POSTPARTUM HEMORRHAGE : A

CASE STUDY
Muhammad Redzuan bin Jokiram 030.08.281 Nadirah bt Roslan 030.08.288 Advisor: dr. Rhabbi, Sp.OG

IDENTITY
Name: Mrs W

Age: 22 yrs
Occupation: full time housewife

Religion: Islam
Address: Desa Karajan, Sirnabaya, Teluk Jambe Timur, Karawang Race: Sundanese Admittance: 16th October 2013

Main complaint: Additional complaint:

midwife referral for premature rupture of membrane for 12 hours prior to arrival. Irregular tightening with no other symptoms of labor

HISTORY OF PRESENT DISEASE

Patient, a G1P0A0 of term pregnancy came to RSUD Karawang with a midwife referral for carrying a term baby with premature rupture of membrane. She admits to having leaking liqour for about 12 hours prior to arrival. She also admits that she is having an irregular contractions for 3 hours prior to arrival. She has no vaginal bleeding nor fever. She admits of having vaginal discharge throughout her pregnancy. The discharge is foul smelling, yellowish in colour and adherent.

MENSTRUAL HISTORY
LMP: 6th January 2013 ED: 13th October 2013 GA: 40 wks Menarche: 15 y.o Menstrual cycle: regular (28-30 days), for 4-5 days, 3 pads/day, dismenorrhea (-) ANC: 4x TT: 2x

HISTORY OF MARRIAGE & PAST PREGNANCY

Status married for 2 years

Marital age 20 y.o

G1P0A0: Present pregnancy

HISTORY OF OTHER ILLNESSES

Hypertension (-) Asthma (-) DM (-) Heart Disease (-) Seizure (-)

HISTORY OF CONTRACEPTION

CONTRACEPTION (-)

GENERAL CONDITION

APPEARANCE

MODERATELY ILL

CONCIOUSNESS

FULL OF CONSCIOUSNESS

VITAL SIGNS

BLOOD PRESSURE 110/70 mmHg

PULSE 88x/min

RESPIRATION 20x/min

TEMPERATURE 36.9 C

HEAD EYES

Normochepaly, black hair and good distribution Anemic conjungtiva (-/-), Icteric sclera (-/-) Hiperemic (-/-), Tenderness (-/-), Secret (+/+) Septum deviation (-), Hiperemic concha (-/-), Secret (-/-), Mass (-/), Nostril breathing (-)
Red lips (+), Dry (-), Tongue (N), Arcus faring (N), Tonsil (N), Posterior pharyng (N)

EARS NOSE
MOUTH NECK

Limph node : enlargement (-), Tenderness (-); Thyroid gland : enlargement (-), tenderness (-)

THORAX - HEART
INSPECTION
ICTUS CORDIS VISIBLE

PALPATION
ICTUS CORDIS PALPABLE AT ICS V LEFT PARASTERNAL LINE

PERCUSSION
RIGHT HEART BORDER ICS III-V RIGHT STERNAL LINE LEFT HEART BORDER ICS V 1cm RIGHT LATERAL MIDCLAVICULA STERNAL LINE UPPER LEFT HEART BORDER ICS III LEFT PARASTERNAL LINE

AUSCULTATION
REGULAR I II HEART SOUND MURMUR (-) GALLOP (-)

THORAX - LUNG
INSPECTION
SYMMETRIC SUPRACLAVICULA RETRACTION (-) INTERCOSTAL RETRACTION (-)

PALPATION
EQUAL VOCAL FREMITUS

PERCUSSION
SONOR IN BOTH LUNG

AUSCULTATION
VESICULAR BREATH SOUND IN BOTH LUNG RONCHI (-/-) WHEEZING (-/-)

ABDOMEN
INSPECTION
DISTENDED AS PER PREGNANCY

PALPATION
UNDULATION (+) PAIN ON PALPATION (-) LIVER AND SPLEEN NOT PALPABLE

PERCUSSION
PAIN ON PERCUSSION (-) SHIFTING DULLNESS (-) CVA (-/-)

AUSCULTATION
BOWEL SOUND (+) ARTERIAL BRUIT (-) VENOUS HUM (-)

EXTREMITIES

OEDEMA

Warm Acrals

+ +

+ +

OBSTETRICS STATUS

Fundal height: 32cm, Fetal heartbeat: 150 bpm

Inspection: portio smooth, livide, closed ostium, fl (), flx (-),valsava (+) amniotic fluid (+).

Genitals: v/v calm, w.o abN

VE : cervix position posterior, consistency: firm, effacement 2cm, dilation 1cm, Hodge I-II, membrane absent

PEMERIKSAAN LEOPOLD
Leopold II- smooth hard part on the right side, and small parts on left side identified as back and limbs respectively

Leopold I- fundal position: felt round and soft, identified as breech

Leopold III : lowest part: smooth, hard, round and ballotable part identified as head

Leopold IV: examiners hands form a convergent shape, descended 4/5 in the pelvic inlet

ADJUNCT TESTS (05/06/13)

Hb: 11,5g/dl Leu: 11210/mm3 Tr: 433.000/mm3 Ht: 34.4% HbsAg: -ve Random blood glucose: 68 mg/dL

USG

BPD 94.8mm

HC 314.7mm

AC: 329 mm AFI : 4

FL: 77mm
EFW 3361g

WORKING DIAGNOSIS
G1P0A0 term pregnancy, singleton live cephalic presentation. Premature rupture of membrane (PROM) Oligohydramnios

MANAGEMENT

Observe vital signs, His, and FHR per hour Recheck labor progress after 8hrs Observe the signs of chorioamnionitis and cord compression Check for CBC, UL, ABO and rhesus incompatibility, BT/CT, HbsAg CTG non reassuring: emergency LCSC
- reassuring : vaginal delivery

CTG-REASSURING

CTG-REASSURING: VAGINAL DELIVERY

Induced labour (misoprostol 4x25mcg every 6 hours)

16/10/13 10.00PM: misoprostol I 25mcg/pv

17/10/13 4 .00 AM Misoprostol II 3cm.

10.00 AM Misoprostol III 3cm

4.00 PM Misoprostol IV

Perinelal lacerations-2nd degree>Perineorraphy

5 i.u oxytocine i.m, placenta is completely born

11.10 PM lfully dilated Ssecond stage of labour->the baby was born

10.00PM 6cm CTG->reassuring ->acceleration of labour: iv infusion of oxytocin 20 IU in RL 500cc-

POST PARTUM HEMORRHAGE

11.20 PM: S:massive vaginal bleeding O:Vital signs: BP 110/70mmHg PR:98x/m, Obs status: FH: 2 fingers above the umbilicus, not firmly contracted, active bleeding A : PPH

DIAGNOSIS P1A0 post spontaneous vaginal birth Post partum hemorrhage secondary to uterine atony

P: A: patent
B: spontaneously C: BP : 110/70mmHg, PR : 98x/m IVFD 2 lines: -RL 500CC -RL 500CC+oxytocin 20 IU D : GCS : 15

Administration of uterotonics drugs Misoprostol 1000mcg Methergin 0.5mg IV

Uterus massagebleeding

Exploration 1) No retained products (e.g:placenta) 2) Perineal lacerationsno active bleeding 3)

Bimanual uterine compression for 3 minutes-uterine began to conract 5 minutes irreguler contractions

Intrauterine balloon tamponade for 24 hours

INSTRUCTIONS Progressive mobilization v/V hygiene Vital signs, contraction and bleeding monitoring/ 15 minutes for the 1st hour FC 1 x 24 hours Ceftriaxone 1 x 2 gram IV Metrodinazol 3 x 500 mg IV Oksitosin 20 IU + 500 cc RL 8 tpm Methergin 3 x 1 amp Misoprostol 3 x 1

FOLLOW UP (24/05/2013)
S: breastmilk (+/+), micturition (+), excrement (-), flatus (+), bleeding (-), pain at perineorraphy site is mild O: BP 110/80mmHg, HR 84x/, RR 20x/, T 36,8C GC : CM, in normal range Obstetrics status: lactation (+/+), uterine fundal height 1 fbu, uterine contraction sufficient. v/v: calm, active bleeding (-), lochia rubra (+) A: PPH secondary to uterine atony in P1A0 Post partum P: Observe VS, pain, Mefenamic acid 3 x 500 mg, SF 1 x 24 hrs, ceftriaxone 1x1g, oxytocin 20IU in 500 ml RL, methergin 1x1amp, misoprostol 3x1

CASE DISSCUSSION
1)DIAGNOSIS 2) MANAGEMENT

CASE DISCUSSION : DIAGNOSIS G1P0A0 TERM PREGNANCY, SINGLETON LIVE

CEPHALIC PRESENTATION WITH PREMATURE RUPTURE OF MEMBRANE AND OLIGOHYDRAMNIOS Gravidity: total number of 1st time of pregnancy and pregnancy regardless of never had an abortion its outcome, including She admitted of full term present one pregnancy and from her Parity : number of live LMP her gestational age births and stillbirths is 40 weeks delivered after stage of Leopold III : lowest part: viability smooth, hard, round and Term : 37-42 weeks ballotable part identified as head Cephalic presentation

Premature rupture of membrane: spontaneous rupture of membrane before onset of labor Oligohydramnios defined as an AFI of 5 cm or less

There was an evidence of leaking liqour prior, irregular contractions and no bloody show means the patient was not in labor Oligohydramnios because AFI=4 as PROM is the most possible cause

CASE DISCUSSION : MANAGEMENT

Complications from PROM 1) maternal : chorioamnionitis, sepsis, dystocia 2) fetal : hypoxia, asphyxia, neonatal sepsis, IUFD.

Monitoring 1) Vital signs , His, FHR/hour, Delivery progress/8 hours Signs of chorioamnionitis and cord compression

CTG as a method of monitoring FHR and maternal uterine contraction.

To find any abnormality such as anemia, hypoglycemia, blood group, infection and etc.

Laboratory work up: CBC UL Random blood glucose ABO and rhesus incompatibility BT/CT, HbsAg

The use of prophylactic antibiotics may prevent the progression of a subclinical infections to clinical amnionitis.

Administration of Ceftriaxone 1 x 1 gram I.V

Induction implies stimulation of contractions before the spontaneous onset of labor, with or without ruptured membranes Indications include immediate conditions : ruptured membranes with chorioamnionitis or severe preeclampsia Contraindications to induction : Fetal factors include appreciable macrosomia, multifetal gestation, severe hydrocephalus, malpresentation, or nonreassuring fetal status

There was an evidence of PROM The induction using misoprostol because the PS is 3 which means the cervis is infavourable and the CTG is reassuring

CASE DISCUSSION: DIAGNOSIS

POST PARTUM HEMORRHAGE

PPH is defined as blood loss in excess of 500 ml in time of vaginal delivery after completion of the third stage of labor Cesarean delivery > 1000ml Early PPH : bleeding within the 1st 24 hours after delivery Late PPH : after 24 hours of delivery

Loss of 700 ml from the genital tract after 15 minutes of delivery.

CASE DISCUSSION: MANAGEMENT

The common cause for PPH are 4Ts: 2 Tone-uterine atony Trauma-genital tract trauma Tissue-retained products of conceptions or blood clot. Thrombincoagulopathy

In PE : hypotonic uterus Grade II perineal ruptureperrineoraphy with no active bleeding No retained conception products , e.g: placenta BT/CT within normal range

Once PPH has been identified,management involves four components, all of which must be undertaken SIMULTANEOUSLY: communication, resuscitation,monitoring and investigation, arresting the bleeding A primary survey of a collapsed or severely bleeding woman should follow a structured approach of simple ABC,

Primary survey and resuscitation: A : patent B : spontaneousO2 6L/minute C : PR : 98, BP: 110/70mmHG 2 lines IVFD D : GCS : 15

When uterine atony is perceived to be a cause of the bleeding, the following mechanical and pharmacological measures should be instituted, in turn, until the bleeding stops: Bimanual uterine compression (rubbing up the fundus) to stimulate contractions. Ensure bladder is empty (Foley catheter, leave in place). 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.

Bimanual

uterine compression

Misoprostol 1000 micrograms rectally 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 500ml Hartmanns solution at 125ml/hour) unless fluid restriction is necessary.

Uterotonics 1) oxytocin20 IU in 500ml RL 2)Misoprostol 1000 mcg 3) Methergin0.5 mg im.

If pharmacological measures fail to control the haemorrhage, initiate surgical haemostasis sooner rather than later. Intrauterine balloon tamponade is an appropriate firstline surgical intervention for most women where uterine atony is the only or main cause of haemorrhage. If this fails to stop the bleeding, the following conservative surgical interventions may be attempted, depending on clinical circumstances and available expertise: 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.

Intrauterine balloon tamponade

RESUME

Female, 22 y.o, G1P0A0, GA 40 weeks, presenting with premature rupture of membrane. She admits to having leaking liqour for about 12 hours prior to arrival. She also admits that she is having an irregular contractions for 3 hours prior to arrival. She has no vaginal bleeding nor fever. She admits of having vaginal discharge throughout her pregnancy. The discharge is foul smelling, yellowish in colour and adherent. Fetal movement is active. With induced labor, born a baby girl, 3400g, 49cm, with complete placenta delivery and grade II perineal rupture.15 minuter after the delivery, patient had a post partum hemorrhage with estimated blood loss of 700ml. Physical examination revealed: 1.Vital signs: BP 110/70mmHg, HR: 98x/, RR: 20x/, T: 36,15C 2. General status in normal range Obs status: FH: 2 fingers above the umbilicus, not firmly contracted, active bleeding

CONCLUSION

Obstetric haemorrhage remains one of the major causes of maternal death in both developed and developing countries

The most common cause of primary PPH is uterine atony

The practical management of PPH may be considered as having at least four components: communication with all relevant professionals; resuscitation; monitoring and investigation; measures to arrest the bleeding

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