Primary postpartum haemorrhage

· Uncategorized

PPH is responsible for most of the maternal deaths during delivery.It can be prevented with the active management of the third stage of labour and can be controlled if cause is diagnosed and managed properly.

Primary post partum haemorrhage is defined as the loss of more than 500ml of blood from the genital tract within 24 hrs of delivery.

It can be

Atonic( 80% )

(20% ) other causes are

  • Trauma of lower genital tract
  • Retained placenta
  • Uterine rupture
  • Uterine inversion
  • DIC

Causes of uterine atony are :

  • Proloned first and second stage of labour
  • Multiparity
  • Placenta accreta
  • Retained placenta or a piece of placenta
  • Pregnancy associated with fibroid
  • Precipitate labour

Active management of the 3rd stage of labour

Prophylatic oxytocin in IV fluids is usually started in most of the cases.
Controlled cord traction and removal of placenta.
There are two schools of thought.Some prefer to wait for the separation of placenta ,till then they

stitch the episiotomy and afterwards give inj ergometrine .5mg IM or IV.
Some obstetricians give inj ergometrine at the time of the delivery of shoulder , remove placenta by controlled cord traction and then stitch episiotomy.
Carbaprost or 15 methyl analogue of prostaglandin has caused revolution in gynec practice by reducing the chances of PPH. It is given IM along with Inj stemetil as it causes diarrhoea and vomiting.
oral or rectal misoprostol 600microgram is less effective than oxytocin and methergine.
One should never forget to put a catheter if bladder is full and there are predisposing factors to precipitate the PPH.

Management of atonic uterus

Resuscitation with crystalloids like compound sodium lactate IV and .9% Iv saline.
meanwhile arrange for the blood and try to find out the cause . See the lower genital tract for any tear or laceration in the vagina and cervical tear.Catch hold of the apex of episiotomy wound in proper light.See the apposite vaginal wall and paraurethral tear.If not found , fundus is massaged and upto 40 IU of oxytocin are put in the drip and carbaprost can be repeated.Catch hold the lips of cervix with sponge holding foceps and use 3 to 4 sims speculum. Call anaesthetist , if not available give sedation and explore the uterine cavity. usually there is a small piece or membrane of placenta, remove it and do bimanual massage which is very helpful in controlling the pph. Panic is unavoidable so keep your calm , do not shout on the staff , otherwise attendants and patient also becomes panicky.rest leave in the hands of god.Send the blood sample for BT, CT, platelets to exclude DIC.If it is DIC ( disseminated intravascular coagulation )
arrange for FFP.one litre of FFP is given after 6 units of blood (15ml /kg).platelet transfusions are also given in DIC. It is better to involve a haematologist.Use of factor 7 plays a definitive treatment in DIC.
But why I am thinking that is DIC, think of the common cause first.
Baloon tamponade
SBOC , a stomach balloon filled with 70 to 500ml of warm saline is fixed in the uterine cavity.if no bleeding is observed from CX and in the lumen of balloon,test is considered positive and no surgical intervention is required.

Surgical management of atonic uterus

when trauma of lower genital tract , coagulopathy, retained pieces are exluded and bleeding still persists , thenlaparotomy is planned.

B- lynch suture

Prevents hazardous surgery and preserves fertility of the woman.It is applied if bimanual compression of the uterus reduces the vaginal bleeding.
0 vicryl or no 2 chromic catgut is used.Absorbable suture is better, delayed absorbable can cause erosion of the uterine wall.Modifications have been done by applying the horizontal sutures in the lower uterine segment without obliterating the cervical canal , especially in placenta praevia.
Multiple square sutures to approximate the anterior and psterior uterine wall with no space left in the cavity can be performed by less experienced surgeon as it doesn’t involve the uterine vesels in the vicinity.It was decribed by Cho et al.
B-lynch suture
  1. A 70 mm round bodied hand needle on which a No. 2 chromic catgut suture is mounted is used to puncture the uterus 3 cm from the right lower edge of the uterine incision and 3 cm from the right lateral border.
  2. The mounted No. 2 chromic catgut is threaded through the uterine cavity to emerge at the upper incision margin 3 cm above and approximately 4 cm from the lateral border (because the uterus widens from below upwards).
  3. The chromic catgut now visible is passed over to compress the uterine fundus approximately 3 – 4 cm from the right cornual border.
  4. The catgut is fed posteriorly and vertically to enter the posterior wall of the uterine cavity at the same level as the upper anterior entry point.
  5. The chromic catgut is pulled under moderate tension assisted by manual compression exerted by the first assistant. The length of the catgut is passed back posteriorly through the same surface marking as for the right side the suture lying horizontally.
  6. The catgut is fed through posteriorly and vertically over the fundus to lie anteriorly and vertically compressing the fundus on the left side as occurred on the right. The needle is passed in the same fashion on the left side through the uterine cavity and out approximately 3 cm anteriorly and below the lower incision margin on the left side.

Christopher B-Lynch Consultant (Obstetrics and Gynaecological Surgery),

Adeyemi Coker Registrar (Obstetrics and Gynaecology),
Adegboyega H. Lawal Registrar (Obstetrics and Gynaecology),
Jaf Abu Senior House Officer (Obstetrics and Gynaecology),
Michael J. Cowen Consultant (Anaesthesia)1991; 7: 883—897.

Uterine and internal artery ligation

uterine artery ligation should be tried before internal iliac ligation.Bilateral ligation results in 85% reduction in the blood loss.Tissue oedema and haematoma are the complications.long term complications are buttock pain.It can also cause ischaemic damage to the pelvis, laceration of the iliac veins , accidental ligation of the external iliac artery and ureteric injury as surgeon is always in hurry to control the bleeding.

Uterine artery embolisation

Requires trained intervention radiologist.The femoral artery is punctured and catheterisation of the internal iliac artery, uterine and ovarian artery is performed.thereafter using contrast media and angiography , active bleeding can be located.Absorbable gelatine sponge or polyurethane foam is used.Success rates are 85 to 90 %.time taken is 1 hour,  and failure in cases of placenta accreta .
recovery time is rapid and it does not require laparotomy and fertility is also maintained. but complications reported are , haematoma, pelvic infection,tissue ischaemia, ischemic bowel damage, and risk of nephrotoxicity.

Hysterectomy

when all above procedures fail then hysterectomy is the only choice left.subtotal hysterectomy is usually performed.

Conclusion

PPH being the most common cause of the maternal deaths should be managed properly by active management of the third stage of labour.Prophylactic oxytocin and methergine should be used. catheterisation is very important.inj carbaprost plays a very important role.with bimanual massage and prostodin inj , usually the bleeding is controlled.BT, CT, platelet counts, cross matching should always be done.lower genital tract is explored for tears.Vitals are watched carefully.uterine inversion which is very rare can occur due to forceful traction on the cord especially in multiparous woman.It should be diagnosed immediately and uterus reposited under GA. Uterine ”tamponade” is tried usually to see the amount of

bleeding. It Is therapeutic as well as diagnostic and can be performed by junior dr also if consultant is not available.Uterine artery embolisation is another choice depending upon the surgeon and radiologist.Laparotomy is last resort but should not be delayed if rquired.B-lynch suture is very effective and fertility is also maintained. uterine artery and internal iliac artery ligations are tried before subtotal hysterectomy.DIC must be ruled out before planning for laparotomy. FFP, platelets transfusions are needed for its treatment.

Ref
  1. Report on Confidential Enquiry into Maternal Deaths in England and Wales 1982—1984. London: HMSO, 1989.
  2. Varner M. Obstetrics emergencies (postpartum haemorrhage ). Crit Care Clin
  3. Waters EG. Surgical management of postpartum haemorrhage with particular reference to ligation of uterine arteries. Am J Obstet Gynecol 1952; 64:1143—1148.
  4. Evans S, McShane P. The efficacy of internal iliac artery ligation in obstetric hemorrhage. Surg Gynecol Obstet 1985; 160:250—253
  5. Report on Confidential Enquiry into Maternal Deaths in the United Kingdom 1991-1993. London: HMSO, 1996.
  6. Report on Confidential Enquiry into Maternal Deaths in the United Kingdom 1985—1987. London: HMSO, 1991.
  7. Clarke SL, Koonings P, Phelan JP. Placenta accreta and prior cesarean section. Obstet Gynecol 1985; 66:89—92.
  8. Day LA, Mussey RD, DeVoe RW. The interuterine pack in the management of postpartum hemorrhage. Am J Obstet Gynecol 1948; 55: 231—243.
  9. Bobrowski RA, Jones JB. A thrombogenic uterine pack for postapartum haemorrhage. Obstet Gynecol 1995; 85: 836-837.
  10. Report on Confidential Enquiry into Maternal Deaths in the United Kingdom 1988—1990. London: HMSO, 1994.
  11. http://www.cblynch.com

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