POSTPARTUM HEMORRHAGEA

Definition:
Excessive bleeding from or into the genital tract during the 3rd stage of labour till the end of Puerperium
 Primary PPHge: Excessive bleeding from or into the genital tract during the 3rd stage of labour or within 24 hours after delivery.
 Secondary PPHge: : Excessive bleeding from or into the genital tract after 1st 24 hours following the delivery till the end of Puerperium (6 weeks)
Causes:
Primary PPHge (ART-CA) Secondary PPHge
 Atonic PPhge(Atony of the uterus) o Most common: Retained
 Retained PPHge o Most serious: Choriocarcinoma
 Traumatic PPHge o Sepsis
 Coagulation defects(DIC) - Infected C.S wound
 Acute inversion of the uterus(rare) - Infected laceration of the genital tract
- Infected placental sites
o Subinvolution of the uterus
o Submucous fibroid polyp
o Others:  Local gyn. condition:
Cervical erosion – cancer cervix
Puerperal inversion of the uterus
Estrogen withdrawl if used to stop lactation
 General: coagulation defects
 Atonic PPHge Retained PPHge
Definition Excessive bleeding from or into the genital tract during the 3rd stage of Excessive bleeding from or into the genital tract during the 3rd stage of
labour or within 24 hours after delivery due to week contractility & reactivity
labour or within 24 hours after delivery due to failure of delivery of the
placenta within 1/2 of delivery of fetus
A/E 1. During pregnancy: ‫مجهد‬ 1. Retained separated placenta:
 APHge (Placenta previa - Accidental hge) (Uterine atony - Contraction ring - Complete rupture uterus)
 Maternal dse (Preeclampsia - Anemia) 2. Retained adherent placenta:
 Overdistended uterus (Polyhydramnios - Twins) (Uterine atony - abnormal adhesions: in LUS or C.S scar - Submuc. fibroid)
2. During labour: ‫تم اجهاده‬ A. Simple adherence:
1st stage 2nd stage 3rd stage  The decidua basalis is present
 There is a Line of cleavage and so manual separation can
 Prolonged 1st stage  Prolonged 2nd stage - Retained parts of
be done easily.
 Excessive straining  Excessive manipulation placenta
B. Morbid adherence:
 Sedative overuse  Halothane overuse
 The decidua basalis is absent or defective
3. Causes in the uterus: ‫تم منعه من قبل عناصر خارجية‬  There is no Line of cleavage between the uterine muscle and
(Multiple fibroid - Congenital malformations - Grand multipara) placenta due to invasion.
o According to the depth of invasion:
1. Placenta accreta: < 1/2 myometrial invasion
2. Placenta increta: > 1/2 myometrial invasion
3. Placenta percreta: invading peritoneum
Diagnosis History: History:
History of prolonged labour History of failure of placental delivery for 1/2 hr
Bleeding: Severe vaginal bleeding after delivery of the fetus& placenta. Bleeding:
- If the placenta is not separated at all  No bleeding
- If the placenta is completely separated  Minimal bleeding
- If the placenta is partially separated  Massive bleeding
Examination: Examination:
 General examination: Mild Anemia Severe Shock  General examination: Shock {{(Hypovolemic ± Neurogenic(Crede's) }}
 Abdominal examination:  Abdominal examination:
 Fundal level: Higher than expected(uterus is large)  Fundal level: Higher than expected(uterus is large)
 Consistency: Uterus is Soft& lax  Consistency: Uterus is Firm(Contracted) – Soft& lax(Atonic)
 Tenderness: Uterus is tender  Signs pf placental separation +ve or –ve
 Local examination: Vaginal: Dark blood – No lacerations  Local examination: Vaginal: bleeding if the placenta separated
TTT  Prophylactic
Avoid all pdf + proper Antenatal care
Proper management of 1s, 2nd &3rd stages of labor
 Active: Resuscitation +  Active: Resuscitation +
1. : Massage A. Active 3rd stage management:
 Ecbolics (Oxytocin, Methergine, PGE1- misoprostone 800pg ) o Ecbolics, massage.
 Empty bladder + Stop halothane o Brandt Andrews method (Deliver an unadherent placenta in the
2. : Exploration of birth tract under GA absence of contraction ring)
 Exclude trauma
 Evacuate blood clots or retained placental parts B. Manual separation of the placenta under GA
3. : bimanual compression of the uterus Introduce right hand along the cord , you may find
1. Contraction ring
 Closed fist of the right hand is placed into anterior fornix
 Forceps delivery under GA esp. Fluothane and Ether
 Left hand is placed abdominally to compress the uterus in between  If failed  Uterine relaxant as amyl nitrite or other tocolytics
 Kink uterine vessels & compress placental site 2. Rupture uterus: laparotomy
4. : laparotomy 3. Placenta adherent
 Patient completed her family  Supravaginal hysterectomy  Reach the margin (line of cleavage between placenta & uterus)
 Patient not completed her family   Take a fold of membrane, separate the placenta by sawing manner
o Direct uterine massage, hot fomentations  Placenta must be fully inspected for missing parts.
o Intra-myometrial prostaglandins (PG-F2α)
o Bilateral uterine & ovarian artery ligation C. Morbid adherence of the placenta
o Bilateral internal iliac artery ligation
 Supravaginal hysterectomy (ideal TTT)
o If all failed  Supravaginal hysterectomy
 Traumatic PPHge

Perineal tears Rupture uterus

Definition Trauma on the perineal body {{Pyramidal mass of tissues between the
lower vagina (Ant.) and the lower end of rectum& anal canal (Post.)}}
A/E 1. Causes in the passages: During pregnancy During labour
 Rigidity( Elderly Primirgravida or Pervious unhealthy scar) A. Spontaneous A. Spontaneous
 Edema( Preeclampsia or Obstructed labour)  Ruptured previous uterine scar  Ruptured previous uterine scar
2. Causes in the power: Rapid stretch of the perineum  Rupture of anterior sacculation: in  Obstructed labour
 Precipitated labour fixed RVF  idiopathic
 After-coming head of breech  Rupture of posterior sacculation: B. Traumatic:
 Abuse of syntocinon in ventrofixation  Obstetric operation
3. Causes in the passenger: Over stretching of the perineum  Rupture of pregnancy in  Excessive fundal pressure
 I \f head is allowed to extend before crowning rudimentary horn at 4th or 5th m  Manual dilatation of cervix
 Large head(Macrosomia)  Perforating VM  Manual removal of placenta
 Malpresentation& malposition as Face to pubis  Placenta percreta
 Narrow vaginal introitus or subpubic arch  Concealed accidental Hge
B. Traumatic:
- Trauma to the abdomen
- External cephalic version
Types  1st degree  Vaginal wall + perineal skin  Complete rupture: (UUS) all 3 layers (including peritoneum) are
 2nd degree  Perineal muscles + levator ani ruptured  Massive intraperitoneal hemorrhage
 3rd degree  External anal sphincter  Incomplete rupture (LUS) muscle layer is only ruptured with intact
 4th degree  Rectal mucosa (some consider it 3'd degree) peritoneum Subperitoneal hematoma (occult rupture)
Clinical picture Clinical picture of Old complete perineal tear A. During pregnancy
Symptoms:
Incontinence: At first , the pt. is incontinent to both stool & flatus then Silent Frank
pt. regains control of hard stools Symptoms: lower abdominal pain Symptoms: Sudden severe
Symptoms of 2ry Vulvitis: irritation d.t. soiling by stool with or without vaginal spotting abdominal pain followed by collapse
Signs: Examination: Examination:
General: Increased pulse General: Shock
1. Absent or deficient perineum
Abdominal: Tender scar Abdominal:
2. Loss of corrugations around he anus
Local: Spotting - Uterus: felt separate from the fetus
3. The bright red color of rectal mucosa
Investigation: U/S: thin scar - Fetus: parts: easily felt – FHS: not
4. PR examination: absent sphincter tone and voluntary control
Local: - Vaginal bleeding
- Cervix is closed
B. During Labour

Obstructed Traumatic
Symptoms: of obstructed labour + Symptoms: history of instrumental
- Cessation of labor pain vaginal delivery
- Vaginal bleeding Examination:
- Collapse - Vaginal examination: Tear
- Cessation of fetal movements - Broad ligament hematoma
Examination:
General: Shock +dehydration
Abdominal: as during pregnancy
Local: vaginal: as Obs. Labour
Investigation: U/S: thin scar
Complication  Early: Hge + infection Maternal Fetal
 Late: - Mortality: 10% d.t. shock ± ARF - Fetal mortality rate: 100%
 Incomplete tear (1+2)  Prolapse - Morbidity: - Asphyxia d.t. placental detachment
 Complete tear (3+4)  Incontinence of flatus & stools Infertility
 Improper healing Recto-vaginal fistula Rupture uterus in the next
 Poor healing  Scar  Dyspareunia. pregnancy
Injury of the UB

TTT  Prophylactic: Proper management of delivery± episiotomy  Prophylactic:

 Active TTT:  Proper antenatal care:
- Immediate surgical repair(24-48 hrs of delivery)  Early detection of any abnormalities needing C.S
 Incomplete: 4 layers under local anesthesia  Grand multipara: deliver in hospital
 Complete: 6 layers under general anesthesia  Proper intranatal care:
- Old complete perineal tear :  Early detection of signs of Obstructed labour
 If later  Wait 3-6 m (tissues may be edematous ± infected)  Proper use of oxytocin
 Anatomical repair in layers [Lawson Tait operation]  Carful intrauterine manipulation
 Active TTT: Resuscitation +
 Immediate laparotomy: Midline incision with removal of the
fetus& placenta
 Examine the uterus:
If extensive tear  Supravaginal hysterectomy
If not extensive  Try to repair with precautions
 Exploration of injury of other structure\res as bladder & ureter