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Snapshot
  • A 17 year-old woman, gravida 1, now para 1, just underwent a spontaneous delivery of a 4200 g (9 lb 4 oz) male with Apgar scores of 8 and 9 at 1 and 5 minutes. Onset of regular contractions were at noon. The delivery took place 8 hours later. She received IV oxytocin for the last 5 hours of delivery. After the placenta was delivered, she experienced postpartum hemorrhage estimated at 1200 ml of blood.
Introduction
  • Defined as the loss of
    • > 500mL of blood within the first 24 hours after delivery
    • 1000ml with cesarean
  • Usually occurs immediately after the delivery of the placenta
  • Five most common causes are
    • uterine atony (most common)
    • genital track trauma (lacerations)
    • retained placental tissue
    • uterine inversion
    • coagulation disorder
Uterine Atony
  • Normally uterus contacts and compresses down on spiral arteries
  • Uterine atony defined as a boggy and enlarged uterus
  • Causes 90% of postpartum hemorrhages
  • Risk factors include
    • multiple gestations
    • hydraminos
    • multiparity
    • macrosomia
    • previous h/o postpartum hemorrhage
    • fibroids
    • magnesium sulfate
    • general anaesthesia
    • prolonged labor
    • amnionitis
  • Diagnosis by palpation of a soft, flaccid, boggy uterus without a firm fundus
  • Treatment includes
    • first give bimanual uterine massage to stimulate contractions 
    • resuscitate with IV fluids and transfusions
    • Medical treatment
      • oxytocin infusion
      • IM methergine
      • prostaglandins if patient is not hypertensive or asthmatic
    • If refractory
      • surgical ligation of uterine artery
      • arterial embolization
      • hysterectomy
Genital Track Trauma
  • Risk factors include
    • precipitous labor
    • operative vaginal delivery (forceps, vacuum extraction)
  • Laceration greater than 2 cm are repaired surgically
Retained Placental Tissue
  • Occurs when separation of placenta from uterine wall or expulsion of placenta is incomplete
  • Risk factors include
    • placenta accreta, increta, percreta
    • preterm delivery
    • placenta previa
    • previous cesarean
    • prior uterine curettage
    • uterine leiomyomas
  • Diagnose with careful inspection of the placenta for missing cotyledons
  • Ultrasound may also be helpful
  • Treat with
    • manual removal of the retained placental fragments
    • curretage with suctioning with special care not to perforate the uterine fundus
  • In cases of placenta accreta, increta, percreta, where the placenta villi has invaded into the uterine tissue, hysterectomy is often required as a life saving procedure
Coagulation Disorders
  • DIC associated with
  • severe preeclampsia
  • amniotic fluid embolism
  • placental abruption
 
 

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