Download Postpartum Hemorrhage

Postpartum Hemorrhage(PPH)
产后出血
林建华
Major causes of death for
pregnancy women
（maternal mortality)
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Postpartum hemorrhage（28%)
heart diseases
pregnancy-induced hypertension
(or Amniotic fluid embolism )
infection
Definition of PPH
• be defined as a blood loss exceeding 500ml
after delivery of the infant
• PPH: occurs in 24 hour of delivery
• the late PPH: occurs after 24 hour of delivery
to 6 weeks
Major causes
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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
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
• Methegine
• prostaglandin
• Mechanical stimulation of uterine contraction:
• Massage of uterus through the abdomen and
bimanual compression
• intrauterine packing
Surgical methods
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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
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
• 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
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
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Lab tests:
• Hb,
• BT(bleeding time), CT( clotting time),
• platelets count
• fibrinogen
• prothrombin time and patial thromboplastin
time
• FDP
• women’s 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,
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Potential complications of PPH:
Postpartum infection
Anemia
Transfusion hepatitis,
Sheehan’s syndrome
Asherman’s syndrome
• The best management of PPH is prevention
Key words
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the definitio n of HHP
The causes of HHP
treatment methods of Uterine atony
the types of retained placenta
the degrees of the perineal and vaginal
laceration