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Antepartum & Postpartum Hemorrhage• Obstetrics is "bloody business."• Death from hemorrhage still remains a leading cause of maternal mortality.• Hemorrhage was a direct cause of more than 18 percent of 3201 pregnancy-related maternal deaths.
Postpartum Hemorrhage• In spite of marked improvements in management, PPH remains a significant contributor to maternal morbidity and mortality both in developing and developed countries.• One of the most challenging complications a clinician will face.• Prevention, early recognition and prompt appropriate intervention are the keys to minimizing its impact.
DEFINITION: The loss of >500ml of blood from the genital tract inthe first 24 hrs after delivery (or) < 500 ml with haemodynamic changes in the mother. (or) >1000 ml – cesarean section within 24 hrs. (or) > 1400 ml – Elective cesarean hysterectomy (or) > 3000 ml – Emergency cesarean hysterectomy
- In a recent ACOG study PPH is defined as Haematocrit change of 10% or theneed for red cell transfusion. Severe PPH - > 1500ml blood loss or Drop in Hb concentration 40g/l. or units of blood transfusion. 4Secondary PPH - Blood loss between 24 hrs and 6 weeks Post-delivery.In general, early PPH involves heavier bleeding and greater morbidity.
Haematological Changes in Pregnancy• 40% expansion of blood volume by 30 weeks• 600 ml/min of blood flows through intervillous space• Appreciable increase in concentration of Factors I (fibrinogen), VII, VIII, IX, X• Plasminogen appreciably increased• Plasmin activity decreased• Decreased colloid oncotic pressure secondary to 25% reduction in serum albumin
Reduced Maternal Blood Volume• Small stature• Severe preeclampsia/eclampsia• Early gestational age
PREVENTION OF PPH• Although any woman can experience a PPH, the presence of risk factors makes it more likely.• For women with such risk factors, consideration should be given to extra precautions such as: – IV access – Coagulation studies – Crossmatching of blood – Anaesthesia backup – Referral to a tertiary centre
PREVENTION OF PPH• UTEROTONIC DRUGS – Routine oxytocic administration in the third stage of labour can reduce the risk of PPH by more than 40% – The routine prophylaxis with oxytocics results in a reduced need to use these drugs therapeutically – Management of the third stage of labour should therefore include the administration of oxytocin after the delivery of the anterior shoulder.
Intranatal:• Hasty delivery of the baby is to be avoided.• Adequate amount of blood should be cross matched and available when haemorrhage is anticipated.• Coagulation studies are done in cases of Abruptio placenta and retained dead fetus.
Active Management of 3rd Stage of Labour:1. Uterotonic Agents: • 10 units of oxytocin IM or • Syntometrine (5 units of oxytocin and 0.5mg ergonovine maleate). • Misoprostol, a prostaglandin E1 analogue, 600g orally.2. Early cord clamping3. Controlled cord traction.
MANAGEMENT OF PPH• Early recognition of PPH is a very important factor in management.• An established plan of action for the management of PPH is of great value when the preventative measures have failed.• Lab:- CBC / BG / Cross match of 4-6 units of blood- KFT / Coagulation profile- Give FFP / cryoprecipitate if coagulation test results are abnormal- Give platelet concentrates if the platelet count is < 50 X 109/L & bleeding continues
Evaluation of response- Monitor pulse, blood pressure, blood gas status, &acid-base status + monitoring central venous pressure.- Measure urine output using an indwelling catheter- Order regular FBC counts and coagulation tests toguide blood component therapy