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    Post Partum Hemorrhage

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    Gita Girsang
    This case report describes a 21-year-old woman who presented with postpartum hemorrhage due to retained placenta. On examination, she had blood pressure of 90/60 mmHg, heart rate of 104 beats/min, and vaginal bleeding. Laboratory tests found hemoglobin of 7.7 g/dL. She had a history of giving birth at home and the placenta not delivering after 30 minutes. Her diagnosis was retained placenta and anemia. She received fluid resuscitation, blood transfusion, and curettage was planned once hemoglobin reached 10 g/dL. Retained placenta and uterine atony are common causes of postpartum hemorrhage, which is

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    Post Partum Hemorrhage

    Uploaded by

    Gita Girsang
    321 views40 pages
    This case report describes a 21-year-old woman who presented with postpartum hemorrhage due to retained placenta. On examination, she had blood pressure of 90/60 mmHg, heart rate of 104 beats/min, and vaginal bleeding. Laboratory tests found hemoglobin of 7.7 g/dL. She had a history of giving birth at home and the placenta not delivering after 30 minutes. Her diagnosis was retained placenta and anemia. She received fluid resuscitation, blood transfusion, and curettage was planned once hemoglobin reached 10 g/dL. Retained placenta and uterine atony are common causes of postpartum hemorrhage, which is

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    This case report describes a 21-year-old woman who presented with postpartum hemorrhage due to retained placenta. On examination, she had blood pressure of 90/60 mmHg, heart rate of 104 beats/min, and vaginal bleeding. Laboratory tests found hemoglobin of 7.7 g/dL. She had a history of giving birth at home and the placenta not delivering after 30 minutes. Her diagnosis was retained placenta and anemia. She received fluid resuscitation, blood transfusion, and curettage was planned once hemoglobin reached 10 g/dL. Retained placenta and uterine atony are common causes of postpartum hemorrhage, which is

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    321 views40 pages

    Post Partum Hemorrhage

    Uploaded by

    Gita Girsang
    This case report describes a 21-year-old woman who presented with postpartum hemorrhage due to retained placenta. On examination, she had blood pressure of 90/60 mmHg, heart rate of 104 beats/min, and vaginal bleeding. Laboratory tests found hemoglobin of 7.7 g/dL. She had a history of giving birth at home and the placenta not delivering after 30 minutes. Her diagnosis was retained placenta and anemia. She received fluid resuscitation, blood transfusion, and curettage was planned once hemoglobin reached 10 g/dL. Retained placenta and uterine atony are common causes of postpartum hemorrhage, which is

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    Case Report

    Postpartum Hemorrhage
    Preceptor :
    Dr Gioseffi Sp.OG
    By :
    Gita Larasastri Tarigan
    (406127113)
    Varla Septrinidya Gharatri
    (406127121)

    Case Report
    PATIENTS IDENTITY

    Name
    Age
    Gender
    Address
    Ethnic
    Religion
    Education
    Occupation

    : Mrs. S
    : 21 years
    : Female
    : Kp. Cilember
    : Sunda
    : Islam
    : elementary
    : Housewife

    PATIENTS HUSBANDS IDENTITY


    Name
    Age
    Gender
    Address
    Ethnic
    Religion
    Education
    Occupation

    : Mr. A
    : 29 years
    : male
    : Kp. Cilember
    : Sunda
    : Islam
    : Junior High School
    : Housewife

    History
    Autoanamnesa on April 28, 2014.
    Main complaints: Bleeding after
    childbirth since 3 hours before
    arriving at the hospital
    Additional Complaint: headache (+)

    Disease History
    The patient was referred by a midwife Siti Mulyanti
    with diagnosis P2A0 inpartu stage II with retained
    placenta. Patients admitted to having a baby
    helped by shaman at 09.00 am (dated 28 April
    2014), the patient said that the placenta had not
    come out about half an hour after the baby is born.
    In addition the patient also complained of
    headache (+), the body weak (+). Complaints of
    blurred vision (-), nausea (-). Already bore 2
    children, a history of previous miscarriages (-).
    LMP: 8-9-2013. History of menstruation is regularly
    every 28 days, a history of contraception (-).

    History of Past Medical : Asthma (-), Hypertension


    (-), DM (-), Allergy (-), Heart (-)
    History of Familys Disease: Asthma (-),
    Hypertension (-), DM (-), Allergy (-), Heart (-)
    History of Menstruation:
    Menarche
    : 13 years
    Cycle
    : 28 days
    Older
    : 3-4 days
    The number of pads per day : 3-4 pads
    Menstrual pain
    : never

    History of marital: Married 1 time,


    at the age of 16 years.
    History of Pregnancy: It gave birth
    to 2 children, a history of miscarriage
    (-).
    History of Contraception: The
    patient had never used contraception
    History of Surgery: Never any
    surgery

    Physical Examination

    Height: 160 cm
    Weight: 61 kg
    Blood Pressure: 90/60 mmHg
    Heart rate: 104 x / min
    Temperature: 36.9 C
    Respiratory rate: 24 x / min
    State of Nutrition: Good
    Awareness: Compos Mentis

    General examination
    Head
    Eye : CA +/+ , SI -/- , pupils isokor, the
    light reflex + / +
    Ear : an intact of the tympanic
    membrane (+ / +) , wax (-)
    nose : deviation of septum (-),
    discharge(-)
    mouth : good oral hygiene
    neck : lymph nodes and thyroid was not
    palpable enlarged

    General examination
    Breast :normal breast shape, inverted nipple -/-, fissure -/ Lungs
    o Inspection : normal chest shape
    o palpation : stem fremitus of right and left chest is equally
    strong
    o percussion : sonor +/+
    o Auscultation : vesicular, ronchi - / -, wheezing - / Cor
    o Inspection : ICTUS cordis is not visible
    o Palpation : ICTUS cordis ICS VI palpable in the left MCL
    o Percussion : dim
    o Auscultation : BJ I - II regular, murmur (-), gallop (-)

    Status of Obstetric
    Abdominal
    o Inspection : flat
    o Palpation : high of fundus is 1 finger
    above center, tenderness (-)
    o Auscultation : bowels sounds(+)
    Genitalia external : no abnormalities of
    vulva and vagina, bleeding (+)
    Examination in : not done

    Laboratory (Date 28 April 2014)


    - Hb
    : 7.7 g / dL
    CT : 11'45 "
    - HT
    : 22%
    BT : 3'30 "
    - Leukocytes : 25500 / uL
    - Platelets : 177000 / mL
    - Blood
    :B
    Rhesus
    : (+)

    Follow up
    Dated 28 April 2014 at 13: 30 pm
    Ultrasonographys results: retained
    placenta (+)
    P: Plan curettage if Hb 10 g / dL

    Dated 29 April 2014


    S: headache (+), weak (+), blood coming from the vagina (+)
    O: General Examination
    General Situation: Looks Moderate Pain
    Awareness: Compos Mentis
    Signs - Vital Signs:
    Blood pressure: 90/60 mmHg
    HR: 78 x / m
    RR: 22 x / m
    Temperature: 36.9 C
    Eyes: CA + / +
    Abdomen: flat, high of fundus uteri is 1 finger center, tenderness (+),
    BU (+)
    Genitalia: v / v was bleeding (+) slightly
    Extremities: edema - / A: P2A0 spontaneous post partum with gestationals age is 32-33 weeks
    with retained placenta + anemia
    P: Plan curettage if Hb 10 g / dL

    Dated 30 April 2014


    S: headache (-), weak (+), blood coming from the vagina
    (+)
    O: General Examination
    General Situation: Looks Moderate Pain
    Awareness: Compos Mentis
    Signs - Vital Signs:
    Blood pressure: 90/60 mmHg
    HR: 82 x / m
    RR: 22 x / m
    Temperature: 38.1 C
    Eyes: CA + / +
    Abdomen: flat, TFU 1 finger center, NT (+), BU (+)
    Genitalia: v / v was bleeding (+) slightly
    Extremities: edema - / -

    Laboratory (Date 30 April 2014)


    - Hb : 10.1 g / dL
    CT: 11'07 "
    - HT : 23% BT: 3'20 "
    - Leukocytes : 15500 / uL
    - Platelets : 257000 / mL
    - Blood: B
    Rhesus: (+)
    A: P2A0 spontaneous post partum with gestationals
    age is 32-33 weeks with retained placenta + anemia
    P: Curettage
    PCT 3X500 mg

    RESUME
    Have examined a woman (21 years old)presenting with bleeding after
    childbirth since 3 hours before arriving at the hospital. The patient said
    that the placenta had not come out after about half an hour a baby is
    born. Complaints of headache(+), the body weak (+), blurred vision (-).
    Already bore 2 children, a history of previous miscarriages (-).
    On physical examination found :
    Blood pressure 90/60 mmHg
    HR 104 x / min
    RR24 x / min.
    Eyes : CA (+ / +)
    Abdomen : flat, high of fundus uteri 1 finger center, tenderness (-),
    BU (+)
    Genitalia: v / v was bleeding (+) slightly
    Routine blood tests (28/04/14)
    Hb : 7.7 g / dL Ht : 22%
    Leukocytes: 25500 / uL Platelets : 177000/L

    Basic Diagnosis
    Retained placenta
    In the complaint obtained history of bleeding after
    delivery, the placenta has not come out about half
    an hour after the baby is born. On physical
    examination of the abdomen, high of fundus uteri is
    1 finger above the center, genital examination
    found bleeding (+) minimum.
    Anemia
    In the complaint obtained history of bleeding after
    childbirth, headache (+), limp +. On physical
    examination found CA + / +. In laboratory tests Hb
    7.7g/dL

    Management
    Fluid resuscitation
    PRC transfusion to Hb> 8 g / dL
    If the Hb 10 g / dL plan to
    curettage
    Paracetamol 3 x 500 mg
    Observation KU, TTV, and bleeding

    Definition Postpartum Hemorrhage


    postpartum hemorrhage has been
    defined as the loss of 500 mL of
    blood or more after completion of the
    third stage of labor

    Predisposing Factors and Causes of


    Immediate Postpartum Hemorrhage
    Bleeding from Placental Implantation Site
    o Hypotonic myometriumuterine atony
    Some general anestheticshalogenated
    hydrocarbons
    Poorly perfused myometriumhypotension
    (Hemorrhage, Conduction analgesia)
    Overdistended uterus: large fetus, twins,
    hydramnios
    Prolonged labor

    Predisposing Factors and Causes of


    Immediate Postpartum Hemorrhage
    Very rapid labor
    Induced or augmented labor
    High parity
    Uterine atony in previous pregnancy
    Chorioamnionitis
    o Retained placental tissue
    Avulsed lobule, succenturiate lobe
    Abnormally adhered: accreta, increta,
    percreta

    Predisposing Factors and Causes of


    Immediate Postpartum Hemorrhage
    Trauma to the Genital Tract
    o Large episiotomy, including
    extensions
    o Lacerations of perineum, vagina, or
    cervix
    o Ruptured uterus
    Coagulation Defects
    o Intensify all of the above

    Retained placental tissue


    In most instances, the placenta
    separates spontaneously from its
    implantation site during the first few
    minutes after delivery of the infant.
    Infrequently, detachment is delayed
    because the placenta is unusually
    adhered to the implantation site.

    Retained placental tissue


    placenta accreta is used to describe
    any implantation in which there is
    abnormally firm adherence to the
    uterine wall. As the consequence of
    partial or total absence of the decidua
    basalis and imperfect development of
    the fibrinoid or Nitabuch layer,
    placental villi are attached to the
    myometrium in placenta accreta

    Retained placental tissue


    o Total placenta accreta : the abnormal
    adherence may involve all lobules
    o Partial placenta accreta: it may
    involve only a few to several lobules
    o focal placenta accreta : all or part of
    a single lobule may be attached

    Retained placental tissue


    Placenta increta, villi actually invade
    into the myometrium
    Placenta percreta, villi penetrate
    through the myometrium.

    Management of Retained placental


    tissue
    Preoperative Arterial Catheter Placement
    Experience has accrued with preoperative
    placement of pelvic arterial catheters.
    Balloon-tipped catheters are placed before
    surgery into the internal iliac arteries and are
    inflated after the fetus is delivered to
    decrease blood loss during placental delivery
    and hysterectomy, if indicated. Alternatively,
    the catheters can be injected with a
    substance to embolize the arterial sites.

    Management of Retained placental


    tissue
    Delivery of the Placenta
    Problems associated with delivery
    of the placenta and subsequent
    developments
    vary
    appreciably,
    depending
    on
    the
    site
    of
    implantation, depth of myometrial
    penetration, and number of lobules
    involved.

    Uterine Atony
    Failure of the uterus to contract
    properly following delivery is the most
    common cause of obstetrical
    hemorrhage
    Women with a large fetus, multiple
    fetuses, or hydramnios are prone to
    uterine atony
    High parity may be a risk factor for
    uterine atony.

    Uterotonic Agents
    Oxytocin
    Oxytocin is given intravenously or
    intramuscularly. This or other oxytocics will
    prevent most cases of uterine atony.
    Ergot Derivatives
    If oxytocin does not prove effective to reverse
    uterine atony, we usually administer 0.2 mg of
    methylergonovine intramuscularly. Importantly,
    if ergot agents are intravenously administered,
    they may cause dangerous hypertension,
    especially in women with preeclampsia.

    Uterotonic Agents
    Prostaglandin Analogs
    The 15-methyl derivative of prostaglandin
    F2carboprost tromethaminehas been
    approved since the mid-1980s for
    treatment of uterine atony. The initial
    recommended dose is 250 g (0.25 mg)
    given intramuscularly. This is repeated if
    necessary at 15- to 90-minute intervals
    up to a maximum of eight doses

    Genital Tract Lacerations


    Perineal Lacerations
    All except the most superficial perineal
    lacerations are accompanied by varying
    degrees of injury to the lower portion of the
    vagina.
    Vaginal Lacerations
    These are usually longitudinal and frequently
    result from injuries sustained during a forceps
    or vacuum delivery. However, they may even
    develop with spontaneous delivery.

    Genital Tract Lacerations


    Injuries to Levator Ani Muscles
    These result from overdistension of
    the birth.
    Injuries to the Cervix
    The cervix is lacerated in more
    than half of all vaginal deliveries.
    Most of these are less than 0.5 cm,
    although deep cervical tears may
    extend to the upper third of the
    vagina

    Inversion of the Uterus


    Complete uterine inversion after
    delivery of the infant is almost
    always the consequence of strong
    traction on an umbilical cord
    attached to a placenta implanted in
    the fundus. Incomplete uterine
    inversion may also occur.

    Inversion of the Uterus


    Contributing to uterine inversion is a
    sturdy cord that does not readily
    break away from the placenta,
    combined with fundal pressure and a
    relaxed uterus, including the lower
    segment and cervix.

    Management of Uterine inversion


    Immediate assistance is summoned to
    include anesthesia personnel and
    other physicians
    The recently inverted uterus with
    placenta already separated from it
    may often be replaced simply by
    pushing up on the fundus with the
    palm of the hand and fingers in the
    direction of the long axis of the vagina

    Management of Uterine inversion


    Adequate large-bore intravenous
    infusion systems are established, and
    crystalloid and blood are given to
    treat hypovolemia
    Tocolytic drugs such as terbutaline,
    ritodrine, magnesium sulfate, and
    nitroglycerin have been used
    successfully for uterine relaxation and
    repositioning

    Management of Uterine inversion


    After removing the placenta, steady pressure
    with the fist is applied to the inverted fundus
    in an attempt to push it up into the dilated
    cervix. Alternatively, two fingers are rigidly
    extended and are used to push the center of
    the fundus upward. As soon as the uterus is
    restored to its normal configuration, the
    tocolytic agent is stopped. An oxytocin
    infusion is begun while the operator
    maintains the fundus in its normal anatomical
    position.

    Coagulation Defects
    Hypofibrinogenemia
    In late pregnancy, plasma fibrinogen levels
    typically are 300 to 600 mg/dL. To promote
    clinical coagulation, fibrinogen levels must
    be approximately 150 mg/dL.
    Fibrin and Fibrinogen Derivatives
    Monoclonal antibodies to detect D-dimers
    are
    commonly
    used.
    With
    clinically
    significant consumption coagulopathy, these
    measurements are always abnormally high.

    Coagulation Defects
    Thrombocytopenia
    With severe preeclampsia and eclampsia,
    there may also be qualitative platelet
    dysfunction
    Prothrombin and Partial Thromboplastin
    Times
    Prolongation of the prothrombin time and
    partial thromboplastin time need not be the
    consequence of consumptive coagulopathy.

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