Postpartum Hemorrhage

Case Report
Hanisah Idris
Norfarah Izzati Azman
Identity

Name : Mrs Y
Sex :
Age : 34 y.o
Religion : Islam
Race : Jawa
Address : Teluk Jambe
Anamnesis (18th of January 2014, 0650hrs)
RPS
Menstrual History
First day of LMP :-
Estimated Due Date : 22-01-2014 (ANC)
Past Medical History
Gestational Age : 40 wks HTN (-) , DM(-), asthma
Menarche : 15 thn (-), Heart Failure (-)
Menstrual Cycle : regular
Duration : 4 days Family History
Volume : 2 pads/day HTN (-) , DM(-), asthma
Dismenore : (-) (-), Heart Failure (-)
Marital Status
Married once at 14 y.o

Past Obstetrics History

G3P2A0 : I : 13yo,, SVD, 3500gr.
II : , SVD,3600gr
III : This pregnancy
Routine antenatal care (ANC)
Contraceptive History
Contraceptive Injection (every 3mo)
Antenatal Care and Immunization

ANC once in every month

TT Twice
USG (-)
 Physical Examination
General Examination
Appearance : Tampak sakit ringan
Kesadaran : Compos mentis
Vital Sign
Blood Pressure : 130 / 80 mmHg
Pulse : 84 x /mins, regular
Temperature : 36,20 C
Respiratory : 18 x /menit
Head : Normocephali.
Eyes : Pupil bulat isokor, CA -/-, SI -/-
Nose : Normosepta, NCH -/-, sekret -/-
Mouth : Karies -, mukosa intak.
Neck : KGB tidak teraba membesar, Tiroid tidak teraba.

Thorax
Mammae : Simetris, hiperpigmentasi pada kedua areola, retraksi putting -/-
Cor : Bunyi jantung I-II regular, murmur -, gallop
Pulmo : Suara nafas vesikuler, rhonki -/-, wheezing -/-
Abdomen : membesar sesuai usia kehamilan, striae gravidarum (+)

Ekstrimities : akral hangat +/+, edema -/-

Obstetrics Examination
I. INSPECTION : Distention (+)
II. PALPATION (4 manouvers of
Leopold)

1. Examination of uterine
fundus
Symphysio- fundal
height(35cm)
2. Fetal back (right side)
3. Presenting part : vertex
4. Engagement of presenting
part (4/5)

III. Auscultation : Fetal

heart rate 144bpm
Vaginal Examination
Vulva & vagina Tenang

Cervix-dilatation 6cm ,effacement (thin), position (axial) &

consistency (soften)

Presenting part : Vertex

Hodge : I-II

Membranes (+) Liquor (-)

Pemeriksaan penunjang
Hematologi 18 Januari 2014
Hb : 10,8 USG
Ht : 32,8%
BPD : 95,2 mm
Leukosit : 26, 270
Trombosit :299.000
FL : 76,4 mm
HBsAg : HC : 324 mm
nonreaktif AC : 351,8 mm
Blood type/ rhesus : B/ + EFW : 3712gram
Bleeding time : 2 mins
ICA :9
Clotting time : 11 mins

GDS : 100
mg/dl JPKTH, plasenta di
fundus
Resume
Wanita, 29 tahun, G2P1A0 hamil 39-40 minggu,HPHT : 09-
04-2013, TP: 16-01-2014 dirujuk bidan dengan keluhan
ketuban pecah sejak 1 hari SMRS, mengaku hamil 9 bulan,
keluhan keluar air-air sejak 18 jam SMRS. berwarna bening,
amis, banyak, tidak disertai lendir bercampur darah. keluar
tiba-tiba saat pasien bangun dari tempat tidur untuk kekamar
mandi. Keputihan sejak 3 hari SMRS.tidak banyak, putih,
gatal. mules-mules hilang timbul sejak 18 SMRS. tidak
bertambah kuat. Pasien masih merasakan gerakan janin.
Riwayat terbentur/ trauma, demam dan nyeri saat BAK
disangkal. Pasien berobat ke bidan terdekat dikatakan oleh
bidan ketuban pasien sudah pecah. Kemudian pasien di
rujuk ke RSUD Karawang.
Diagnosis
PK1 aktif pada G3P2A0 hamil 38-39minggu, JPKTH
Therapy
Observasi tanda tanda vital, HIS, DJJ dan kemajuan
persalinan.

Observasi tanda tanda infeksi intrauterin, infeksi

intrapartum, maupun tanda tanda gawat janin.

Terapi medikamentosa ;
Ceftriaxone 2 x 1 gram IV bolus
Rencana Persalinan Per Vaginam
Prognosis

Mother : dubia ad bonam

Fetus : dubia ad bonam

Follow up (1) 18th of January 2014

1100hrs : Fully dilated Active phase

1120hrs : Lahir bayi perempuan, BBL 3400, PBL 50cm, A/S
5/7, ketuban jernih, jumlah cukup, cacat (-), anus (+),
mekonium (+), posisi lahir kepala
1130hrs : Dilakukan PTT. Plasenta lahir spontan lengkap
dengan berat 500gr, ukuran 12x12x1,5cm. Dilakukan
masasefundus, kontraksi lemah dengan perdarahan aktif
700cc injeksi metergin 1 ampul iv, oksitosin 20iu/500RL,
misoprostol 1000mcg dan KBI selama 2 menit
perdarahan aktif pervaginam (+) KBI lagi, persiapkan
tampon kondom
A : HPP ec Atonia Uteri
 Planning :
Survey A : Free
B : Spontaneous
C : BP 100/60mmhg, pulse 110x/m
D : -IVFD 2 line, loading1000cc
-calcium gluconas 1 ampul IV
-D40% II
-drip oksitosin 40 IU/500cc + metergin 1
ampul dengan metergin 1 ampul IM
Observasi keadaan umum, TTV, kontraksi, perdarahan
Pasang monitor
Cek DPL cito
Pasang tampon kondom kateteri intravakum dengan isi 500cc
Asam traneksamat 1000 mg IV
Follow up (2) (19th of January 2014)

S : Pusing (-), perdarahan aktif (-),

O : KU baik, CM
Tanda Vital : TD : 110/700mmHg RR : 20x/m
N : 88x/m S : 36,4 C
Status generalis : dbn
Status obstetrikus : TFU sepusat , kontraksi baik,
I: v/u tenang, perdarahan aktif (-)
Lochia rubra (+)
Terpasang DC, terpasang kondom kateter 500cc, tampon bola
intravaginal
A : Riwayat HPP pada P3 post partus spontan
 P : Observasi TTV, kontraksi, perdarahan
Diet TKTP
Mobilisasi aktif
Rawat ruangan
Th/ - As. Traneksamat 3 x 500mg IV
- Keluarkan kondom kateter 250cc, tersisa 250cc
untuk dikeluarkan pada jam 1230
- Cefadroxil 3 x 500mg p.o.
- As. Mefenamat 3 x 500mg
- SF 1x1 p.o.
Analisa kasus
Introduction
Postpartum hemorrhage (PPH) is the leading cause of
maternal mortality. All women who carry a pregnancy beyond
20 weeks gestation are at risk for PPH and its sequelae.
Although maternal mortality rates have declined greatly in the
developed world, PPH remains a leading cause of maternal
mortality elsewhere.
Major causes of death for pregnancy
women
(maternal mortality)

Postpartum hemorrhage28%)
heart diseases
pregnancy-induced hypertension
(or Amniotic fluid embolism )
infection
 Definition of PPH
PPH is defined as blood loss of more than 500 mL following vaginal
delivery or more than 1000 mL following cesarean delivery. A loss of
these amounts within 24 hours of delivery is termed early or primary
PPH, whereas such losses are termed late or secondary PPH if they
occur 24 hours after delivery.
Major causes
Uterine atony (90%)
lacerations of the genital tract(6%)
retained placenta(3%-4%)
coagulation defects (blood dyscrasia)

(4T: tone, tissue,trauma,thrombin)

1. Uterine atony (Tone)
Local factors
overdistention of the uterine
(hydramnios, multiple pregnancy,
macrosomia )
condition that interfere with
contraction(leiomyomas)
complications(PIH,anaemia, placenta
praevia
Systemic factors:
nervous
drugs(magnesium sulfate,sedative)
abnormal labor(prolonged,precipitous)
History of previous PPH
Preeclampsia, abnormal placentation,
pathology
Contraction constricting the spiral
arteries
preventing the excessive bleeding
from the placenta implantation site
the uterine atony give rise to PPH
when no contraction occur
Prevention and therapeutic of
uterine atony
Administration of medicine:
Promotes contraction of the uterine corpus
Decreases the likelihood of uterine atony

Oxytocin agents
Methergine
Prostaglandin
 Mechanical stimulation of uterine contraction:

Massage of uterus through the abdomen and bimanual compression

intrauterine packing
Surgical methods
If massage and agents are unsuccessful:
Ligation of the uterine arteries
ligation of the hypogastric arteries
selective arterial embolization
hysterectomy
taking into account the degree of hemorrhage,the overall
status of patient,her future childbearing desires
2. Lacerations of the genital tract
(Trauma)
Causes:
Instrumented delivery (forceps)
manipulative delivery(breech
extraction,precipitous labor, macrosomia)
Types:
perineum laceration
vaginal laceration
cervical laceration
Perineum and Vaginal laceration

The first degree tear:

involves only skin and a minor part of the perineal body
the second degree tear:
involves the perineal body and vagina
the third degree tear:
involves the anal sphincter and anal canal
management
Vaginal examination soon after delivery

repair:
cervical laceration >2cm in length and be actively bleeding
laceration of vaginal and perineum
3. Retained placenta (Tissue)

Separation and explosion of placenta is caused by strong uterine

contraction

Placenta tissue remaining in the uterus

prevent adequate contraction and predispose to excessive
bleeding
causes:
adherence of placenta (previous cesarean delivery,prior uterine
curettage)
succenturiate placenta
placenta accreta (into the decidua)
placenta increta(into the myometrium)
placenta pericreta(through the myometrium to the peritoneal)
 Prevention and treatment
The placenta should be examined to see that it is complete or not
part of placenta is missing, removed digitally
not separated, manual removal of placenta is done
hysterectomy is required for placenta increta(percreta,accreta)
uterine contraction drugs
4. Coagulation defects (Thrombin)
Acquired abnormality in blood clotting:
abruptio placenta,
amniotic fluid embolism
severe preclampsia
congenital abnormality in blood clotting:
thrombocytopenia
severe hepatic diseases
leukemia
Disseminated intravascular
coagulopathy(DIC)
if bleeding persists in spite of all other treatment described, DIC
should be suspected
the blood passing from the genital tract is not clotting
shock: reduction of effective circulation
inadequate perfusion of all tissues
oxygen depletion
depression of functions
Record:
pulse
blood pressure
maternal heart rate
central venous pressure
urine output
Lab tests:
Hb,
BT(bleeding time), CT( clotting time),
platelets count
fibrinogen
prothrombin time and patial thromboplastin time
FDP
womens group and cross-matching
Treatment:
the key is correcting the coagulation defect
resuscitation must be started as soon as possible
infusion of crystalloid(saline) and Dextran is started firstly while
arranging the blood transfusion
blood transfusion is essential
infusion of platelets, fresh frozen plasma, FDP , clotting factors,
 Potential complications of PPH:
Postpartum infection
Anemia
Transfusion hepatitis,
Sheehans syndrome
Ashermans syndrome

The best management of PPH is prevention