Postpartum hemorrhages

Postpartum hemorrhages, definition

PH – the hemorrhages which appear after
delivery, in a volume more than 500 ml after
following a vaginal birth or a loss and more
than 1000 ml after SC.
Postpartum hemorrhages, clasification
• Hemorrhages in immediately postpartum
period – appear during the first 24 hours after
delivery;
• Hemorrhages in late postpartum period after
24 hours to 42 days after delivery.
Postpartum hemorrhage, classification
• primary hemorrhage occurring within the first
24 hours of delivery;
• secondary hemorrhage occurring between 24
hours and 6–12 weeks postpartum;
• primary postpartum hemorrhage, occurs in
4–6% of pregnancies, is caused by uterine
atony in 80% or more of cases;
 Etiology of postpartum hemorrhage

Primary:
• uterine atony;
• retained placenta—especially placenta accreta;
• defects in coagulation;
• uterine inversion;

Secondary
• subinvolution of placental site;
• retained products of conception;
• Infection;
• inherited coagulation defects.
 Risk Factors for postpartum
hemorrhage
• prolonged labor;
• augmented labor;
• rapid labor;
• history of postpartum hemorrhage;
• episiotomy, especially mediolateral;
• preeclampsia;
• overdistended uterus (macrosomia, twins,
hydramnios);
• operative delivery;
• Asian or Hispanic ethnicity;
• chorioamnionitis.
 Postpartum hemorrhages, causes
!!! In Occident are recognized the follow causes –
TTTT:
- T – tissue (placental tissue retained in uterus);
-T – tonus (cause of hemorrhage is uterine
hypotonia or atonia);
-T – trauma (trauma of the genital organs after
delivery – cervical, vaginal, perineum, uterine
rupture, trauma during SC, postnatal uterine
inversion);
- T – thrombin (cause of hemorrhage are
coagulopathies).
 Postpartum hemorrhages, clinical
features
• Hemorrhage which passes the phisiological
loss bleeding after delivery or SC;
• For uterine hypotonia is characterized the
hemorrhage in portions/in wave;
• For uterine atonia is characterized – continue
profuse hemorrhage;
• For coagulopathies – forming of the clot blood
is late or it is not form.
 Postpartum hemorrhages, diagnosis
1. anamnesis, depending on the cause in each T, for eg.:
- T (tissue), complicated anamnesis by medical abortion, anomalies
of placental implantation (placenta accreta), placental desertions after
delivery, fetal membranes desertions;
- T (tonus), polihydramnios, multiple pregnancy, macrosomia,
multiparity, high temperature during delivery, premature rupture of the
fetal membranes and prolonged alichidian period (intrauterine infections
during delivery – corioamnionitis, endometrities), uterine
malformations, functional disturbances of the uterus (myoma, lower
placental implantation);
- T (trauma) – obstetrical interventions (forceps, embriotomies,
vacuum extractor), obstructed pelvis, traumatism during SC (uterine
scar, hardness at fetal extracting by SC), uterine inversion;
- T (thrombin) - liver disease (hepatitis, etc), heretical
coagulopathies, or obtained coagulopathies (placental abruption, severe
preeclampsie, intrauterine fetal death, amniotic fluid embolism).
 Postpartum hemorrhages, diagnosis
2. clinical features;
3. physical exam: color of the skin, respiratory
frequencies, Ps, blood pressure, the level of
the uterine fundal, consistence of the uterus,
diuresis;
4. Blood smear – Hb, Ht each hour.
Determination of bleeding: bleeding time,
Lee-White time.
 Postpartum hemorrhages, treatment

Appreciating of the causes which lead to hemorrhage for each T:

- T (tissue): express placental exam → placental desertions and hemorrhage touched

500 ml → manual uterine control;
- T (tonus): external massage of the uterus through the abdomen → concomitent
oxytocine 20 UA (4 ml) i/v by sol. NaCl 0.9% - 1l, the speed of infusion – 60
dr/min → hemorrhage continue → 20 UA (4 ml) i/v by sol. NaCl 0.9% - 1l, the
speed of infusion 40 ml/min. !!! Maximal doses shouldn`t pass 50 UA of
Oxytocine → hemorrhage continue → bimanual compression of uterus or aortal
compression (this maneuveres can stopped hemorrhage definitively or
temporary) →volume of loss blood touched 1000-1200ml→surgical intervention
(bilateral ligature of the a. ovarica, aa. uterine, aa. Iliaca interna) or applying of
the sutures to the uterus which can stopped hemorrhage (B-Lynch) or subtotal
histerectomi or total histerectomie (indications – DIS syndrome, uterine rupture
which involve cervix, placenta accreta implanted in lower uterine segment).
Postpartum hemorrhages, treatment
!!! Absences of the of the oxytocine, it is
possible to use – Metylergometrine 0,2 g-1ml
i/v or i/m, each 15 min , not more than 5
doses (1g). Contraindications: hypertensive
disorders, asthma, cardio-vascular disease.
!!! Prostoglandine drugs – F2α – Enzoprost , 2.5
mg i/m each 15 min., not more than 8 doses.
It is possible intamyometral injection after
bladder catheterisation;
 Postpartum hemorrhages, treatment
-T (trauma) – revision of the delivery ways by
speculum exam and suturing of the
lacerations;
-T (thrombin) – in profuse hemorrhage
associated by DIC and hemorrhage shock →
total histerctomy → concomitant infusion of
the plasma.
!!! In case Hb less than 80 g/l, Ht less than 25 –
indications for blood infusion.