विवरण
Postpartum hemorrhage (PPH) is a significant complication following childbirth, characterized by excessive bleeding within 24 hours of delivery. It's a leading cause of maternal mortality globally. PPH can occur due to various factors, including uterine atony (failure of the uterus to contract), trauma during childbirth, retained placental tissue, or coagulation disorders. Prompt recognition and intervention are crucial to prevent severe consequences. Management typically involve uterine massage, administration of uterotonic medications, uterine artery embolization, or, in severe cases, surgical interventions like hysterectomy. Timely and effective management strategies are essential to reduce maternal morbidity and mortality associated with PPH.
सारांश
- Postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity globally, affecting approximately 5% of deliveries. It's unpredictable, requiring constant preparedness in labor rooms, even for low-risk patients. Early diagnosis and prompt intervention are crucial for reducing complications.
- Primary PPH is defined as excessive bleeding (over 500 ml) from the genital tract within the first 24 hours after delivery. Secondary PPH occurs after 24 hours and up to six weeks postpartum. For cesarean sections, PPH is defined as blood loss exceeding 1000 ml, or 1500 ml if a cesarean hysterectomy is performed.
- Hemostasis after delivery relies on myometrial contraction and retraction, effectively clamping spiral arteries. Timely separation of the placenta is also vital in minimizing blood loss. Primary PPH is attributed to four major categories: tone (uterine atony), tissue (retained placental fragments or clots), trauma (perineal or cervical lacerations, uterine inversion or rupture), and thrombin (coagulation disorders).
- Predisposing factors for PPH include anemia, previous PPH history, operative deliveries, prolonged or rapid labor, chorioamnionitis, uterine infection, shoulder dystocia, and antenatal coagulopathy. Prevention involves active management of the third stage of labor, including uterotonic administration (oxytocin), controlled cord traction, and potentially delayed cord clamping (at least one minute if no fetal distress).
- Management requires a rapid and coordinated team approach, involving qualified obstetrical staff, equipment, blood transfusion services, and anesthesia. Initial steps include rapid diagnosis, stabilizing the patient with IV access and oxygen, continuous monitoring of vital signs, and sending blood samples for relevant tests. Resuscitation focuses on securing the airway, ensuring proper breathing, and maintaining circulation.
- Fluid management in hypovolemic shock involves rapid infusion of warm crystalloid solutions until blood is available. Blood transfusion protocols should be in place, considering PRBCs, fresh frozen plasma, platelets, and cryoprecipitate based on coagulation profiles. Pharmacological interventions include oxytocin, methylergonovine, carboprost, misoprostol, and carbetocin to promote uterine contraction.
- Mechanical and surgical interventions include bimanual compression, uterine balloon tamponade, non-pneumatic anti-shock garments, suction cannulas for PPH, compression sutures (B-Lynch, Hayman, Cho), uterine artery ligation, ovarian artery ligation, internal iliac artery ligation, and ultimately, hysterectomy as a last resort. In cases of retained placenta, manual removal under anesthesia is required.
- Uterine inversion requires immediate manual repositioning, prioritizing the most recently inverted portion. Hydrostatic repositioning can be attempted, followed by laparotomy with a Huntington procedure if necessary. Cervical and vaginal lacerations must be explored and repaired meticulously under anesthesia, ensuring the apex of the laceration is addressed. Complications of PPH include anemia, hypovolemic shock, acute organ failure, pulmonary embolism, disseminated intravascular coagulation, transfusion reactions, Sheehan's syndrome, and chronic renal failure.
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डॉ. ईशा रानी
प्रसूति एवं स्त्री रोग निदेशक, नागरिक चिकित्सा केंद्र (सीएमसी), झारखंड
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