Case Presentation

Andalas University

Management of

Post Partum Hemorrhage

Caused by Uterine Atony

By : Sri G. Bahertry

With guidance ofH. Mahjoeddin Soeleman, M.D.

CONSULTANT OF OBSTETRIC AND GYNECOLOGY

DEPARTEMENT OF OBSTETRIC AND GYNECOLOGYFACULTY OF MEDICINE ANDALAS UNIVERSITY

DR. M. DJAMIL HOSPITALPADANG

2004

Chapter I

INTRODUCTION

Obstetrics is “bloody business” even though the maternal mortality rate

has been reduced dramatically by hospitslization for delivery and the availability

of blood for transfusion, death from hemorrhage remains prominent in the

majority of mortality reports. ( Cunningham, 2001)

Traditionally post partum hemorrhage has been defined as the loss of 500

ml or more of blood after completion of the third stage of labor. Nonerheless,

nearly a half of all women who are delivered vaginally shed that amount of blood

or more, when measure quantitatively. ( Arias F, 1993)

Pospartum hemorrhage is the consequence of excessive bleeding from

placental implantation site trauma to the genital tract and adjacent structures or

both. Uterine atony, degrees retained placenta including placenta accreta and its

variants, and genital tract lacerations account for most cases of postpartum

hemorrhhage. ( Cunningham, 2001)

Obstetricians usually resort to hysterectomy when the classic

conservative measures fail to control nontraurnatic postpartum hemorrhage.

Hysterectomy is a radical prosedure that carries the undesirable side effect to

reproductive sterillity, secondary amenorrhea, and physical and psychologic

trauma. (AbdRabbo. SA, 1994)

In this paper, we will discuss a case of 28 years old patient, diagnosed

with postpartum hemorrhage caused by uterine atony. Before that the patient

was diagnosed with post partum hemorrhage which cause of residual plasenta.

Then the patient have been curretage, Oxytocin had been given and massage of

uterine and bimanual compression were performed, the blood still flew from the

cervical canal but all manuver were failed. Laparatomy was done. Uterine artery

ligation was performed, the blood couldn’t be controlled. So decided

Supravaginal Hysterectomy.

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Chapter II

CASE PRESENTATION

ANAMNESIS

Patients identity Husband’s identity

Name : Fidyawati

Age : 28 years

Occupation : Housewife

Address : Palinggam No. 3

MR No : 388730

Name : Afrizal

Age : 30 years

Occupation : Private employee

Address : Palinggam

A 28 year old patient was admitted to the emergency room of Dr. M.

Djamil Hospital on November 3rd, 2004 at 21.15, accompanied by midwife with

the chief complaining of massive vaginal bleeding since one hour ago.

Present Illnes History :

Massive vaginal bleeding since one hour ago.

Before that she has been delivering the health male baby spontaneously, 3200

gram in weight, and 50 cm in height. The baby cried spontaneously.

After delivering baby, the placenta had not delivered then the midwife

performed manual removal of the placenta.

The vaginal bleeding still continued then the patient reffered to the M.

Djamil Hospital by the midwife in intravenous line.

There was no history of fever .

There was no history of injury.

History of Previous Diseases :

No history of heart, lung , liver, kidney, diabetes nor hypertension diseases.

History of Familial Disorders :

None of family member ever had hystory of contagious, hereditary nor

psychiatric disorders

Marietal history :

Once, in 1998

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History of pregnancies/abortions/deliveries :

1. 1996, female, 2.800 gram, term, midwife, spontaneous, alive

2. 1998, female, 2.500 gram, term, midwife, spontaneous, alive

3. Present, male, 3.200 gram, term, midwife, spontaneous, alive

PHYSICAL EXAMINATION

General Condition : Poor

Consciousness : Conscious

Blood Pressure : 90/60 mmHg

Pulse Rate : 132 x/minute

Respiratory Rate : 28 x/minute

Temperature : 37 OC

Eyes : Conjunctiva was anemic, sclera was not icteric

Neck : JVP 5-2 cm H2O, thyroid glands were not enlarged

Thorax : Heart and lungs were in normal condition

Abdomen : Obstetrical Record

Genital : Obstetrical Record

Extremities : Edema -/-, Physiological reflexes +/+, Pathological reflexes -/-

OBSTETRICAL RECORD

Abdomen

Inspection : Seen of few enlarged

Palpation : Uterine fundal was palpable at umbilical, contraction was

weak

Abdominal tenderness was (-), release pain (-) and no

muscle rigidity

Auscultation : Bowel sound was (+) normal

Genital Examination

Inspection : Vulva and urethra was normal, seen the blood flew from

the introitus vagina, dark red in color.

Speculum examination

- Vagina : Fluxus was (+), dark red, no tumor, no laceration

Seen the blood collected at the posterior fornix

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- Portio : Normal size, no tumor, no laceration, fluxus was (+). OUE

was opened about 3 cm, seen blood flew from the OUE,

dark red in color.

VT/ bimanual :

- Vagina : no tumor

- Portio : normal size, OUE was opened about 3 fingers, it was

palpable residual tissues in cervical canal

- CUT : size equal to term baby’s head, the weak contraction

- AP : rigidless both sides

- CD : not protruded, pressure pain was negative

Laboratory :

Hb : 5,7 gr%

Leucocyte : 19.700

Trombocyte : 270.000 /mm

CT : 4’

DIAGNOSIS : P3A0A3, post outside spontaneous delivery + early post

partum hemorrhage caused by residual placenta with

severe anemia

MANAGEMENT : Improve general condition, uterotonic

Prepare whole blood

Antibiotics :

Consultation with anesthesiologist

Preparing for curattage in general anasthesia

PLAN : Curattage in general anasthesia

Consult to the consultant : agree to perform curattage

On Nov 4 th ,2004 at 22.15

Performed curattage in general anasthesia,

Took out the residual placenta about 100 gram

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DIAGNOSIS : P3A0A3 post outside spontaneous delivery + post

curattage on indication early post partum hemorrhage

caused by residual plasenta with severe anemia

MANAGEMENT : Control of general condition, vital sign, vaginal bleeding,

and uterine contraction

At 22.30

The patient was still in anasthesia

PHYSICAL EXAMINATION

Blood Pressure : 100/60 mmHg

Pulse Rate : 128 x/minute

Respiratory Rate : 24 x/minute

Temperature : 37 OC

The blood still flew from the vagina. The uterine contraction was weak

DIAGNOSIS : P3A0A3 post outside spontaneous delivery + early post

partum hemorrhage caused by uterine atony

MANAGEMENT : control of general condition, vital sign, vaginal bleeding,

and uterine contraction

Uterotonica and uterine massage

Bimanual compression

At 22.45

The blood still flew from the vagina about 200 cc, the uterine contraction was still

weak

PHYSICAL EXAMINATION

Blood Pressure : 90/60 mmHg

Pulse Rate : 128 x/minute

Respiratory Rate : 28 x/minute

Temperature : 37 OC

DIAGNOSIS : P3A0A3 post outside spontaneous delivery + early post

partum hemorrhage caused by uterine atony + failure of

uterine massage and bimanual compression.

MANAGEMENT : Control of general condition, vital sign, vaginal bleeding,

and uterine contraction

PLAN : Laparatomy

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At 22.50

Consult to the consultant : agree to perform laparotomy

At 23.00

Performed laparotomy

Done ligation of right and left uterine arteries and ovarian artery

Performed the bleeding observation

The blood still flew from the cervical canal about 300 cc

Impression :

Uterine atony + failure of uterine and ovarian arteries ligation

Plan :

Supravaginal hysterectomy

At 23.15

Performed supravaginal hysterectomy

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Chapter III

LITERATURE REVIEW

3.1. Definition

Postpartum Hemorrhage complicates approximately 3.9 % of vaginal and

6.4 % of cesarean deliveries. Postpartum bleeding has serious consequences

and account by bleeding during pregnancy. (Arias F. 1993)

Traditionally post partum hemorrhage has been defined as the loss of 500

ml or more of blood after completion of the third stage of labor. Nonetheless

nearly a half of all women who are delivered vaginally shed that amount of blood

or more, when measuured quatitatively. This compares with 1000 ml blood loss

for cessarean section, 1400 ml for elective cessarean hysterectomy.( Cunningham, 2001)

Martohoesodo and Abdullah divided postpartum hemorrhage as primary

hemorrhage which begin at the first 24 hours, and secondary hemorrhage after

24 hours. While the other author categorized as early postpartum hemorrhage

and late postpartum hemorrhage. (Cunningham FG 2001, . Martohoesodo S, Abdullah MN, 1999)

3.2. Etiology

Excessive bleeding affects approximately 5 to 15 percent of women after

giving birth. The etiologies of early postpartum hemorrhage era most easily

understood as abnormalities of one or more of four basic processes (four T's)

namely; Tone, Tissue, Trauma and Thrombin. bleeding will occur if for some

reason the uterus is not able to contract well enough to arrest the bleeding at the

placental site. Retained products of conception or blood clots, or genital tract

trauma may cause large blood losses postpartum, especially if not promptly

identified. Coagulation abnormalities can cause excessive blood loss alone or

when combined with one of the other processes. (Schuurmans N, at al. 2000)

bleeding will occur if for some reason the uterus is not able to contract

well enough to arrest the bleeding at the placental site. Retained products of

conception or blood clots, or genital tract trauma may cause large blood losses

postpartum, especially if not promptly identified. Coagulation abnormalities can

cause excessive blood loss alone or when combined with one of the other

processes. (Schuurmans N, at al. 2000)

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Uterine atony, degree of retained placental, including placental accreta

and its variants and genital tract lacerations account for most case of Postpartum

Hemorrhage. (Cunningham FG, 2001)

In certain situations, there is a distrubance in this mechanism, leading to uterine

atony.The following is a list of factors that predispose to uterine bleeding :

Trauma to the Genital Tract

Large episiotmy, including extensions

Lacerations of perineum, vagina or cervix

Ruptured uterus

Bleeding from placental implantation site

Hypotonic myometrium – uterine atony

Some general anasthetic – halogenated hydrocarbones

Poorly perfused myometrium – hypotension

Hemorrhage

Conduction analgesia

Overdistended uterus – large fetus, twins, hydramnions

Following prolonged labor

Following oxytocin – induced or augmented labor

High parity

Uterine atony in previous pregnancy

Chorioamnitis

Retained placental tissue

Avulsed cotyledon, succenturiate lobe

Abnormally adherent – accreta, increta, percreta

Coagulation defects

Intensify of the above ( Cunningham, 2001 )

3.3. Diagnosis

Sometimes bleeding may caused by both atony and trauma, especially

after major operative delivery. In general, inspection of the cervix and vagina

should be performed after every delivery to identify hemorrhage from lacerations.

Anesthesia should be adequate to prevent discomfort during such an

examination. Examination of the uterine capacity, the cervix and all of the vagina

essential after breech extraction, after internal podalic version and following

vaginal delivery in a woman who previously underwent cessarean section. The

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same is true when unusual bleeding is identifed during the seconf stage of labor.. ( Cunningham, 2001 )

3.4. Uterine Atony

Metabolic factors contribute to uterine atony. For effective contraction to

be maintained, it is necessary to have an adequate supply of oxygen and fuel to

support the aerobic metabolism of myometrial cells. Hypoxia or acidosis from any

cause, including acute respiratory insufficiency, diabetic ketoacidosis, and sepsis,

may disturb myometrial metabolism. Patients who deliver after difficult or

obstructed labor may suffer from uterine atony. The mechanism of uterine in

these case is complex, and muscle exhaustion, lactate buildup, and glycogen

depletion may be implicated. Because calcium is an important regulator of

smooth muscle tone, hypocalcemia can be implicated in some case of uterine

atony. (Arias F, 1993)

There are many reasons why the uterus may fail to adequately contract in

the immediate postpartum period. Mechanical factors include inability of the

uterus to contract because of an intrauterine object, usually placental fragments

or blood clots. Also it has been observed that extreme uterine distention before

labor, as in multiple gestation or polyhydramnions, is accompanied by poor

uterine tone postpartum.

3.5 Management

Management of postpartum hemorrhage begins before excessive blood

loss has occurred by carefully observing for rate of bleeding immediately

following delivery. Although spontaneus placental delivery is preferable to

attempts to express the placenta, a sudden increasi in vaginal bleeding may be

an indication for manual removal of the placenta. Immeditely after placenta

delivery, bimanual massage of the uterine promotes uterine contraction and

homeostasis. The placenta should be examined, as described above, for

completeness. If uterine bleeding does not promptly diminish, the obstetrician

should proceed in serial fashion to consider possible causes of bleeding and

institute therapeutic measure. If manuver is unsuccesful in stoppping

hemorrhage, an alternative should be attempted. When less invasive measure

are not initially succesful, it is usually fruitless to repeat them while the patient

continues to bleed. ( Andersen HF 1992 )

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Clinicians should assess each woman's risk for Postpartum Hemorrhage

and make appropriate arrangements for her care. Routine prophylactic oxytocin

after delivery of the shoulder reduces the risk of Postpartum Hemorrhage.

Administration of oxytocin before delivery of placental is associated with a

reduction in length of the third stage of labor (mean 5 minutes) and low incidence

of manual removal of placenta (2 percent) compared with physiologic

management of third stage labor (15 minutes and 2.5 %).(Benedetti,1996,

Schuurmans N, et al, 2000)

Drugs may have important effects on postpartum uterine tone. The use of

large dosages of oxytocin to stimulate desultory or obstructed Iabor may result in

relative oxytocin insensitivity. It is not clear whether this tachyphylactic effect of

exogenously administered oxytocin results from down regulation of oxytocin

receptor or simply from individual variability of oxytocin effect.

Simultaneously, pharmacologic methods should be employed to control

uterine bleeding. Initial therapy includes the administration of dilute solution of

oxytocin usually 10 to 20 units of oxytocin in 1000 ml of physiologic saline

solution. The solution can be administrated in rates as high as 500 ml in 10

minutes without cardiovascular complications. (Benedetti TJ, 1996, Chan PD. Johnson SM, 2003)

The second step in the management of Postpartum Hemorrhage involves

attention to the specific cause; proceed with massage, compression and

medication for atony, evacuation of the uterus for retained blood clots or products

of conception, physical repair of any trauma and reversal of coagulation defects. (Schuurmans N, at al, 2000)

If retained blood clots or products of conception are identified, they should

be carefully removed, including complete manual removal of the placenta if

necessary. After the uterus is empty, massage, compression and medication

should be used to combat atony. Initial exploration may also reveal trauma

including uterine inversion or rupture and laceration of the cervix or lower genital

tract. If uterine inversion is identified, prompt replacement should be undertaken

prior to administration of further oxytocic drugs. Laceration must be carefully and

completely visualized and repaired. If uterine rupture has occurred, arrangements

for laparatomy should be initiated. If a coagulation abnormality is known or

suspected, direct pressure at the bleeding site should be employed to minimize

losses until specific therapy has taken effect. (Schuurmans N, et al, 2000)

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The approach to intractable Postpartum Hemorrhage will be individualized

depending on the clinical situation and the skills and technology available.

Continued monitoring and fluid and blood component replacement and use of all

available expertise are essential. (Schuurmans N. et al, 2000)

Schuurmans N, et al, 2000 recommended

1. Uterine vessel ligation may be effective in controlling Postpartum

Hemorrhage

2. Internal illiac artery ligation has been reported for use in Postpartum

Hemorrhage, however its effectiveness is not yet proven. This procedure

requires more extensive surgical skills and the situation may deteriorate if

the illiac veins are injured.

3. Peripartum hysterectomy can be life saving in Postpartum Hemorrhage A

clamp, cut and drop technique should be used to gain control of bleeding

as rapidly as possible.

4. Diffuse post hysterectomy bleeding may be controlled by abdominal

packing to allow time for normalization of the woman's haemodynamic

and coagulation status. Specific vessels which hemorrhage persistently

may be controlled with embolization procedures.

If bilateral uterovarian vessel ligation does not stop the bleeding,

temporary occlusion of the infundibulopelvic ligamen vessels may be attempted.

It may be an especially usefull technique if the patient is low of parity and future

child bearing is importance. If this appears to control hemorrhage, ligation

infundibulopelvic ligament can be performed by passing an absorbable suture

from anterior to posterior through the avascular area inferior to and including the

ovarian vessel. (Benedetti TJ, 1996)

If bleeding continues, attention should next be paid to interrupting the

blood flow to the uterus from the infundibulopelvic ligament . There are a number

of techniques to accomplish this. The easiest involves ligation of the anastomosis

of the ovarian and uterine artery, high on the fundus, just below the uterovarian

ligament. (Benedetti TJ, 1996)

During pregnancy the blood supply to the uterus comes mainly from

uterine artery (90%) and from ovarian, cervical and vagina] vessels. Occlusion of

the uterine arteries reduces most of the uterine blood flow and produce uterine

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ischemia. Occlusion of the ovarian vessels results in additional deprivation of

uterine blood supply. this vascular occlusion is a temporary procedure, because

recanalization appears to be the rule, and normal uterine circulation will be

established. (AbdRabbo, SA, 1994)

3.6 Emergency Peripartum Hysterectomy

Emergency hysterectomy is the most common treatment modality when

massive postpartum hemorrhage requires surgical intervention. The incidence of

emergency peripartum hysterectomy reported in the literature varies from 7 to 13

peritoneum 10,000 births, and is much higher after caesarean section than

vaginal delivery. (Schuurmans N, et al. 2000)

The advantages of emergency hysterectomy in the situation of massive

hemorrhage are the ability to remove the source of bleeding and the familiarity of

the obstetrician with the procedure of hysterectomy, which, albeit more

technically difficult in this situation, is still a familiar operation to any obstetrician/

gynecologist. The disadvantage of hysterectomy may include the loss of uterus in

a woman who wishes to continue childbearing. Hysterectomy is associated with

more blood loss and longer operative time but this may reflect the fact that

hysterectomy is reserved for the worst cases of PPH. (Schuurmans N. et al, 2000)

Subtotal hysterectomy has been advocated to reduce operative time and

blood loss. It is hard to find data which will support this as subtotal hysterectomy

is often performed in the worst cases which already have larger blood loses and

longer operating times. Leaving the cervix in place would appear to be a

reasonable option if the bleeding secondary to uterine atony. If the bleeding site

is in the lower uterine segment or cervix, as occurs with placenta previa or with

abnormal placentation, bleeding will not be controlled as it is supplied by the

cervical branches of the uterine arteries. (Schuurmans N. et al, 2000)

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CHAPTER IV

DISCUSSION

A patient was referred by a midwife with complaining of a massive

vaginal bleeding after delivery. The cause of bleeding after performing

examination was placenta residual. The bleeding was still continuing even had

performed curratage and uterotonica. Found there was inadequate of uterine

contraction.

Uterine massage had also performed but unsuccessfully. Then bimanual

compression was performed according to literature that stated in the

management of Postpartum Hemorrhage involves attention to the specific

cause ; proceed with massage, compression and medication for atony,

evacuation of the uterus for retained blood clots or products of conception,

physical repair of any trauma and reversal of coagulation defects. ( Schuurmans N, et al,

2000)

Performed of uterine and ovarian arteries ligation to avoid the bleeding,

but after performing of observation the bleeding was still continuing so that

suggested to be performed of supravaginal hysterectomy. (Schurrmans N, et al 2000)

The cause of uterine atony in this case is unclear. Metabolic factors

contribute to uterine atony. For effective to be maintained, it is necessary to have

an adequate supply of oxygen and fuel to support the aerobic metabolism of

myometrial cells. Hypoxia or acidosis from any cause including acut respiratory

insufficiency, diabetic ketoacidosis and sepsis may disturb myometrial

metabolism. (Arias F, 1993)

CHAPTER V

CONCLUSION

1. Diagnose of Postpartum Hemorrhage that caused of uterine atony is right

2. Management of uterine atony until performed supravaginal hysterectomy in

this case is true according to standard procedure.

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3. The cause of uterine atony is unclear, many factors contribute it.

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REFERENCES

1. Cunningham FG, Obstetrical Hemorrhage, In Williams Obstetrics 21th Ed. The

Mc Graw-Hill Companies. New York, 2001; 1184-6.

2. Arias F, Postpartum Complications, In practical Guide to High Risk

Pregnancy and Delivery, 2nd Ed, Mosby Year Book, Boston USA, 1993; 433-

422.

3. AbdRabbo, SA, Stepwise Uterine Devascularazation, In American Journal

Obsterics and Gynecology, 1994; 171.

4. Martodohoesodo, S, Abdullah MN, Gangguan dalam Kala III Persalinan,

Dalam Ilmu Kebidanan Ed Ketiga, cetakan Kelima. Yayasan Bina Pustaka

Sarwono Prawirohardjo. Jakarta, 1999; 653-663.

5. Andersen HF, Hopkins M: Post partum Hemorrhage Gynecology and

Obstetric volume 2, revised edition, JB lippincott Copmpany,

Philadelphia ,1992, chap 80, 1-9

6. Schuurmans, et al. Prevention and Management of Postpartum Hemorrhage,

in Journal SOGC Clinical Partice Guidelines, 88; 2000: 1-11.

7. Benedetti, TJ, Obstetric Hemorrhage, In Obstetrics Normal and Problem

Pregnancies, Churchill Livingstone, USA, 1996; 517-526.

8. Johnson SM, Postpartum Hemorrhage, Current Clinical Strategies

Gynecology and Obstetrics, 2004 Ed, 2002; 162-164.

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