CASE PRESENTATIONCASE PRESENTATION

PRIMARY POSTPARTUM HEMORRHAGEPRIMARY POSTPARTUM HEMORRHAGE

PREPARED BY:PREPARED BY:MOHD HELMY B ABU BAKARMOHD HELMY B ABU BAKAR

012007030057012007030057

IntroductionIntroduction►PPH is one of the most leading causes of PPH is one of the most leading causes of

maternal mortality after delivery of baby.maternal mortality after delivery of baby.►PRIMARY PPH:PRIMARY PPH:

the loss of 500cc or more of blood during the the loss of 500cc or more of blood during the first 24 hours after the delivery of the baby.first 24 hours after the delivery of the baby.

►Can be divided into 4 main causes :Can be divided into 4 main causes :

1. T - TONE (Uterine Atony)1. T - TONE (Uterine Atony)2. T - TRAUMA (Genital trauma & lacerations)2. T - TRAUMA (Genital trauma & lacerations)3. T - TISSUE (Retained placenta)3. T - TISSUE (Retained placenta)4. T - THROMBOSIS (Bleeding disorders)4. T - THROMBOSIS (Bleeding disorders)

Tone: Uterine AtonyTone: Uterine Atony► 90% of cases:90% of cases:► EtiologyEtiology

1.1. Over distended uterusOver distended uterus

PolyhydramniosPolyhydramnios

Multiple gestationMultiple gestation

MacrosomiaMacrosomia

2. Uterine exhaustion2. Uterine exhaustion

Prolonged laborProlonged labor

Rapid laborRapid labor

High parityHigh parity

3. Intra amniotic infection3. Intra amniotic infection

ChorioamnitisChorioamnitis

FeverFever

Prolonged ROMProlonged ROM

4. functional/anatomic distortion of 4. functional/anatomic distortion of uterusuterus

Fibroid uterusFibroid uterus

Placenta previaPlacenta previa

Uterine anomaliesUterine anomalies

Objective StudyObjective Study

1.1. To identify the best treatment for To identify the best treatment for primary postpartum hemorrhage due primary postpartum hemorrhage due to uterine atonyto uterine atony

2.2. To observe management of primary To observe management of primary postpartum hemorrhage due to postpartum hemorrhage due to uterine atony at HRPZIIuterine atony at HRPZII

MethodologyMethodology

►History takingHistory taking►Physical examinationPhysical examination► InvestigationInvestigation

FBCFBC

PT/APTTPT/APTT

Patient’s ProfilePatient’s Profile

Name Name : Madam S : Madam SAgeAge : 38: 38RaceRace : Malay: MalayRNRN : 557715: 557715ParityParity : Para 6, postnatal of unplanned pregnancy: Para 6, postnatal of unplanned pregnancyDeliveryDelivery : 21/03/10 at 0915H with EBL 400cc: 21/03/10 at 0915H with EBL 400ccDOADOA : 20/03/10 : 20/03/10 Chief ComplaintChief Complaint : Presented with show, leaking with ¼ pad : Presented with show, leaking with ¼ pad

soaked with soaked with irregular contraction painirregular contraction painL.M.PL.M.P : 25/06/09 (sure of date, regular menstrual : 25/06/09 (sure of date, regular menstrual

period)period)E.D.DE.D.D : 02/04/10 (confirmed by scan at 18 weeks): 02/04/10 (confirmed by scan at 18 weeks)

History of Present IllnessHistory of Present Illness► unplanned pregnancy. unplanned pregnancy. ► First scan was done at 17 weeks and First scan was done at 17 weeks and

expected date of delivery was 02 April 2010. expected date of delivery was 02 April 2010. ► A referred case from KK Lundang Paku A referred case from KK Lundang Paku ► Patient presented with show, leaking with ¼ Patient presented with show, leaking with ¼

pad soaked, and irregular contraction pain, pad soaked, and irregular contraction pain, fetal movement was good.fetal movement was good.

►During that time, patient was watching During that time, patient was watching television and suddenly felt water gushing television and suddenly felt water gushing out from vagina with irregular contraction out from vagina with irregular contraction pain.pain.

► This patient was known case of anemia in This patient was known case of anemia in pregnancy but patient denied any vaginal pregnancy but patient denied any vaginal bleeding during pregnancy.bleeding during pregnancy.

►On admission: On admission: Patient had intermittent pain Patient had intermittent pain

contractioncontraction ShowShow leaking liquorleaking liquor FM goodFM good No s&s of UTI No s&s of UTI NO s&s of anemiaNO s&s of anemia

Labor SummaryLabor Summary

► Patient was being admitted to ward 25 on Patient was being admitted to ward 25 on 20/03/10 at 1942H with c/o of show, leaking with 20/03/10 at 1942H with c/o of show, leaking with ¼ pad soaked with ¼ pad soaked with

irregular contraction painirregular contraction pain► Os opening was 6cm at 0230H and was being Os opening was 6cm at 0230H and was being

sent to LR.sent to LR.► ARM was doneARM was done► 22ndnd stage of delivery start at 0350H stage of delivery start at 0350H ► Child had been born at 0915H, 3.4kg, Length Child had been born at 0915H, 3.4kg, Length

51cm,51cm,,, no fetal anomely no fetal anomely► Complete placenta expelled at 0925H, weight at Complete placenta expelled at 0925H, weight at

0.7kg 0.7kg ► EBL was 400ccEBL was 400cc

►33rdrd stage : Placenta completely stage : Placenta completely delivereddelivered

►Noted blood oozing post placenta Noted blood oozing post placenta delivery.delivery.

►Noted also that the uterus doesn’t Noted also that the uterus doesn’t contracted well.contracted well.

► IM pitocin had been given 10iU at IM pitocin had been given 10iU at both leg.both leg.

►Uterine massage was then being Uterine massage was then being done, followed by IV pitocin 40iU in done, followed by IV pitocin 40iU in 1pint NS.1pint NS.

►Blood taken for FBCBlood taken for FBC

Antenatal HistoryAntenatal History► Booking was done 17 weeks of gestation, her Booking was done 17 weeks of gestation, her

body weight was 45kg and height was 144cm, body weight was 45kg and height was 144cm, BMI was 21.7. her blood pressure was 120/70 BMI was 21.7. her blood pressure was 120/70 mmHg. mmHg.

► On systemic examination all system was found On systemic examination all system was found to be normal and uterine size was corresponded to be normal and uterine size was corresponded to the date. hemoglobin level was 10.6 and her to the date. hemoglobin level was 10.6 and her blood and rhesus group is B positive. blood and rhesus group is B positive.

► The serology test for syphilis (Venereal Disease The serology test for syphilis (Venereal Disease Research Laboratory) and HIV rapid test was Research Laboratory) and HIV rapid test was non reactive. Anti tetanus toxoid (ATT) injection non reactive. Anti tetanus toxoid (ATT) injection was completed at 10 February 2010. She also was completed at 10 February 2010. She also had rubella vaccination which is taken in 1987. had rubella vaccination which is taken in 1987.

►MOGTT at 24 weeks, result was MOGTT at 24 weeks, result was normalnormal

►Her first ultrasound examination was Her first ultrasound examination was done during her booking; the result done during her booking; the result showed the fetus growth and showed the fetus growth and progress was good. She was not progress was good. She was not having any vaginal bleeding and having any vaginal bleeding and discharge during pregnancy. discharge during pregnancy.

Obstetric HistoryObstetric HistoryNoNo Year Year Period of Period of

GestationGestationPlace of Place of DeliveryDelivery

Mode of Mode of DeliveryDelivery

WeightWeight StatusStatus

11 19951995 Full term Full term HRPZIIHRPZII SVDSVD 3.13.1 Alive and WellAlive and Well

22 19971997 Full term Full term HRPZIIHRPZII SVDSVD 3.03.0 Alive and WellAlive and Well

33 20002000 Full term Full term HRPZIIHRPZII SVDSVD 3.13.1 Alive and WellAlive and Well

44 20032003 Full term Full term HRPZIIHRPZII SVDSVD 3.83.8 Alive and WellAlive and Well

55 20052005 Full term Full term HRPZIIHRPZII SVDSVD 3.33.3 Alive and WellAlive and Well

66 20102010 Full term Full term HRPZIIHRPZII SVDSVD 3.43.4 Alive and WellAlive and Well

Gynecology HistoryGynecology History

►Since menarche at 16 yrs old, her Since menarche at 16 yrs old, her menses had been regular of 28 - 30 menses had been regular of 28 - 30 days cycle with normal flow for 6-7 days cycle with normal flow for 6-7 days with only slight dysmenorrhoea days with only slight dysmenorrhoea not requiring any medication not requiring any medication

►Not on any contraceptivesNot on any contraceptives►done Pap Smear at 1998done Pap Smear at 1998

Past Medical/ Surgical HistoryPast Medical/ Surgical History

►No significant past medical history and No significant past medical history and she did not underwent any surgeries.she did not underwent any surgeries.

Medicine/Allergies HistoryMedicine/Allergies History

►Not on any medicationNot on any medication►No history of allergic to seafood No history of allergic to seafood

or medicationor medication

Family HistoryFamily History

►Her father was passed away with Her father was passed away with natural death, her mother still alive natural death, her mother still alive but has hypertension and gout. but has hypertension and gout.

►No history of malignancy in the family, No history of malignancy in the family, no history of hereditary illness and all no history of hereditary illness and all the siblings are healthy.the siblings are healthy.

Social HistorySocial History

►She is a housewife but before this She is a housewife but before this work as operator in factory near their work as operator in factory near their househouse

►husband work in construction sitehusband work in construction site►she denied smoking and alcohol intake she denied smoking and alcohol intake

but her husband was occasional but her husband was occasional smokersmoker

► all the children are healthy.all the children are healthy.

Systemic ReviewSystemic ReviewCentral Nervous SystemCentral Nervous System no headache, no seizure, no abnormal no headache, no seizure, no abnormal

movements, no paraesthesiaemovements, no paraesthesiae

Ear, Nose and Throat Ear, Nose and Throat no ear and nasal dischargeno ear and nasal discharge

Gastrointestinal System Gastrointestinal System no vomiting, no hematemesis, no abdominal no vomiting, no hematemesis, no abdominal

pain, no diarrhoea, no constipation, no per rectal pain, no diarrhoea, no constipation, no per rectal

bleedbleed

Cardiovascular System Cardiovascular System no chest pain, no palpitation, no orthopnea, no no chest pain, no palpitation, no orthopnea, no

ankle swellingankle swelling

Genitourinary System Genitourinary System no dysuria, no hematuria, no incontinence, no no dysuria, no hematuria, no incontinence, no

loin pain, no frequency or urgencyloin pain, no frequency or urgency

Respiratory System Respiratory System no shortness of breath, no cough, no wheezingno shortness of breath, no cough, no wheezing

Musculoskeletal SystemMusculoskeletal System no joint, muscle and bone pain, no limitation to no joint, muscle and bone pain, no limitation to

joint movementjoint movement

Haematological and lymphatic systemHaematological and lymphatic system no rash, no bruising, no lymphadenopathy, no no rash, no bruising, no lymphadenopathy, no

spleen and liver enlargementspleen and liver enlargement

Physical ExaminationPhysical Examination

General examinationGeneral examination

►Medium built women, alert, conscious, not Medium built women, alert, conscious, not palepale

► Patient not in pain and comfortablePatient not in pain and comfortable► BP: 143/70, PR: 112, T: 37BP: 143/70, PR: 112, T: 37°°cc► Currently : Currently :

►PV Bleeding – 2 pad soakedPV Bleeding – 2 pad soaked►No s&s of anemiaNo s&s of anemia►No short of breath No short of breath ►No calf tendernessNo calf tenderness►Patient was stablePatient was stable►BF establishedBF established

Systemic ExaminationSystemic Examination

►All the system were found to be All the system were found to be normal, the thyroid was not palpablenormal, the thyroid was not palpable

►no murmur and any additional sound no murmur and any additional sound detected. detected.

►Both lungs are clear, there is present Both lungs are clear, there is present of normal vesicular breath sound, no of normal vesicular breath sound, no rhonchi, no crepitation and no added rhonchi, no crepitation and no added sound detected.sound detected.

Abdominal examinationAbdominal examinationINSPECTION:INSPECTION:► No lesions, no scars or dilated vein notedNo lesions, no scars or dilated vein noted► No distended abdomenNo distended abdomen► Linea nigra, striae gravidarum, striae albicanLinea nigra, striae gravidarum, striae albican► Blood clot evacuated from vagina Blood clot evacuated from vagina

PALPATION:PALPATION:► Soft and non-tenderSoft and non-tender► Uterine contract at 22 weeks, softUterine contract at 22 weeks, soft

AUSCULTATION:AUSCULTATION:► Bowel sound presentBowel sound present► No other altered bowel soundNo other altered bowel sound

InvestigationInvestigation

FBC 20/0310&21/03/10FBC 20/0310&21/03/10Lab viewLab view ValueValue Normal rangeNormal range StateState

White blood cellWhite blood cell 8.98.9 11.011.0 4.0-11.0 ×10 /L4.0-11.0 ×10 /L Normal Normal NormalNormal

Red blood cellRed blood cell 4.084.08 3.313.31 4.5-6.5 ×10 /L4.5-6.5 ×10 /L NormalNormal LowLow

RBC distribution widthRBC distribution width 15.415.4 14.814.8 11.3-14.9 %11.3-14.9 % NormalNormal NormalNormal

HemoglobinHemoglobin 11.211.2 9.49.4 12-14g/dL12-14g/dL NormalNormal LowLow

HematocritHematocrit 35.135.1 28.128.1 39-52 %39-52 % NormalNormal LowLow

Mean cell hemoglobinMean cell hemoglobin 27.527.5 28.428.4 26-32 pg26-32 pg Normal Normal Normal Normal

Mean cell volumeMean cell volume 86.686.6 84.984.9 77-91 fl77-91 fl Normal Normal Normal Normal

Mean cell hemoglobin Mean cell hemoglobin

concentrationconcentration

31.931.9 33.533.5 31-40pg/cell31-40pg/cell Normal Normal Normal Normal

PlateletPlatelet 245245 198198 150-400 ×10 /L150-400 ×10 /L NormalNormal NormalNormal

NeutrophilNeutrophil 72.672.6 78.578.5 40.0-75.040.0-75.0 NormalNormal NormalNormal

LymphocyteLymphocyte 19.419.4 12.512.5 0.00-500.00-50 NormalNormal NormalNormal

MonocyteMonocyte 0.740.74 0.880.88 0.00-0.800.00-0.80 NormalNormal NormalNormal

EosinophilEosinophil 0.60.6 0.10.1 0.00-0.500.00-0.50 NormalNormal NormalNormal

BasophilBasophil 0.00.0 0.10.1 0.00-0.200.00-0.20 NormalNormal NormalNormal

PT/APTTPT/APTTPT/APTT Test PT/APTT Test ResultResult Normal RangeNormal Range

Prothrombin Time Test Prothrombin Time Test 13.813.8 10.7-13.8 10.7-13.8

Prothrombin Time Control Prothrombin Time Control 13.513.5

INR INR 1.031.03

APTTAPTT 29.029.0 24.6-37.5 24.6-37.5

APTT ControlAPTT Control 38.338.3

RatioRatio 0.760.76

Patient’s ProgressionPatient’s Progression

21/03/10 11:20am21/03/10 11:20am► estimated blood lost is 850cc. on estimated blood lost is 850cc. on

examination patient alert, conscious and examination patient alert, conscious and mild pale, blood pressure was taken mild pale, blood pressure was taken 145/81 mmHg, pulse rate is 112 bpm.145/81 mmHg, pulse rate is 112 bpm.

►On palpation abdomen is soft and uterus On palpation abdomen is soft and uterus contracted well 20 weeks, the pad still contracted well 20 weeks, the pad still staining with blood.staining with blood.

► Impression: primary postpartum Impression: primary postpartum hemorrhage hemorrhage

due uterine atonydue uterine atony

21/03/10 9:00pm 21/03/10 9:00pm

Currently completed transfusion 20PC and Currently completed transfusion 20PC and 2Ü FFP, the pad still ¼ staining with blood 2Ü FFP, the pad still ¼ staining with blood within 2 hours. No anemic symptoms, the within 2 hours. No anemic symptoms, the plan were allow orally, vital sign plan were allow orally, vital sign monitoring ½ hourly until patient stable, IV monitoring ½ hourly until patient stable, IV Lasix 20mg STAT, strict I/O chart.Lasix 20mg STAT, strict I/O chart.

21/03/10 12:00 midnights21/03/10 12:00 midnights

Currently patient alert, conscious and not Currently patient alert, conscious and not pale, no anemic symptoms, no excessive pale, no anemic symptoms, no excessive bleeding, breastfeeding established and bleeding, breastfeeding established and taken orally well. Blood pressure was taken orally well. Blood pressure was 118/78 and pulse rate is 98, on palpation, 118/78 and pulse rate is 98, on palpation, abdomen is soft, non tender and no calf abdomen is soft, non tender and no calf tenderness.tenderness.

Management PlanManagement Plan

1. Encourage orally and high iron diet1. Encourage orally and high iron diet2. Strict pad chart and to inform if per 2. Strict pad chart and to inform if per vaginal bleedingvaginal bleeding3. Encourage ambulation3. Encourage ambulation4. Encourage breastfeeding4. Encourage breastfeeding5. off CBD5. off CBD

SummarySummary

►Madam S, 38 years old malay, Madam S, 38 years old malay, housewife, Para 6, post SVD with skin housewife, Para 6, post SVD with skin nick repairednick repaired

1.1.Postnatal with primary PPH due Postnatal with primary PPH due to uterine atony, EBL 1050ccto uterine atony, EBL 1050cc