Escolar Documentos
Profissional Documentos
Cultura Documentos
PPH today
living in the
shadow of
TAJMAHAL
Incidence:
Definition
Hemorrhage
class
Estimated blood
loss
(ml)
<500
500-1000
Blood volume
loss
(%)
<10
15
1200-1500
20-25
1800-2100
30-35
>2400
>40
none
minimal
urine output
pulse rate
respiratory rate
Postural
hypotension
Narrow pulse pr
management
none
Observation+/-RP
Tx
Replacement
therapy with
oxytocics
Hypotension
Tachycardia
Tachypnea
Cold clammy
Urgent active
management
Profound shock
Critical active Mx
Types of PPH
Pathophysiology
Blood vessels(spiral arteries) supplying
placental bed pass through an interlacing
network of muscle fibres of myometrium.
Myometrial contraction is main driving force
for placental separation & constriction of blood
vessels.
This hemostasic mechanism is known as
physiological sutures or living ligatures
So bleeding occures from placental beds due to
Uterine atony(myometrium fails to contract)
Retained products(that interferes contraction)
F= 2T/r
F= The compressive force acting on the uterine
vessels.
T= The wall tension (generated by uterine
contraction)
r = The radius of the uterus
It is apparent that the force compressing the
vessels can not be high if r is large
[Schellenberg JC .Geneva University Hospital]
So PPH occurs with atonic overdistended
uterus
Uterine atony
1.
2.
3.
4.
5.
6.
7.
8.
9.
Coagulation defects
Congenital :Von Willebrand`s disease
Acquired
Secondary PPH
1.
2.
3.
4.
5.
6.
management of PPH
postpartum Hemorrhage (PPH)
Predict
Prepare
Handle
Prevention of PPH
Patients at
risk
Prevention of PPH
1.- Prepare for PPH
Personnel
-Nursing
-Anesthesia
- Surgical
assistance
Drugs/Equipment
-Oxytocin
-Crystalloids
-Carbetocin
-Blood/Bl.products
-Methergine
-Surg. Instruments
-Prostaglandins
-Hemostatic ballons
( Cook, S-B, Foley)
Prevention of PPH
2.- Timing of Delivery
Elective C/S
after completion of 37 weeks
Avoids uterine rupture
Avoids significant hemorrhage
- Placenta previa
- Previous classical cs
- Previous
myomectomy
- Fibroid uterus
BRASSS-V DRAPE
low cost
Having calibrated receptacle at
the bottom
Developed by NICHD funded
global network
Name was coined by adding 1st
letters of the seven collaborators
Easy to miss
Physicians underestimate blood loss by
50%. Estimate blood loss accurately.
Slow steady bleeding can be fatal. Evaluate
all bleeding, including slow bleeds.
Abdominal or pelvic bleeding can be
hidden. If mother develops hypotension,
tachycardia or painrule out intraabdominal blood loss.
Class I
Class II
Class III
Class IV
Blood loss (% )
10-15
15-30
30-40
>40
Consciousness
alert
Respiratory rate
Complexion
Extremities
unconscious
raised
raised
pale
pale
grey
cool
cool
cold
Capillary refill
slow
slow
Minimal/absent
Pulse rate
elevated
SBP
N/slighted
hypotension
Urine output
reduced
reduced
oligoanuric
HAEMOSTASIS algorithm
H- ask for help
A- assess (vitals, blood loss) & resuscitate
E1. Establish etiology(tone,tissue,trauma,thrombine)
2. Ecbolics (syntometrine,ergometrine)
3. Ensure availability of blood
M - massage the uterus
O oxytocin infusion & prostaglandin
Intravenous fluids:
CRYSTALLOIDS
SALINE
Disadvantage:
hyperchloremic acidosis,
some procoagulant effect.
HARTMANNS
SOLUTION
Mildly hypotonic
5% DEXTROSE
HYPERTONIC
SALINE
Insufficient data.
COLLOIDS
GELATINS
Largely remains in
intravascular space
for 2-4 hrs
Risks of anaphylaxis,
no clear survival over
crystalloids
4% HUMAN
ALBUMIN
More physiological
than gelatin,remains
intravascular for 12
hrs
Expensive, no clear
advantage over
crystalloids
HYDROXY
ETHYL
STERCH
Remains in
Risk of coagulopathy,
intravascular space for renal injury
12-24 hrs
Establishment of etiology
T-tone-thorough assesment of uterine size&
tone
Uterine atony
T-tissue-manual exploration of uterine cavity
anaesthesia
Retained products
T-trauma-exanaesthesia 4 extended tear in
cervix,vagina
lacerations
T-thrombine-defect in coagulation
Uterine atony
Misoprostol 600g
Shivering
56/199(28%)
38/198(19
%)
Pyrexia>38C
15/199(7.5%)
4/195(2%) 6/199(3%)
25/200(12.5%)
Volume/unit
Contents/unit
Effects
Whole blood
500ml
RBCs, plasma,
fibrinogen
Volume restoration
Hct 3-4 vol%
Packed RBCs
250ml
RBCs only
Colloids &
fibrinogen & all
clotting Factors
Volume restoration
Clotting factors
supplementation
Cryoprecipitate
15ml
Fibrinogen, FcVIII,
XIII, VWF,
fibronectin
Restore fibrinogen
Platelets
50ml
Platelets only
Platelet
supplementation
Coagulopathies :
Coagulopathies are rare.
Suspect if oozing from puncture sites noted.
Work up with platelets, PT, PTT, fibrinogen
level, fibrin split products, and possibly
antithrombin III.
if retained product
Gentle suction & curettage
Conclusion
Most of the deaths & disabilities attributed to
childbirth are avoidable, because the medical
solutions are well known. Indeed 99% of maternal
deaths occur in developing countries that have an
inadequate transport system, limited access to
skilled care givers & poor emergency obstetric
service.(Abou Zahr C. 1998)
So ,we need an Intelligent anticipation, skilled
supervision, prompt detection and effective
institution of therapy to prevent disastrous
consequences of PPH.
Special thanks to
DR S PATI
DR S BHATTACHARYA
DR A HALDER
DR P MISTRI
DR A MITRA