Bleeding In Late Pregnancy & After Delivery

 Bleeding In Late Pregnancy ( Antepartum Hemorrhage - APH ) :

 Any bleeding from the genital tract occurring in antenatal period after 24 week
gestation & before the end of second stage of labor i.e. before delivery of fetus
 Vaginal bleeding from 24 weeks to the delivery of baby .
 Causes :
A. Placental causes : "most common worrying causes of APH  affect mother& fetal
life) " 2/3 of causes
1) placental abruption 1/3
2) placenta praevia 1/3
B. Maternal/local causes :
1) cervicitis
2) cervical ectropion
3) cervical carcinoma
4) vaginal trauma
5) vaginal infection
6) bloody show " at term " – blood mixed with mucous indicate onset of labour
when it excessive  D.D of APH
7) vaginal varicosity
C. Fetal causes :
a) vasa praevia
 Incidence :
 APH 3% : 1% is attributable to placenta praevia , 1% is attributable to placental
abruption & remaining 1% from other causes .
 Commonest cause of APH is abruptio placenta or placental abruption " accidental
hemorrhage"
 Hints
 The bleeding in APH is maternal origin except in vasa praevia where the bleeding is
fetal in origin .
 Often with relatively small amount blood loss , but signify that pregnancy is at
increased risk of complications .
 APH must always be taken seriously & any pregnant with fresh vaginal bleeding must
be investigated promptly & properly .
 A pale, tachycardic women looking anxious with a painful, firm abdomen,
underwear soaked in fresh blood and reduced fetal movements
 Need emergency assessment & management for a possible Abruptio placenta .
 Women with small postcoital bleed with no systemic signs or symptoms represents
another cause rather than AP
 Most APH involve relatively small amounts of blood loss
 How To reach the cause ??
 History :
 How much bleeding ?
 Triggering factors ( e.g. Postcoital bleeding )
 Associated with pain or contractions ?
 Is the baby moving ?
 Last cervical smear ( Date / normal or abnormal )
 Examination :
 Pulse , Blood pressure
 Is the uterus soft or tender & firm ?
 Fetal hear auscultation/CTG
 speculum vaginal examination with Cervix visualization
 Investigations :
 CBC , Clotting , Rh , Blood group
 If suspected AP/PP  Cross-match 6 units of blood
 U/S (fetal size, presentation, amniotic fluid, placental position and
morphology )
 Note : The key question is whether the bleeding is placental and is compromising the
mother and/or fetus or whether it has a less significant cause
 Complications of APH :
A. Maternal complications
1. anemia
2. infection
3. maternal shock
4. Renal tubular necrosis
5. consumptive coagulopathy
6. PPH
7. prolonged hospital stay
8. psychological sequelae
9. complications of blood transfusion
B. Fetal complications
1. Fetal hypoxia
2. small for GA & FGR
3. prematurity
4. Fetal death
  Placenta Praevia P.P.
 A condition in which the placenta is totally or partially implanted in the lower uterine
segment . Bleeding maybe provoked or spontaneous
 Abnormal implantation of the placenta in the lower uterine segment .

Normally ; the placenta is implanted in the upper uterine segment (60-80% posterior wall
"fundo-posterior" )

 How to Differentiate that this placenta is P.P not normal rare placental implantation ?
By U/S : Depend on Distance of lower edge of placenta & internal os . If distance <2cm
minor P.P . >2cm rare site of placental normal implantation .
 New classification of P.P. :
A. Minor placenta praevia : placenta sited within the lower uterine segment but not
cover the internal os .
B. Major placenta praevia : placental cover or encroaching the cervical internal os
 Old I-IV classification of P.P. :
a) Grade 1 = type 1 =1st degree = P.P lateralis = low lying placenta :
the lower edge of placenta reaches the upper part of the lower uterine
segment .
b) Grade 2 = type 2 = 2nd degree = P.P marginalis :
the lower edge of the placenta reaches down to the margin of the internal os
but does not cover it .
c) Grade 3 = type 3 =3rd degree = incomplete P.P. centralis = partial P.P. :
The placenta covers the internal os when the cervix is close but not when
dilated .
d) Grade 4 = type 4 =4th degree = complete P.P. centralis =total P.P. :
the placenta covers completely the internal os whether closed or dilated .
 Mechanism Of Bleeding In P.P. :
 Normally ; the lower uterine segment expressing progressive stretching during 3 rd
trimester & the placenta is not elastic and cannot stretch inevitable/unavoidable
separation tearing of vascular connection between placenta and uterine wall
bleeding .
 During first stage of labor : the lower uterine segment is pulled upward by
contractions and retractions of upper segment while the lower pole of membrane
together with placenta move downward " shearing movement " placental
separationbleeding .
 Notes :
- In case of P.P. centralis , bleeding may occur early and usually severe because a great part
of placenta is attached to the lower uterine segment .
- P.P. marginalis posterior is of bad prognosis than marginalis anterior because :
 1) it encroaches the true conjugate diameter delaying the engagement of the head
2) engagement of head will compress the placenta against the sacrum , casing fetal
asphyxia .
 Predisposing factors :
1. Previous uterine surgery as in pt. with uterine myoma
2. Uterine structural anomaly
3. Assisted conception "IVF"
4. Previous cesarean section : >> Increased Number increase risk of complications "
morbid adherent of placenta"
5. Previous History of P.P.
6. Multiple pregnancy especially fused placenta "large size"
7. Multiparity "common"
8. advanced maternal age >40 "common"
9. smoking
10.Deficient endometrium due to presence or History of :
- Uterine scar
- endometriosis
- manual removal of placenta
- curettage
- submucous fibroids
 Note : P.P is related to conditions existing prior to pregnancy

 Prevention : By avoidance of non-clinically indicated C/S

 Diagnosis : By Clinical+ U/S

 Clinical presentation :
 Symptoms :
 Causeless, painless and recurrent bright red/fresh vaginal bleeding
- It is causeless but may follow sexual intercourse or vaginal examination .
- It is painless unless it occur during labor ( usually painless not always )
- It is usually recurrent because the lower uterine segment undergoes intermittent
stretching during pregnancy causing intermittent separation of the placenta
note : the bleeding in type 1 P.P. may not recur .
 Irregular abdominal pain associated with uterine contractions " if bleeding trigger
preterm labour"

 Signs :
A. General Examination :
- Depend on the amount of blood loss & severity of bleeding
- Recurrent gradual loss  anemia
- Rapid severe blood loss hypovolemic shock "
B. Abdominal Examination P/A :
 Uterus : soft , non-tender , normal size & consistency and fetal parts are easily palpable
( in contrast to revealed accidental Hg. )
 The presenting part is not engaged - placenta interfere with engagement
 Fetal heart sounds are heard unless more than half of placenta has separated
 Fundal level correspond to the level of amenorrhea
 Malpresentaion as breech & shoulder is common & Transverse and oblique lie .
 Suprapubic fullness/bulge obscuring the presenting part is rarely felt with anterior P.P
 Stallworthy signs : in case of posterior P.P. ; Pressure on the fetal head downward into
pelvis  fetal bradycardia
C. Vaginal Examination P/V :
- Absolute contraindicated unless Major . P.P. Is excluded by U/S
- Speculum ex. to exclude local causes only permissible when major P.P is excluded .
- P/V can provide information on cervical dilatation when P.P is associated with pain or
uterine activity
- it provoke severe bleeding , so should be done with the following precautions :
(in the operating theater , under general anesthesia , cross matched blood is at hand ,
double IV set , operating theater ready for C/S . )
 Investigations :
Major/massive Hemorrhage :
 CBC , Rh , Blood group , kleihauer test when Rh-ve
 Cross-match 6 or 4 units of blood
 Urea, Electrolytes and LFT
 Coagulation screen indicated only when PLT is low
 CTG when stable mother or resuscitated
Ultrasonography U/S
 Simplest, Safest & most accurate and most widely used method for placental
localization and diagnosis of P.P is provided by trans-vaginal U/S - accuracy : 98%
 If the distance between the lower edge of Placenta & margin of internal os less
than 2cm ; it is diagnosed as minor P.P.
It determines :
 type of P.P.
 viability
 fetal maturity are essential to decide the management .
 presentation and position
 congenital anomalies
 Note :
- 15-20% of pregnant women exhibit a low-lying placenta in the early 2 nd trimester -
before 24 ( at 20 week scan ) ; of these, 90% resolve without symptoms & 10% develop
P.P " placental migration " . So , it's recommended to repeat U/S scan when P.P. is
diagnosed before 24 Week gestation .

- At 20 week, the lower uterine segment has not yet been formed and most low-lying
placenta will migrate upwards as the lower segment stretches in the late 2 nd and 3rd
trimesters
 Warning Signs in P/P:
 Low-laying placenta at 20 week anomaly scan
 Maternal collapse
 Feeling cold
 Light-headedness, restlessness , distress
 Panic & painless vaginal bleeding
Notes : Placenta previa is most dangerous for mother because bleeding is from the mother
rather than fetal circulation
 Management :
P.P. is a part of obstetric emergencies that need prompt recognition & treatment to limit
morbidity and mortality .

 Treatment Steps :
1. Call for help [ Senior obstetrician, Anesthetist, senior midwife, porter ] "First Action" .
2. Resuscitate using ABC "First Line"+ High-flow O2 administration + two large bore
cannula
3. Blood drawn for blood grouping, cross-matching, baseline hematology and
biochemistry
4. IV crystalloid fluids
5. Blood transfusion if severe bleeding
6. U/S
7. Definitive treatment depend on :
 Maternal & fetal condition
 Type of P.P.
 Severity of bleeding
 If P.P. present in labor or not
 Fetal condition
 Gestational age
A. Minor P.P
1) If preterm & the amount of bleeding is mild & the fetus uncompromised 
admission for observation and evaluation & not allowed home until at least 24
hours has passed without further bleeding
- At end of 37 weeks  termination & mode of delivery is vaginally .
2) If preterm with severe vaginal bleeding  immediate termination after
resuscitation
3) If term Termination
B. Major P.P
- Mode of delivery : C/S
- Indications :
 Massive Bleeding  immediate C/S regardless of GA
 After complete 37 week
 Continuing significant bleeding of lesser severity
 Detailed Management :
 Call for help
 Resuscitate the pt. using the structured approach ABC ( Airway , Breathing and
ventilation , Circulation with volume replacement ): first-line .
Airway : "maintain airway patency "
 Ask a simple question, a normal voice implies an intact airway .
 If no response (Look , listen & feel) . Suction of airway, chin lift head tilt , passing a
plastic oropharyngeal or nasopharyngeal airway
Breathing :
 look , listen & feel then ventilate with bag-valve mask and administer of high
concentration of oxygen either mask or nasal catheter & connect the pt. to pulse
oxymeter
Circulation :
 Assess pulse , BP, capillary refill , skin temperature mental status , identify any
source of bleeding …(look, listen & feel ) .
 Insert IV access via two wide bore cannula in anticubital fossa, blood is drawn for
blood grouping and cross-matching, baseline hematology and biochemistry
 Fluid resuscitation
 Anti-shock measures as pethidine IM , fluids and blood transfusion may be given If
bleeding is severe .

Notes :
 Absent breathing indicate lack of circulation  CPR immediately
 If circulation present but no breathing (respiratory arrest )  ventilation breaths with
high flow oxygen should be given at rate of ten breaths per minute with regular
carotid check every ten breaths
 Absent circulation need immediate CPR .
 Decision of definitive treatment initially depend on the maternal condition. the first
priority is to stabilize the mother .
 Exclude cervical carcinoma by smear History & direct visualization of cervix
If there is minimal bleeding & the cause is clearly local vaginal bleeding ; symptomatic
management may be given ( e.g. anti-fungal for candidiasis ) .
 When her condition is stable , Assessment of pt. condition , general & abdominal
examination .
 Ultrasonography U/S
 The definitive management depend upon :
 type of P.P.
 severity of bleeding
 if P.P. present in labor or not
 fetal condition
 Gestational age
A. If there is major maternal or fetal compromise  immediate delivery regardless
of gestational age + steroid injection
 B. If pt. Dx by U/S as minor P.P. ; we Look if this pregnant women preterm or term &
with mild or sever vaginal bleeding .
1) if preterm & the amount of bleeding is mild & the fetus uncompromised 
admission for observation and evaluation " and not allowed home until at
least 24 hours (or 48h)has passed without further bleeding .
Evaluate for :
☆ Recurrent vaginal bleeding
☆ Correct anemia with blood transfusion
☆ Rh group ( if negative : send a kleihauer test & mandatory given anti-D ),
☆ Observation of fetal well-being .
☆ If bleeding is substantial in excess of 500 ml  maternal corticosteroids
is considered if under 35 years .
☆ Conservative treatment is indicated till the end of 37 weeks but not
more & the mode of delivery is vaginal .
2) If preterm with severe vaginal bleeding : require resuscitation & immediate
termination of pregnancy by CS .
3) If term : Immediate delivery " vaginal " ( no observation )
C. If pt. Dx by U/S as major P.P. :
All the cases of major P.P. must be delivered by C/S .
Indications for delivery by C/S :
- Massive bleeding > 1500 mL regardless of Gestational age - need immediate CS .
- Term fetus after complete 37 weeks
- Continuing significant bleeding of lesser severity
 Complications Of Placenta Praevia :
C. Maternal Complications : A. Fetal Complications :
1. Morbid adherent of placenta 1. Prematurity
2. PPH : Due to 2. Asphyxia
- weak contractions and retractions in LUS 3. IUGR
- Uterine atonia due anemia 4. IUFD
3. Hypovolemic shock 5. Cord prolapse
4. Renal failure B. Effect on Puerperium :
5. Complications for surgery & anesthesia 1. Retained part of placenta
6. Non-engagement 2. puerperal sepsis
7. Preterm labour 3. Anemia
8. Malpresentations 4. Sub-involution
9. Higher incidence of C/S & it is complications 5. Sheehan syndrome

 Note : 10% of P.P. cases  Complicated by placental abruption

  Morbid Adherent Placenta :
 Aberrant placentation characterized by abnormally implanted, invasive or adherent
placenta "Accreta syndromes"
 Pathogenesis :

- Partial or total absence of the spongy layer of decidua basalis and imperfect development
of the fibrinoid or Nitabuch layer  absent physiological line of cleavage Placental villi
attach to smooth muscle fibers rather than to decidual cells prevent normal placental
separation after delivery

 Classification :

3 Types :

1. Placenta Accreta (78%) : The placenta is abnormally adherent to the uterine wall
- villi are attached to the myometrium
2. Placenta Increta (17%) : Placenta is abnormally invade to the uterine wall
- villi actually invade the myometrium
3. Placenta Percreta (5%) : Placenta is invading through the uterine wall
- villi penetrate through myometrium and to or through serosa

Adherence may be :

A. Total Placenta Accreta : involve all lobules of placenta

B. Focal Placental Accreta : involve all or part of single lobule

 Risk factors :
1) P.P
2) Previous C/S ( Increase with increased number of CS )
3) Combination of the two
4) Curettage & endometrial ablation
5) Risk markers : MSAFP levels >2.5 MoM , Maternal serum free B-hCG >2.5 MoM

 Clinical Presentation And Diagnosis :

 Coexistence Placenta previa  Bleeding in first & second trimester
 Not associated P.P  Third stage of labour  Failure of placental delivery within 30
minutes after fetus delivery
 Vaginal Examination  No plane of cleavage
 TVUSS  antepartum identification of abnormal placental ingrowth
 Better  3D-sonography & Power Doppler
  Management :
 Preoperative assessment begin antenatally once accreta syndrome is recognized .
- Timing & plan for delivery
- Type of Accreta syndrome
- Risk of Hysterectomy
 Cesarean Delivery
 Time of C/S
 Assessment of placental invasion extent without attempts for manual placental removal
 Obvious increta or Percretaplanned Hysterectomy is mandatory with placenta left in
situ
 Hysterectomy after full assessment unless spontaneous separation with bleeding
Emergency Hysterectomy is mandatory .

 Complications :
 Pregnancy Outcomes :
1)
 Complications of retained placenta :
1)
 Placental Abruption=Accidental Hemorrhage=Abruptio Placenta
 Premature(befre 3rd stage of labour ) separation of the normally implanted placenta
from the uterine wall .

The bleeding is maternal and/or fetal and is acutely dangerous for both fetus and mother

More dangerous for fetus .

Etiology/Predisposing factors :

1. Unknown in the majority . the primary cause is idiopathic in most cases

2. Defective trophoblast invasion as in PET & IUGR
3. HTN
4. Sudden decompression of uterus as in ROM in polyhydramnios and delivery of 1 st
twin
5. Uterine over distension (polyhydrmina + multiple gestation
6. Maternal cocaine use and smoking
7. Trauma to maternal abdomen
8. High parity
9. Previous hx of AP
10.Traction on placenta by short cord
11.Anticoagulant therapy
Note : AP is related to conditions occurring during pregnancy

 Types :
1) Revealed : most cases 2/3

- the separation reach the edge of the placenta tracks down to the cervix

- main C/P is vaginal bleeding

2) concealed/hidden

- significant separation between the placenta and uterus but blood in trapped between the
placenta and uterus so there is little vaginal bleeding seen

- main C/P is sever constant abdominal pain "main" + fetal distress + maternal shock
without any obvious bleeding

 Diagnosis : mainly based on the clinical grounds . Pain is a constant feature In all
cases

History : HTN, abdominal trauma , tobacco or cocaine use

Symptoms :

- sudden onset Dark painful vaginal bleeding . it can be concealed , so its absence doesn’t
exclude AP.( the degree of vaginal bleeding does not correlate with the degree of abruption
as it may be concealed )

- acute constant severe abdominal pain (knife like )

- frequent short lasting uterine contractions " irritable effect of blood in uterus

-large abruption : maternal shock & fetal distress

- sweating, hypotension, tachycardia "shock"

- reduced/absent fetal movements & CTG non-reassuring fetal heart rate pattern

signs :

P/A :

- Tense rigid tender uterus " woody hard uterus " = " Couvelaire=apoplexy uterus" due to
large volume of blood within the myometrium "mostly in concealed type"

- tense rigid abdomen " the absence of that does not exclude AP "
- the uterus is large than the period of amenorrhea

- Difficult to palpate fetus due to abdominal rigidity

- fetus may be dead. distressed, or un affected

U/S : can Dx AP , but absence of changes does not rule out AP

it's not a reliable diagnostic tool in AP. it has rule in :

1- exclude PP

2- can detect large retroperitoneal clot

Differential Dx :

1- concealed must be D.D from other causes of acute abdominal pain during pregnancy

[ hypertonic inertia, rupture uterus , sever pre-eclampsia,

2- revealed must be differentiated from the other causes of APH

Complications :

1) hypovolemic shock
2) DIC " 2ry phenomenon due to generalized activation of coagulation system "
3) Acute Renal failure " pt. oliguric or ATN "
4) fetomaternal hemorrhage
5) perinatal mortality
6) FGR
7) prematurity
8) Sheehan's syndrome

 Management :
1. Resuscitation using ABC "life-threating emergency"
2. Depend on severity :
- in severe cases :
if fetus alive C/S
if died Vaginal delivery
- in mild cases : admission & observation " conservative"

Depend on type :
 A. Revealed type (on severity of bleeding ) :
1. sever bleeding :
- correction of shock
- C/S
2. mild bleeding :
a) pt. is in labour
- Amniotomy & oxytocin drip for spontaneous vaginal delivery
b) pt. is not in labour
- mature : Termination by amniotomy and oxytocin drip
- premature : conservative ttt. until maturity then termination
B. Concealed type :
1. correction of shock
2. termination of pregnancy :
fetus alive : immediate C/S
fetus died : Vaginally by amniotomy and oxytocin drip

Vasa praevia

occurs when fetal blood vessels traverse the fetal membrane over the internal cervical os .

vessels from Either :

1. velamentous insertion of the umbilical cord

2. joining an accessory placental lobe to the main disc of placenta

Dx : Need index of suspicion "Clinically": when spontaneous or artificial rupture of

membrane is accompanied by :painless fresh vaginal bleeding from rupture of fetal vessels .

Vasa previa is not dangerous for the mother but is nearly always fatal for the baby .

Management :

is baby still alive , once suspected Dx ; immediate delivery by emergency C/S

  Complications Of Third Stage Of Labour
 Include :
1) Postpartum Hemorrhage PPH
2) Retained placenta
3) Acute inversion of uterus
4) Postpartum shock
 Postpartum Hemorrhage
 Excessive bleeding from the birth canal following expulsion of the fetus (during or
after the 3rd stage ) which affect the general condition of pt. or associated with CV
compromise .
 Blood loss ≥500 ml from the genital tract after vaginal delivery .
 OR : blood loss ≥1000 ml from the genital tract after C/S .

 Types :

1- primary PPH :

 Tract within first 24hours after delivery (C/S or vaginal)

 serious - leads to shock

2- secondary PPH :

 after first 24hours & up to 12 weeks post delivery

 less serious – leads to anemia

Note : Minor 500-1000 common in practice – tolerable , major >1000 .

- so , losses ≥ 1000 ml emergency PPH protocols

- Any vaginal bleeding post-delivery compromise the maternal condition (CV compromise –
{tachycardia, hypotension, slow capillary refill, dry and pale skin ) or a continuing bleeding
even if estimated losses < 1000  protocols should be instituted .

 Major obstetric hemorrhage :

- blood loss ≥2500 ml or requiring blood transfusion ≥5 units RBC or need ttt. of
coagulopathy .

 Risk factors

- PPH can be predicted &

preventive if Significant risk
factors are present
  Causes of PPH :
A. Primary PPH : 4Ts
1. Tone : uterine atony " most common cause"

- failure of the uterus to contract after the delivery of placenta .

- cause torrential blood loss immediately following delivery . it can be predicted

- prevention : use of oxytocin infusions & active management of 3 rd stage of labour

- causes :

 causes weaken the uterus during pregnancy

 anemia & general condition
 over distended uterus : twins & ployhydromonia
 causes which weaken the uterus during labour
 prolonged first & second stage
 excessive bearing down
 full bladder or rectum
 retained parts of placenta
 hurry in delivery of placenta
 other causes
 multiparity
2. Tissue : retained placenta and/or membranes "occasionally"

- prevent the uterus from contracting efficiently until tissue removal

- identified by careful clinical examination of the placenta after delivery

3. Trauma : injury to vagina , perineum , and uterine tear at C/S "rarely"

- all types of delivery cause some degree of genital tract trauma in form of perineal &
vaginal tear " most common after forceps delivery"

- rare : if delivery occurred before fully dilated cervix

 causes :
 Forceps extraction
 breech extraction
4. Thrombotic : clotting disorders "more rarely"
- women with Von-Willebran's disease or PLTs disorders excessive blood loss

- consumptive coagulopathy as a result of another obstetric complications :

[ massive placental abruption ,unidentified died fetus , amniotic fluid embolus , massive
hemorrhage ]

5. Traction "uterine inversion"

B. 2ry PPH
1. Retained products of conception "commonest cause"
2. intrauterine infection "endometriosis"
3. Choriocarcinoma

 Diagnosis :
 Early recognition of blood loss
 rapid action
 appreciation of risk factors
 accurate estimation of blood loss
 recognition of maternal cardiovascular compromise
 symptoms :anxiety , thirst , nausea , cold, pain, dizziness
 General examination : a variable degree of shock is present , according to amount of
blood loss .
[ reduced urine output – tachypnea-tachycardia-hypotension-narrow pulse pressure ]
 Abdominal examination :-
- rising fundus
- peritonism
-in atonic PPH : the uterus is soft and enlarged than expected leads to gush of
clotted blood per vagina
- in traumatic PPH : the uterus is firm & well contracted
 Local(vaginal) examination :
- atonic :
Bleeding start after minutes form delivery of fetus
Dark & red color
The placenta may not be delivered
- Traumatic :
bleeding start immediately after delivery of fetus
Bright & red color
lacerations can be detected
  Management :
 Prophylactic treatment :
A. Antenatal :
- treatment of anemia
- Pt. at high risk of PPH Instruct that delivery must be at hospital
B. Intrapartum :
- Expect PPH in vulnerable groups
- Active management of third stage of labour
- After the placenta is delivered;
 Active treatment :
1. Call for help [ Senior obstetrician, Anesthetist, senior midwife, porter ] "First Action" .
2. Resuscitate using ABC "First Line"+ High-flow O2 administration by mask + two large
bore cannula
3. Blood drawn for blood grouping, cross-matching 6 units at least , baseline hematology
and biochemistry
4. IV crystalloid fluids
5. Foly catheter into bladder & fluid balance chart
6. Blood transfusion : Uncross matched same group as mother or extreme case O –ve
7. Try to identify the cause
Hx
-
Ex
-
8. If Atonic PPH :
A. Give Uterotonic drugs e.g. PGs , Oxytocin …
B. If failed; apply a uterine massage
C. If failed; perform Bimanual uterine compression ( If contraction appear , maintain for
5 minutes )
D. If failed; perform uterine tamponade or balloone cateter
E. If failed; transport to operating theater, in which these procedures are performed :
1. Re-evaluation
2. Laparotomy ( B-Lynch suturing – Multiple sutures in uterus )
3. Bilateral ligation of Uterine artery
4. Bilateral ligation of internal iliac artery
5. Hysterectomy "Last"
 Complications :
A. Immediate
1.
B. Late

*‫*إضافات على التفريغ من شرح الدكتورة‬

🔰 *Vasa pravia*
Uterine apoplexy or couvelaire uterus : Black colour of uterine wall as result of
Extravastion of blood through the layers of uterus until it reach serosa (Unique
complication)

🔰 *Postpartum hemorrhage*
🔴 Practical definition:
- Any bleeding associated with sings & symptoms of Cardiovascular compromise

- sings & symptoms of Cardiovascular compromise

1- Tachycardia ( First sign )
2- Low BP (late sign)
3- Nasuea and vomiting after labor
4- Felling faint (syncopal attack )
5- pallor
6- Slow capillary refill : takes > 2 sec , (normally <2 sec)
🔴 Complication:
- Short term
1) Anemia
2) Hypovolemic shock
3) Renal failure
4) Poumnary odema
- Long term:
1) shehan’s syndrome
2) puerperal sepsis
3) chronic anemia
🔰 *Retained placenta*
🔴 Def: Failure to delivery of placenta ( after 30 min )

🔴 Stage of delivery of placenta:

1- Separation
2- Desend
3- expulsion

🔴 Types :
1- Retained Separated
2- Retained Unseparated

🔴 Retained Separated :
- Defect in descend & expulsion staged

- Causes: ( No contraction)
1) Uterine atony
2) Contraction ring

- Dx:
1) Vaginal bleeding
2) Uterus somewhat contracted

🔴 Retained Unseparated :
- Defect in separation

- Causes:
1) Uterine atony
2) Morbid adherent placenta

- Dx:
1) No Vaginal bleeding
2) Uterus soft

🔴 Management:
1) Embty the bladder (Fisrt line )
2) Retroatoinc drugs
3) Apply gentle traction of cord
4- Operation room ( Manual removal ) under general anesthesia

🔰 *Uterine inversions ;*

🔴 Defined as descending of the uterine fundus into the uterine cavity , cervix or
vagina , or protruded from vagina
🔴 Causes:
1- miss managed 3rd stage ( retracting the cord while the placenta is still attached )
2-short cord(fundal placenta)
3- Morbid adherent placenta

🔴 Degree of uterine inversion depends on the descending (to which part )

1st degree -descend to uterine cavity
2nd degree -descend to cervix
3rd degree -descend to vagina
4th degree - descend both uterus with vagina

🔴 Diagnosed by :
1- Signs of CVS collapse
- Hypovolemic shock due to bleeding
- Neurogenic shock due to traction of sympathetic system ( tracrion on sympathatic
nerve)
2- Hemorrhage
3-Inverted uterus
4-Felling of dimple

- P/A : lack palpable uterus , feeling of dimple

🔴 Management:
1. Resuscitate using ABC
2. If the placenta is still attached don’t remove the placenta until replacing the uterus
3. Immediate Manual replacement
4. Replace under anesthesia
5. Hydrostatic pressure ( fluid causing ballooning of the vagina and correction of
inversion )
6. Surgical procedure by roand ligament
🔴 *‫*تعديل‬
Uterine apoplexy - Complication of *Placenta aperture*