Definition loss of > 500 mL of blood after delivery (most women probably lose > 500 mL, often underestimated) Etiology (4 T’s) ...
Definition
loss of > 500 mL of blood after delivery (most women probably lose > 500 mL, often underestimated)
Etiology (4 T’s)
- Tone: uterine atony (most common cause of PPH)
- occurs within first 24 hours
- labour (prolonged, precipitous)
- uterus (infection, over-distension)
- placenta (abruption, previa)
- maternal factors (grand multiparity, GA)
- halothane anesthesia
- Tissue: retained placenta (see above)
- Trauma: laceration (vagina, cervix, uterus), episiotomy, hematoma, uterine rupture, uterine inversion (see above)
- Thrombin: coagulopathy
- most identified prior to delivery (low platelets increases risk)
- includes hemophilia, DIC, aspirin use, ITP, TTP, VWD (most common)
- maintain fibrinogen > 1000 mg/mL, platelets > 50 000
determine cause, call for help
supportive :ABC's, fluid, +- transfusions, +/- other blood products
Examination
- reexamine patient, ensure complete delivery of placenta,check for uterine atony and drain bladder
- check for cervical and vaginal lacerations
- elevate the uterus and massage through patient's abdomen
Investigations : pelvic U/S if indicated to look for cause
Medical
- oxytocin (5 U IV push then 40 u/L NS drip)
- methylergonavine maleate (ergotamine; 0.2 mg PO or 0.25 mg IM) (normotensive patients only; must explore uterus before giving ergotamine)
- prostaglandins (PGF-2 alpha intrauterine or IM)
- hemabate (prostaglandin; 0.25-1.00 mg intramyometrium every 15 minutes)
- uterine packing (3-4 five yard Kerlex rolls tied together and soaked in betadine and removed in 12-24 hours; controversial)
surgical
- seek and suture lower genital gract lacerataions
- D&C (beware of vigorous scraping which may cause Asherman)
- hypogastric, ovarian artery or uterine artery ligation
- arterial embolization
- hysterectomy (last option) complications: Sheehan syndrome (pituitary necrosis)
