Postpartum haemorrhage or postpartum hemorrhage ( PPH ) is often defined as loss of more than 500 ml or 1,000 ml of blood in the first 24 hours. hours after delivery. Some have added the requirement that there are also signs or symptoms of low blood volume for existing conditions. Early signs and symptoms may include: increased heart rate, feeling fainted while standing, and an increase in breathing rate. As more blood is lost, women may feel cold, their blood pressure may decrease, and they may become anxious or unconscious. This condition can occur up to six weeks after delivery.
The most common cause is poor uterine contractions after labor. Not all placenta sent, tear wombs, or poor blood clots are another possible cause. This is more common in those who: already have a low red blood count, Asians, with a larger baby or more than one, are obese or older than 40 years. It also happens more commonly after caesarean section, those who use drugs to start labor, and those who have an episiotomy.
Prevention involves the reduction of known risk factors including procedures associated with the condition, if possible, and administering oxytocin drugs to stimulate the uterus to contract as soon as the baby is born. Misoprostol can be used instead of oxytocin in resource-poor settings. Treatment may include: intravenous fluids, blood transfusions, and ergotamine drugs to cause further uterine contractions. Efforts to compress the uterus by hand may be effective if other treatments are unsuccessful. The aorta can also be compressed by pressing the abdomen. The World Health Organization has recommended non-pneumatic anti-shock garments to assist until other actions such as surgery can be performed. In 2017 the study found that tranexamic acid decreased the risk of a woman's death.
In developing countries about 1.2% of shipments are related to PPH and when PPH occurs about 3% of women die. Globally it's about 8.7 million times and producing 44,000 to 86,000 deaths a year making it the leading cause of death during pregnancy. About 0.4 women per 100,000 births die from PPH in the UK while about 150 women per 100,000 births die in sub-Saharan Africa. The death rate has dropped substantially since at least the 1800s in the UK.
Video Postpartum bleeding
Definitions
Depending on the definition in question, postpartum hemorrhage is defined as more than 500ml after vaginal delivery or 1000 ml of blood loss after caesarean section within the first 24 hours after delivery.
Maps Postpartum bleeding
Signs and symptoms
Early signs and symptoms may include: increased heart rate, feeling fainted while standing, and an increase in breathing rate. The more blood is lost, the woman may feel cold, their blood pressure may decrease, and they may become unconscious.
Cause
The causes of postpartum hemorrhage are uterine atony, trauma, placental retention, and coagulopathy, commonly referred to as "four Ts":
- Tone: uterine atony is the inability of the uterus to contract and may cause continuous bleeding. Retention of placental tissue and infection may contribute to uterine atony. Uterine atonia is the most common cause of postpartum hemorrhage.
- Trauma: Injury to the birth canal involving the uterus, cervix, vagina and perineum that can occur even if labor is monitored properly. Bleeding is very important because all of these organs become more vascular during pregnancy.
- Tissues: tissue retention of the placenta or fetus may cause bleeding.
- Thrombin: a bleeding disorder occurs when there is a frozen failure, such as a disease known as coagulopathy.
Prevention
Oxytocin is usually used just after delivery to prevent PPH. Misoprostol can be used in areas where oxytocin is not available. Early binding of the umbilical cord does not reduce the risk and may cause anemia in infants, so it is usually not recommended.
Active management of the third stage is a method of shortening the stage between the time a baby is born and when the placenta is born. This stage is when the mother is at risk of having PPH. Active management involves giving a drug that helps the uterus contract before delivering the placenta through a gentle yet sustained pull on the umbilical cord while exerting upward pressure on the lower abdomen to support the uterus.
Another method of active management that is not recommended right now is fundal pressure. A review into this method found no research and suggested controlled cord traction because fundal pressure may cause unnecessary pain in the mother. Allowing the rope to drain appears to shorten the third stage and reduce the blood loss but the evidence around this subject is not strong enough to draw strong conclusions.
Nipple and lactation stimulation triggers the release of natural oxytocin in the body, therefore it is thought that encouraging the baby to breastfruit immediately after birth can reduce the risk of PPH for the mother. A review that investigated this did not find enough good research to say whether nipple stimulation did not reduce PPH. More research is needed to answer this question.
Management
Uterine massage is a simple first line treatment because it helps the uterus contract to reduce bleeding. Although the evidence around the effectiveness of uterine massage is inconclusive, it is a common practice after delivery of the placenta.
Medication
Intravenous oxytocin is the drug of choice for postpartum hemorrhage. Ergotamine can also be used.
Oxytocin helps the uterus to contract rapidly and contractions last longer. This is the first-line treatment for PPH when the cause is the uterus does not contract well. The combination of syntocinon and ergometrine is usually used as part of the active management of the third stage of labor. This is called syntometrine. Syntocinon itself lowers the risk of PPH. Based on limited available studies it is unclear whether syntocinon or syntometrine is most effective in preventing PPH but worse adverse effects with syntometrine make syntocinon a more attractive option. Ergometrine must also remain cool and in a dark place so it is safe to use. It reduces the risk of PPH by increasing the tone of the uterus when compared to no treatment but should be used with caution as its effect increases blood pressure and causes worse after illness.
More research will be useful in determining the best dose of ergometrine, and syntocinon.
The difficulty of using oxytocin is that it needs to be kept under certain temperatures requiring resources such as refrigerators that are not always available especially in low resource settings. When oxytocin is not available, misoprostol may be used. Misoprostol does not need to be stored at a certain temperature and the research of its effectiveness in reducing blood loss appears promising when compared with placebo in settings where it is inappropriate to use oxytocin. Misoprostol can cause unpleasant side effects such as very high body temperature and chills. Low-dose misoprostol appears to be safer and causes fewer side-effects.
Oxytocin administration in saline solution to the umbilical vein is a method of administering the drug directly to the placental bed and the uterus. But the quality of evidence around these techniques is poor and is not recommended for routine use in the management of the third stage. Further research is needed to ascertain whether this is an effective way to manage uterotonic drugs. As a way of treating retained placenta, this method is harmless but has not proven effective.
Carbetosin compared with oxytocin results in a decrease in women requiring uterine massage and advanced uterotonic drugs for women undergoing cesarean section. There was no difference in PPH levels in women who underwent a caesarean section or women who gave birth to the vagina when given carbetocin. Carbetocin seems to cause less harmful effects. More research is needed to find cost effectiveness using carbetocin.
Tranexamic acid, a blood clot stabilizer, can also be used to reduce bleeding and blood transfusions in low-risk women, but evidence in 2015 is not strong. The 2017 trial found that the reduced risk of dying from bleeding from 1.9% to 1.5% in women with postpartum hemorrhage. The benefits are greater when the drug is given within three hours.
In some countries, such as Japan, methylergometrine and other herbal remedies are given after placental delivery to prevent severe bleeding more than one day after birth. However, there is not enough evidence to suggest that this method is effective.
Surgery
Surgery may be used if medical management fails or in case of cervical lacerations or rips or uterine tears. The methods employed may include uterine artery ligation, ovarian artery ligation, internal iliac artery ligation, selective arterial embolization, B-lynch suture, and hysterectomy. Bleeding caused by traumatic causes should be treated with surgical repair. When there is bleeding due to uterine rupture, repair can be performed but most of the time a hysterectomy is required.
Medical devices
The World Health Organization recommends the use of a device called non-pneumatic anti-shock garment (NASG) for use in shipping activities outside hospital settings, the goal being to increase maternal shock with long-term bleeding to reach the hospitals. External aortic compression devices (EACD) can also be used.
In the uterus, a balloon tamponade may relieve or stop postpartum hemorrhage. Inflating the tubes Sengstaken-Blakemore in the womb successfully treated atonic postpartum refractory hemorrhage against medical management in about 80% of cases. The procedure is relatively simple, cheap and has low surgical morbidity. Bakri balloon is a special balloon tamponade made for uterine postpartum hemorrhage.
Protocol
A gradual phased management protocol has been introduced by the California Maternity Quality Care Campaign. It describes 4 stages of uterine bleeding after delivery and its application reduces maternal mortality.
- Stage 0: normal - treated with a fundal massage and oxytocin.
- Stage 1: more than normal bleeding - build large intravenous access, assemble personnel, increase oxytocin, consider methine-gine use, perform fundus massage, prepare 2 units of packed red blood cells.
- Stage 2: continued bleeding - check coagulation status, response team response, move to operating room, place intrauterine balloon, give additional uterotonic (misoprostol, carboprost tromethamine), consider: uterine artery embolization, dilation and curettage, and laparotomy with uterine stitching compression or hysterectomy.
- Stage 3: continued bleeding - activate massive transfusion protocol, mobilize additional personnel, re-examine laboratory tests, do laparotomy, consider hysterectomy.
A Cochrane review shows that active management (the use of uterotonic drugs, cord clamping and controlled cord traction) during the third stage of labor reduces severe bleeding and anemia. However, the review also found that active management increases maternal blood pressure, nausea, vomiting, and pain. In the active management group, more women return to the hospital with bleeding after return, and there is also a decrease in birth weight because the baby has a lower blood volume. The effect on early umbilical cord clamping is discussed in another review which found that delayed cord binding improves long-term iron supply in infants. Although they are more likely to require phototherapy (light therapy) to treat jaundice, repaired iron shops are expected to improve the practice of cord clamping in healthy infants. For premature infants (infants born before 37 weeks), a review of the study found that cord clamping delay with 30-45 seconds increased the amount of blood flow to the baby. This is important because increased blood volume in infants makes them less developed some serious complications. Most of the research around this subject is poor quality so further, larger research projects tend to produce more reliable results.
Another Cochrane review observing the time of administration of oxytocin as part of active management found similar benefits by giving it before or after expulsion of the placenta.
There is no good quality evidence of the best way to treat secondary PPH (PPH occurs 24 hours or more after birth).
Epidemiology
Methods of measuring blood loss associated with birth vary, complicated comparison of prevalence rates. The systematic review reported the highest level of PPH in Africa (27.5%), and the lowest in Oceania (7.2%), with a global overall rate of 10.8%. Rates in Europe and North America are about 13%. This figure is higher for multiple pregnancies (32.4% compared with 10.6% for singletons), and for first-time mothers (12.9% compared with 10.0% for women in subsequent pregnancies). The overall rate of heavy PPH (& gt; 1000 ml) was much lower at an overall rate of 2.8%, again with the highest rate in Africa (5.1%).
References
External links
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. Geneva: World Health Organization. 2012. ISBN: 9789241548502. - Postpartum haemorrhage and B-Lynch technique
Source of the article : Wikipedia
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