Case Report

Postpartum Hemorrhage
Preceptor :
Dr Gioseffi Sp.OG
By :
Gita Larasastri Tarigan
(406127113)
Varla Septrinidya Gharatri
(406127121)

Case Report
PATIENTS IDENTITY

Name
Age
Gender
Address
Ethnic
Religion
Education
Occupation

: Mrs. S
: 21 years
: Female
: Kp. Cilember
: Sunda
: Islam
: elementary
: Housewife

PATIENTS HUSBANDS IDENTITY

Name
Age
Gender
Address
Ethnic
Religion
Education
Occupation

: Mr. A
: 29 years
: male
: Kp. Cilember
: Sunda
: Islam
: Junior High School
: Housewife

History
Autoanamnesa on April 28, 2014.
Main complaints: Bleeding after
childbirth since 3 hours before
arriving at the hospital
Additional Complaint: headache (+)

Disease History
The patient was referred by a midwife Siti Mulyanti
with diagnosis P2A0 inpartu stage II with retained
placenta. Patients admitted to having a baby
helped by shaman at 09.00 am (dated 28 April
2014), the patient said that the placenta had not
come out about half an hour after the baby is born.
In addition the patient also complained of
headache (+), the body weak (+). Complaints of
blurred vision (-), nausea (-). Already bore 2
children, a history of previous miscarriages (-).
LMP: 8-9-2013. History of menstruation is regularly
every 28 days, a history of contraception (-).

 History of Past Medical : Asthma (-), Hypertension

(-), DM (-), Allergy (-), Heart (-)
History of Familys Disease: Asthma (-),
Hypertension (-), DM (-), Allergy (-), Heart (-)
History of Menstruation:
Menarche
: 13 years
Cycle
: 28 days
Older
: 3-4 days
The number of pads per day : 3-4 pads
Menstrual pain
: never

 History of marital: Married 1 time,

at the age of 16 years.
History of Pregnancy: It gave birth
to 2 children, a history of miscarriage
(-).
History of Contraception: The
patient had never used contraception
History of Surgery: Never any
surgery

Physical Examination

Height: 160 cm
Weight: 61 kg
Blood Pressure: 90/60 mmHg
Heart rate: 104 x / min
Temperature: 36.9 C
Respiratory rate: 24 x / min
State of Nutrition: Good
Awareness: Compos Mentis

General examination
Head
Eye : CA +/+ , SI -/- , pupils isokor, the
light reflex + / +
Ear : an intact of the tympanic
membrane (+ / +) , wax (-)
nose : deviation of septum (-),
discharge(-)
mouth : good oral hygiene
neck : lymph nodes and thyroid was not
palpable enlarged

General examination
Breast :normal breast shape, inverted nipple -/-, fissure -/ Lungs
o Inspection : normal chest shape
o palpation : stem fremitus of right and left chest is equally
strong
o percussion : sonor +/+
o Auscultation : vesicular, ronchi - / -, wheezing - / Cor
o Inspection : ICTUS cordis is not visible
o Palpation : ICTUS cordis ICS VI palpable in the left MCL
o Percussion : dim
o Auscultation : BJ I - II regular, murmur (-), gallop (-)

Status of Obstetric
Abdominal
o Inspection : flat
o Palpation : high of fundus is 1 finger
above center, tenderness (-)
o Auscultation : bowels sounds(+)
Genitalia external : no abnormalities of
vulva and vagina, bleeding (+)
Examination in : not done

 Laboratory (Date 28 April 2014)

- Hb
: 7.7 g / dL
CT : 11'45 "
- HT
: 22%
BT : 3'30 "
- Leukocytes : 25500 / uL
- Platelets : 177000 / mL
- Blood
:B
Rhesus
: (+)

Follow up
Dated 28 April 2014 at 13: 30 pm
Ultrasonographys results: retained
placenta (+)
P: Plan curettage if Hb 10 g / dL

Dated 29 April 2014

S: headache (+), weak (+), blood coming from the vagina (+)
O: General Examination
General Situation: Looks Moderate Pain
Awareness: Compos Mentis
Signs - Vital Signs:
Blood pressure: 90/60 mmHg
HR: 78 x / m
RR: 22 x / m
Temperature: 36.9 C
Eyes: CA + / +
Abdomen: flat, high of fundus uteri is 1 finger center, tenderness (+),
BU (+)
Genitalia: v / v was bleeding (+) slightly
Extremities: edema - / A: P2A0 spontaneous post partum with gestationals age is 32-33 weeks
with retained placenta + anemia
P: Plan curettage if Hb 10 g / dL

Dated 30 April 2014

S: headache (-), weak (+), blood coming from the vagina
(+)
O: General Examination
General Situation: Looks Moderate Pain
Awareness: Compos Mentis
Signs - Vital Signs:
Blood pressure: 90/60 mmHg
HR: 82 x / m
RR: 22 x / m
Temperature: 38.1 C
Eyes: CA + / +
Abdomen: flat, TFU 1 finger center, NT (+), BU (+)
Genitalia: v / v was bleeding (+) slightly
Extremities: edema - / -

Laboratory (Date 30 April 2014)

- Hb : 10.1 g / dL
CT: 11'07 "
- HT : 23% BT: 3'20 "
- Leukocytes : 15500 / uL
- Platelets : 257000 / mL
- Blood: B
Rhesus: (+)
A: P2A0 spontaneous post partum with gestationals
age is 32-33 weeks with retained placenta + anemia
P: Curettage
PCT 3X500 mg

RESUME
Have examined a woman (21 years old)presenting with bleeding after
childbirth since 3 hours before arriving at the hospital. The patient said
that the placenta had not come out after about half an hour a baby is
born. Complaints of headache(+), the body weak (+), blurred vision (-).
Already bore 2 children, a history of previous miscarriages (-).
On physical examination found :
Blood pressure 90/60 mmHg
HR 104 x / min
RR24 x / min.
Eyes : CA (+ / +)
Abdomen : flat, high of fundus uteri 1 finger center, tenderness (-),
BU (+)
Genitalia: v / v was bleeding (+) slightly
Routine blood tests (28/04/14)
Hb : 7.7 g / dL Ht : 22%
Leukocytes: 25500 / uL Platelets : 177000/L

Basic Diagnosis
Retained placenta
In the complaint obtained history of bleeding after
delivery, the placenta has not come out about half
an hour after the baby is born. On physical
examination of the abdomen, high of fundus uteri is
1 finger above the center, genital examination
found bleeding (+) minimum.
Anemia
In the complaint obtained history of bleeding after
childbirth, headache (+), limp +. On physical
examination found CA + / +. In laboratory tests Hb
7.7g/dL

Management
Fluid resuscitation
PRC transfusion to Hb> 8 g / dL
If the Hb 10 g / dL plan to
curettage
Paracetamol 3 x 500 mg
Observation KU, TTV, and bleeding

Definition Postpartum Hemorrhage

postpartum hemorrhage has been
defined as the loss of 500 mL of
blood or more after completion of the
third stage of labor

Predisposing Factors and Causes of

Immediate Postpartum Hemorrhage
Bleeding from Placental Implantation Site
o Hypotonic myometriumuterine atony
Some general anestheticshalogenated
hydrocarbons
Poorly perfused myometriumhypotension
(Hemorrhage, Conduction analgesia)
Overdistended uterus: large fetus, twins,
hydramnios
Prolonged labor

Predisposing Factors and Causes of

Immediate Postpartum Hemorrhage
Very rapid labor
Induced or augmented labor
High parity
Uterine atony in previous pregnancy
Chorioamnionitis
o Retained placental tissue
Avulsed lobule, succenturiate lobe
Abnormally adhered: accreta, increta,
percreta

Predisposing Factors and Causes of

Immediate Postpartum Hemorrhage
Trauma to the Genital Tract
o Large episiotomy, including
extensions
o Lacerations of perineum, vagina, or
cervix
o Ruptured uterus
Coagulation Defects
o Intensify all of the above

Retained placental tissue

In most instances, the placenta
separates spontaneously from its
implantation site during the first few
minutes after delivery of the infant.
Infrequently, detachment is delayed
because the placenta is unusually
adhered to the implantation site.

Retained placental tissue

placenta accreta is used to describe
any implantation in which there is
abnormally firm adherence to the
uterine wall. As the consequence of
partial or total absence of the decidua
basalis and imperfect development of
the fibrinoid or Nitabuch layer,
placental villi are attached to the
myometrium in placenta accreta

Retained placental tissue

o Total placenta accreta : the abnormal
adherence may involve all lobules
o Partial placenta accreta: it may
involve only a few to several lobules
o focal placenta accreta : all or part of
a single lobule may be attached

Retained placental tissue

Placenta increta, villi actually invade
into the myometrium
Placenta percreta, villi penetrate
through the myometrium.

Management of Retained placental

tissue
Preoperative Arterial Catheter Placement
Experience has accrued with preoperative
placement of pelvic arterial catheters.
Balloon-tipped catheters are placed before
surgery into the internal iliac arteries and are
inflated after the fetus is delivered to
decrease blood loss during placental delivery
and hysterectomy, if indicated. Alternatively,
the catheters can be injected with a
substance to embolize the arterial sites.

Management of Retained placental

tissue
Delivery of the Placenta
Problems associated with delivery
of the placenta and subsequent
developments
vary
appreciably,
depending
on
the
site
of
implantation, depth of myometrial
penetration, and number of lobules
involved.

Uterine Atony
Failure of the uterus to contract
properly following delivery is the most
common cause of obstetrical
hemorrhage
Women with a large fetus, multiple
fetuses, or hydramnios are prone to
uterine atony
High parity may be a risk factor for
uterine atony.

Uterotonic Agents
Oxytocin
Oxytocin is given intravenously or
intramuscularly. This or other oxytocics will
prevent most cases of uterine atony.
Ergot Derivatives
If oxytocin does not prove effective to reverse
uterine atony, we usually administer 0.2 mg of
methylergonovine intramuscularly. Importantly,
if ergot agents are intravenously administered,
they may cause dangerous hypertension,
especially in women with preeclampsia.

Uterotonic Agents
Prostaglandin Analogs
The 15-methyl derivative of prostaglandin
F2carboprost tromethaminehas been
approved since the mid-1980s for
treatment of uterine atony. The initial
recommended dose is 250 g (0.25 mg)
given intramuscularly. This is repeated if
necessary at 15- to 90-minute intervals
up to a maximum of eight doses

Genital Tract Lacerations

Perineal Lacerations
All except the most superficial perineal
lacerations are accompanied by varying
degrees of injury to the lower portion of the
vagina.
Vaginal Lacerations
These are usually longitudinal and frequently
result from injuries sustained during a forceps
or vacuum delivery. However, they may even
develop with spontaneous delivery.

Genital Tract Lacerations

Injuries to Levator Ani Muscles
These result from overdistension of
the birth.
Injuries to the Cervix
The cervix is lacerated in more
than half of all vaginal deliveries.
Most of these are less than 0.5 cm,
although deep cervical tears may
extend to the upper third of the
vagina

Inversion of the Uterus

Complete uterine inversion after
delivery of the infant is almost
always the consequence of strong
traction on an umbilical cord
attached to a placenta implanted in
the fundus. Incomplete uterine
inversion may also occur.

Inversion of the Uterus

Contributing to uterine inversion is a
sturdy cord that does not readily
break away from the placenta,
combined with fundal pressure and a
relaxed uterus, including the lower
segment and cervix.

Management of Uterine inversion

Immediate assistance is summoned to
include anesthesia personnel and
other physicians
The recently inverted uterus with
placenta already separated from it
may often be replaced simply by
pushing up on the fundus with the
palm of the hand and fingers in the
direction of the long axis of the vagina

Management of Uterine inversion

Adequate large-bore intravenous
infusion systems are established, and
crystalloid and blood are given to
treat hypovolemia
Tocolytic drugs such as terbutaline,
ritodrine, magnesium sulfate, and
nitroglycerin have been used
successfully for uterine relaxation and
repositioning

Management of Uterine inversion

After removing the placenta, steady pressure
with the fist is applied to the inverted fundus
in an attempt to push it up into the dilated
cervix. Alternatively, two fingers are rigidly
extended and are used to push the center of
the fundus upward. As soon as the uterus is
restored to its normal configuration, the
tocolytic agent is stopped. An oxytocin
infusion is begun while the operator
maintains the fundus in its normal anatomical
position.

Coagulation Defects
Hypofibrinogenemia
In late pregnancy, plasma fibrinogen levels
typically are 300 to 600 mg/dL. To promote
clinical coagulation, fibrinogen levels must
be approximately 150 mg/dL.
Fibrin and Fibrinogen Derivatives
Monoclonal antibodies to detect D-dimers
are
commonly
used.
With
clinically
significant consumption coagulopathy, these
measurements are always abnormally high.

Coagulation Defects
Thrombocytopenia
With severe preeclampsia and eclampsia,
there may also be qualitative platelet
dysfunction
Prothrombin and Partial Thromboplastin
Times
Prolongation of the prothrombin time and
partial thromboplastin time need not be the
consequence of consumptive coagulopathy.