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Postpartum Hemorrhage

 

Definition

Postpartum hemorrhage (PPH) is excessive blood loss at delivery sufficient to affect the general condition of the mother as shown by rising pulse rate, falling blood pressure, and poor peripheral perfusion.

The traditional definition, based on blood loss of 500 ml or more from within the reproductive tract after birth within 24 hours of delivery, is difficult to estimate in clinical practice.

 

There are two types of PPH:

 

 

Postpartum hemorrhage is the leading cause of maternal mortality

 

Risk Factors

Ø      Acquired

-         Pregnancy induced hyepertension

-         Amniotic fluid embolism

-         Placental abruption

-         Placenta praevia

-         Fetal demise

Ø      Inherited

Causes

 

 

Principal clinical signs

 

 

NB In patients with hypertension or pre-eclampsia severe blood loss may cause misleading “normal” blood pressure

 

Laboratory Examination

 

 

Laboratory Findings

 

 

Management

 

Antenatal period

Ø      Routine laboratory examinations

Ø      Iron and Folic acid supplementation

Ø      Educate the patient to come to the hospital early in labor, the importance of iron supplementation, and the need to seek immediate medical attention if vaginal bleeding occurs

Ø      Refer to a tertiary level facility for antenatal management

 

Labor and Deliver

 

 

Hemorrhage after delivery of baby, before delivery of the placenta:

 

 

> If bleeding persists without delivery of placenta, rapidly explore the perineum, vagina, and cervix looking for lacerations

Call the anesthesiologist and perform manual removal of the placenta with adequate sedation (e.g. valium, pethidine) or anesthesia

 

      > If bleeding persists after removal of placenta , see below

 

Hemorrhage immediately after delivery of placenta:

 

 

 

If bleeding persists, explore the perineum, vagina, and cervix looking for lacerations and repair as needed

 

 

If bleeding still persists then a blood coagulation disorder must be suspected and investigated

 

Ø      1st step: Inspect uterus. If lacerated, repair adequately. If atony give direct massage

Ø      2nd step: Inject intramyometrial Carboprost

Ø      3rd step:

 

Ø      4th step: subtotal hysterectomy

 

 

Late postpartum hemorrhage (after 24 hours)

Follow the steps above

 

 

Important considerations

 

 

 

 

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