traction on an umbilical cord attached to a fundal placenta 1:2000-6000 deliveries Immediate replacement is mandatory to prevent life threatening Hg

Etiology of PPH
6-Coagulation defects -Consumptive coagulopathy due to abruptio placenta, retained dead fetus, amniotic fluid embolism, severe PET, septicemia or abortion -Medical causes of coagulation defects Von Willbrands disease, ITP, leukemia, dilutional coagulopathy (when >8 U of blood transfused)

MANAGEMENT
1-Predelivery preparation
-Type & screen blood for all Pt in labor -High risk Pt Cross matching Large bore IV catheter Severely anemic Pt transfused

2-Management at delivery

Oxytocin IM or IV with the delivery of the anterior shoulder blood loss at delivery & PPH by 40% Uterine massage after delivery of the fetus Delivery of the placenta by controlled cord traction

Inspection of the placenta for completeness

3-Management in the immediate post partum period

Manual removal of the placenta MRP

-Timing of MRP immediately if there is HG Wait for 30 if there is no Hg -Usually performed under GA -Prophylactic antibiotics given

Contd/Management in the immediate post partum period

Repair of lacerations

-Episiotomy should be repaired immediately

-The vagina & cx should be inspected & any lacerations repaired -Lacerations extending into the broad ligament require laparotomy -Large hematomas require operative management

4-Evaluation of persistent bleeding

1-Manually compress the uterus 2-Obtain blood for X-matching if not done 3-Start IV fluids or blood replacement 4-Insert a 2nd IV catheter 5-Cathterize the bladder 6-Start IV oxytocin 7-Inspect the cx & vagina

4-Evaluation of persistent bleeding

8-Manually explore the uterine cavity in vaginal delivery following CS, when intrauterine manipulation has been performed, when abnormal uterine contour has been noted or preterm delivery Ensure that there are no retained placental tissue & that the uterus is intact

Look for possible structural abnormalities of the uterus

5-Measures to control bleeding

1-Bimanual compression & massage of the uterus 2-Curettage When manual exploration fails to remove fragments of adherent placenta It may result in perforation or ashermans syndrome 3-Utrotonic agents -Oxytocin 20-40 U/L IV infusion 10-15ml/min -Methylergonovine 0.2 mg IM (contraindicated in hypertensive Pt) -PGF2 intramyometrial injection or IM -Misoprostol rectally

5-Measures to control bleeding

4-Radiographic embolization of uterine arteries or internal iliac 5-Operative management a-Pressure occlusion of the aorta to provide time to identify the source of bleeding B-Uterine artery ligation C-Internal iliac ligation D-B-lynch suture E-Hysterectomy 6-uterine packing

Consumptive coagulopathy DIC

Pregnancy induces hypercoagulbility factor I(fibrinogen), VII, VIII, IX, X Plasminogen but plasmin activity Causes of Obstetric coagulopathy: A-Activation of the extrinsic coagulation pathway through the release of thromboplastin from tissue destruction 1-Abruptio placenta (the most common cause ) 2-Intrauterine fetal death (IUFD) & delayed delivery occurs if the dead fetus is retained for >1 month (25%) Rare before that

Causes of Obstetric coagulopathy:

B-Direct activation of factor X by proteases as present in mucin. Amniotic fluid contains abundant mucin from fetal cells rapid DIC with amniotic fluid embolism C-Septicemia release of bacterial endotoxins disruption of vascular endothelium tissue factor is released activation of the extrinsic coagulation pathway D-Abortion results in coagulopathy when there is prolonged retention of a dead fetus, septic abortion E-HELLP syndrome Deposition of fibrin in endothelial cells of blood vessels (consumptive coagulopathy) microangiopathic hemolysis

Clinical evidence of defective hemostasis

Exessive bleeding at the site of modest trauma Characterizes defective hemostasis eg. Bleeding from venipuncture sites, nicks from shaving, trauma from insertion of a catheter, spontaneous bleeding from nose or gums, continuous oozing from cut surfaces during surgery, petechiae.

Lab. evidence of defective hemostasis

1-Hypofibrinogenemia <100 mg/dl 2-Fibrinogen degradation products

3-Thromboctopenia
4-Prolonged PT & PTT

Amniotic fluid embolism

Abrupt onset of hypotension, hypoxia, and cosumptive coagulopathy

one of these manifestation may dominate 1:20000 deliveries

Amniotic fluid embolism

Clinical presentation In the late stages of labor or immediately postpartum Gasping for air, seizures, cardiorespiratory arrest, DIC, Hg, & death (60-90%) Fetal survival ~70%

No data that any type of intervention improves the prognosis

Treatment of coagulopathy
1-Fresh frozen plasma 2-PLatlets transfusion 3-Cryoprecipitate 4-PRBC 5-Heparin for IUFD Should not be used in cases of abruptio placenta, septicemia 6-Antibiotics for Pt with septicemia or septic abortion