POSTPARTUM

COLLAPSE
Dr.Fath Elrahman Elrasheed
Assistant professor & Consultant
 Definition
Definition
Postpartum Collapse is the onset of shock in the
immediate period following delivery of the fetus.
It is a major cause of maternal mortality and
morbidity in both developed and developing
worlds.
 Aetiology
Aetiology
Obstetric causes:
 Postpartum hemorrhage (PPH).
 Eclampsia
 Amniotic fluid embolism
 Uterine inversion
 Uterine rupture
Incidental causes:
 Pulmonary embolism.
 Vasovagal attacks.
 Epileptic convulsions.
 Cardiac arrhythmias.
 Cardiac arrest.
 Cerebrovascular accident.
 Septic shock.
 Iatrogenic.
Postpartum Hemorrhage

(PPH)
 Definition Definition
Primary postpartum haemorrhage is defined as the
loss of 500 mL of blood from the genital tract
following, but within the first 24 hours of, delivery
of the baby.
Secondary PPH is defined as abnormal or excessive
bleeding from the birth canal between 24 hours and
12 weeks postnatally
PPH can be minor (500–1000 ml) or major (more
than 1000 ml). Major could be divided to moderate
(1000–2000 ml) or severe (more than 2000 ml).
 INCIDENCE
Obstetric haemorrhage remains one of the major
causes of maternal death in both developed and
developing countries.
The incidence is 5% of all deliveries
 Aetiology of PPH
The causes of primary postpartum hemorrhage can
be thought of as the four Ts:

Tone
Tissue
Trauma
Thrombin
 Aetiology of PPH
Tone
 Uterus over-distension: Multiple pregnancy, macrosomia,
polyhydramnios, fetal abnormalities (hydrocephalus)
 Uterine muscle fatigue: Prolonged/precipitate labour,
high parity, previous pregnancy with PPH
 Uterine infection/chorioamnionitis: Prolonged SROM,
fever
 Uterine distortion/abnormality Fibroid uterus, placenta
previa
 Uterine relaxing drugs: Anaesthetic drugs, nifedipine,
NSAIDs, beta-mimetics, MgSO4
 Aetiology of PPH
Tissue

 Retained placenta/membranes: Incomplete

placenta at delivery, esp. 24weeks
 Abnormal placenta-succinturiate / accessory
lobe: Previous uterine surgery, abnormal
placenta on ultrasound
 Aetiology of PPH
Trauma
 Cervical/vaginal/perineal tears: Precipitous
delivery, manipulations at delivery, operative
delivery, episiotomy esp. mediolateral
 Extended tear at CS: Malposition, fetal
manipulation, e.g., version of second twin, deep
engagement
 Uterine rupture: Previous uterine surgery
 Uterine inversion: High parity, fundal placenta,
excessive traction of cord
 Aetiology of PPH
Thrombin
 Pre-existing clotting abnormality e.g., hemophilia/ vWD/
hypofibrinogenemia: History of coagulopathy/liver disease
 Acquired in pregnancy: High BP, bruising
 ITP:Fetal death, fever, raised WCC
 PET with thrombocytopenia (HELLP):APH, sudden
collapse
 DIC from PET, IUD, abruption, severe infection/sepsis
 Dilutional coagulopathy from massive transfusions
 Anticoagulation: History of DVT/PE, aspirin, heparin
 Aetiology of secondary PPH
Retained placental fragments,membranes,blood clots, placental
polyp.
Infections:
 Separation of infected retained products.
 Infected C/S wound.
 Infected genial tract laceration.
 Infected placental site.
Fibroid polyp (Necrosis & sloughing of the tip).
Subinvolution of the uterus.
Local Gyne lesion i.e. Cervical ectopy.
Choriocarcinoma.
Uterine inversion.
 RiskforFactors
Risk factors PPH of PPH
Patient presenting antenatally and associated with
increase in the incidence of PPH:
 Suspected or proven placental abruption
(Thrombin)
 Known placenta praevia (Tone)
 Multiple pregnancy (Tone)
 Pre-eclampsia/gestational hypertension (Thrombin)
 Previous PPH (Tone).
 Asian ethnicity (Tone).
 Obesity (BMI >35) (Tone)
becoming apparent during labour and delivery:
 Delivery by emergency C-section (Trauma)
 Delivery by elective caesarean section (Trauma)
 Induction of labour
 Retained placenta (Tissue)
 Mediolateral episiotomy (Trauma)
 Operative vaginal delivery (Trauma)
 Prolonged labour (> 12 hours) (Tone)
 Big baby (> 4 kg) (Tone/trauma)
 Pyrexia in labour (Thrombin)
 Age (> 40 years, not multiparous) (Tone)
 Management
Managment:
Call for help
Resuscitation:
 A and B – assess airway and breathing: A high
concentration of oxygen (10–15 l/minute) via a
facemask should be administered.
 Evaluate circulation: Establish two 14-gauge
intravenous lines; 20 ml blood sample should be
taken and sent for diagnostic tests, including full
blood count, coagulation screen, urea and
electrolytes and cross match (4 units).
 Position flat.
 Keep the woman warm using appropriate available
measures.
 Transfuse blood as soon as possible.
 Until blood is available, infuse up to 3.5 litres of
warmed crystalloid Hartmann’s solution (2 litres)
and/or colloid (1–2 litres) as rapidly as required.
 The best equipment available should be used to
achieve RAPID WARMED infusion of fluids.
 Special blood filters should NOT be used, as they
slow infusions.
 Recombinant factor VIIa therapy should be based on
the results of coagulation.
Fluid therapy and blood product transfusion :
 Crystalloid :Up to 2 litres Hartmann’s solution
 Colloid :up to 1–2 litres colloid until blood arrives
 Blood :Crossmatched, If crossmatched blood is
still unavailable, give uncross matched group-
specific blood OR give ‘O RhD negative’ blood
 Fresh frozen plasma 4 units for every 6 units of
red cells or Prothrombin time/activated partial
thromboplastin time > 1.5 x normal.
 Platelets concentrates if PLT count < 50 x 109
 Cryoprecipitate If fibrinogen < 1 g/l
 Emergency Trolley

Emergency protocols

Endotracheal tube
GENERAL MANAGEMENT Laryngoscope

Essential drugs

Crystalloids, giving sets, haemacel

 PHARMALOGICAL Management
PHARMACOLOGICAL TREATMENT

 Syntocinon 5 units by slow intravenous injection

(may have repeat dose).
 Ergometrine 0.5 mg by slow intravenous or
intramuscular injection (contraindicated in
women with hypertension).
 Syntocinon infusion (40 units in 500 ml
Hartmann’s solution at 125 ml/hour) unless fluid
restriction is necessary.
 Carboprost 0.25 mg by intramuscular injection
repeated at intervals of not less than 15 minutes
to a maximum of 8 doses (contraindicated in
women with asthma).
 Direct intramyometrial injection of carboprost 0.5
mg (contraindicated in women with asthma), with
responsibility of the administering clinician as it is
not recommended for intramyometrial use.
 Misoprostol 1000 micrograms rectally.
Bimanual Compression
Bimanual Compression
 Surgical
Surgical: Management
 Balloon tamponade
 Haemostatic brace suturing (such as using
procedures described by B-Lynch or modified
Compression sutures)
 Bilateral ligation of uterine arteries
 Bilateral ligation of internal iliac (hypogastric)
arteries
 Selective arterial embolisation.
 Hysterectomy
 TAMPONADE TEST
Therapeutic & Prognostic
For severe PPH

Oesophageal
balloon
Stomach balloon

Condous G, Arulkumaran S et.al.

Obstetrics & Gynecology. 2003
 Complications
Complications of PPH
 Maternal death in 10% of PPH.
 Acute renal failure.
 Embolism.
 Sheehan's syndrome.
 Sepsis.
 Aneamia.
 Failure of lactation.
Amniotic Fluid Embolism
 Definition
Amniotic Fluid Embolism
AFE is a sudden and unexpected rare but life
threatening complication of pregnancy
Over all incidence range from 1 in 8,000 to 1 in
80,000 pregnancies
AFE is thought to occur when amniotic fluid, fetal
cells, fetal hair or other debris entre the maternal
circulation.
 Time ofevent:
Time of events
70% occur in labour.

11% after vaginal delivery.

19% during or after LSCS.

 Risk FactorsRisk Factors
Tumultuous labor (placenta abruption)
Prolonged labor
Induction/augmentation of labor( oxytocin
hyperstimulation).
Trauma
Cesarean delivery
Multiparty
Advanced maternal age
Operative vaginal delivery
Hydramnios
 Uterine rupture
 Multifetal gestation
 Male fetal sex
 Eclampsia
 Allergy history
 Clinical
Clinical Presentation
Presentation
 Acute onset of shortness of breath
 Sudden hypotension
 Hypoxia and or oxygen desaturation
 Diffuse coagulopathy
 Ominous fetal heart rate pattern (profound
bradycardia and loss of variability)
 Seizures
 Cardiopulmonary arrest
 Death
 Diagnosis
Diagnosis
Diagnosis of EFA is suspected when pt suddenly
collapse either in labour or shortly after delivery
with signs of central cyanosis
Confirmation of the diagnosis can be made on
examination of lung tissue at post-mortem or on
examination of blood film for the presence of
squames cells or fetal hair
 Investigations:
Investigations
General:
 CBC
 CHEST X-RAY
 ECG
 ECHO
Specific:
 Serum tryptase
 Zinc coproporphyrin
 Cevical histology
 Management
Management
Initial management = ABC’s
 Two large bore IV cannulae
 Urine output monitored via catheter
 Portable CXR and ECG
 Invasive haemodynamic monitoring
 PEEP, dopamine, frusemide, fluids
 Aggressive treatment of bronchospasm
 Ensure multidisciplinary approach – may need to
involve:
 Consultant obstetrician
 Senior obstetric anaesthetist
 Haematologist
 Intensivist (ITU specialist)
 Transfer to HDU/ITU when resuscitated or post-
delivery
 Watch for worsening DIC and severe PPH
ECLAMPSIA
 Definition
ECLAMPSIA
It is the development of convulsions in a pre-
existing pre-eclampsia.
Incidence>About 1/1000 pregnancies.
The exact cause is unknown but cerebral
ischaemia and odema were suggested.
 Clinical Presentation
ECLAMPSIA>Clinical Picture
Premonitory stage: the eyes are rolled up with twitches of the
face and hands. It lasts for about ½ min.
Tonic stage: generalised tonic contraction of the whole body
muscles with opisthotonus and cyanosis. It lasts for about ½ min.
Clonic stage: convulsions occur where there is alternative
contraction and relaxation of the body muscles. The face is
congested, tongue may be bitten, blood-stained frothy saliva
appears on the mouth, breathing is stertorous, urine and stool
may pass involuntarily, temperature rises due to increased
muscular activity patient is unconscious. This lasts for about 1
min.
Coma: it may last for few hours.
 Incidence
ECLAMPSIA>Types
Antepartum Eclampsia 38%.
Intrapartum Eclampsia 18%.
Postpartum Eclampsia 44% occurs within 48 hours
of delivery. It is usually the most dangerous one.
 Severity of Eclampsia
Severity of Eclampsia
Eclampsia is considered severe if one or more of
the following is present (Eden’s criteria):
 Coma of 6 or more hours.
 Temperature 390C or more.
 Pulse over 120/min.
 Systolic blood pressure over 200 mmHg.
 Respiratory rate over 40/min.
 More than 10 convulsions.
 Management
ECLAMPSIA>Management
General measures:
 Hospitalisation
 Efficient nursing
 After sedation, a self-retained Foley’s catheter
is applied.
 Care for respiratory system
 The tongue is protected from biting by a plastic
mouth gauge.
 Observation for: Maternal vitals& FHS
 Management
ECLAMPSIA>Management
Medical measures:
 Sedation.
 Antihypertensive.
 Anticonvulsant therapy.
 Management
ECLAMPSIA>Management
Obstetric measures
 The policy is that there is no conservative treatment in
Eclampsia and the patient should be delivered but
convulsions should be controlled first.
 Spontaneous labour usually commences within 6
hours. If not induce labour by oxytocin as long as there
is no other indication for caesarean section and vaginal
delivery is anticipated within 8-12 hours. Otherwise,
caesarean section is indicated but never give general
anaesthesia before control of convulsions or if the
patient is in coma.
Uterine inversion
 Definition
Uterine inversion
Inversion of the uterus is rare, occurring with incidence
of one in 10,000 pregnancies.
It may be due to:
 Mismanagement of the third stage, either by
inappropriate traction during CCT or too rapid removal of
the placenta during manual removal.
 Maternal age > 25 years.
 Sudden rise in intra-abdominal pressure in the presence
of a relaxed uterus.
 Fundally placed placenta with a short umbilical cord.
 Even without haemorrhage the mother may become
profoundly shocked.
 EXAMINATION
Patient present with a picture of shock in the
absence of visible blood loss. This due to
neurogenic origin secondary to traction on
adjacent to the uterus
The fundus of the uterus may be visible at the
introitus; however, if not, it will be detected on
vaginal examination
 Management
Management
Managing a shock patient and then replacing the
uterus as soon as possible.
The uterus replaced manually prior the onset of
shock.
If failed: Osullivan hydrostatic technique(4-5 L of
saline).
Laparotmay and Haultain procedure.
If the uterus is correctly sited, a syntocinon infusion
should be commenced to encourage contraction of
the uterus