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Postpartum Haemorrhage: Causes & Treatment

What is Postpartum haemorrhage? Postpartum haemorrhage (postnatal bleeding) is the excessive bleeding from the woman’s genital tract of about 500mls or more following childbirth. Or it can be seen as any amount of bleeding occurring after the birth of the baby which deteriorates the maternal health state following birth of the baby up to 6 weeks after birth Postpartum haemorrhage is the one of the types of obstetric haemorrhage. Remember that obstetric haemorrhage is defined as the blood loss during pregnancy, labour or within the days of pregnancy termination (delivery or abortion). Obstetric haemorrhage accounts 25% of maternal death globally and 90% in developing countries — which are often attributed to DELAY and lack of proper facility for obstetric emergencies. This article would be very lengthy. Hence, consider the table of contents below for quick overview: Signs and symptoms of PPH Causes of Postpartum Haemorrhage (PPH) PPH is caused by 4 “T” s as follows: Tone, Trauma, Tissue and Thrombin. Tone: This is most common cause of post-partum haemorrhage. It is bleeding due to lack of uterine muscle tone, interfering with contraction of the uterus. It is known as uterine atony and predisposing factors are; Trauma: Tissue: Thrombin: Coagulation failure interfering with blood clotting mechanism e.g., DIC Risk factors of PPH Alternatively, PPH is associated with: Before delivery After delivery How common is postpartum haemorrhage? PPH occurs in less than 1% of all births and constitutes the key leading cause of maternal death. PPH remains one of the major obstetric concerns because of the following: Types of postpartum haemorrhage (PPH) Post-partum haemorrhage may be primary or secondary. Primary postpartum haemorrhage Primary Post-Partum Haemorrhage is defined as excessive blood loss from genital tract greater than 500ml occurring during third stage of labour till with 24 hours after delivery. It is a haemorrhage occurs during the third stage of labour and within 24hours of delivery Secondary postpartum haemorrhage Secondary PPH is the abnormal or excessive bleeding from the genital tract after 24hours to about 6-8weeks postpartum period. It is an excessive bleeding after 24hours of birth but within 42 days of the puerperium. Secondary postpartum haemorrhage otherwise called puerperal haemorrhage is far more likely to occur within 10-14 days after delivery but tends to be less severe when compared to primary postpartum haemorrhage. Symptoms of secondary postpartum haemorrhage Secondary PPH may be associated with these: Causes of Secondary PPH Note: The cervical os usually remains patent (opened) when something is retained in the uterus. Secondary postpartum haemorrhage management Vulval haematoma Vulval haematoma is a condition where there is a concealed traumatic haemorrhage into the connective tissues of the vulva and vaginal wall. It is caused by rupture of subcutaneous vessels, which can manifest few hours after delivery. While a small vulval haematoma may be attributed to repair of medio-lateral episiotomy or laceration. Woman with vulval haematoma usually complains of discomfort and pain in the labia and/or perineum. The skin of labia becomes thin —making haematoma to bulge into the vagina. How to treat vulval haematoma Complications of Postpartum haemorrhage Principles of management of Postpartum haemorrhage Principles for managing PPH include the following: Resuscitation (and Rapid Assessment) Calling for medical aid is an important first step to take. Once PPH occurs after delivery, send for obstetrician or a doctor while you get everything in control before the arrival of the doctor there is no problem. Reason for sending aid on time is that the woman’s condition may worsen and the woman may lose her life within few hours. If you are in the community, plan to refer the woman to hospital as you take initial measures to stop the bleeding Stop Bleeding: This involves the following steps: Rub uterus to Contraction: Give uterotonics Empty the uterus Once the uterus is contracted, the midwife ensures that uterus is empty. If the woman is not shock Specific Treatment Treatment depends on the identified. Oxytocin is the drug of choice to administer especially for treating haemorrhage due to uterine atony. Give loading dose of 10IU intramuscularly and 20 – 40 units into infusion to run at the rate of 60 drops per minute maintenance dose of 20IU at 60 drops per unit Second Drug – Ergometrine if oxytocin is not available but is contraindicated in heart problems. Third Drug – Misoprostol General management Rapid Assessment and Resuscitation of the Woman Therefore, there may be need to catheterize the woman. Monitor vital signs every 15 minutes until patient’s condition stabilizes. If the woman is transferred from another place take history of bleeding Note: On no account should a woman in shock be moved before resuscitation and her condition stabilizes. Treatment of the specific cause When the cause of bleeding is identified treat the cause. If it is uterine atony that does not respond to oxytocin do bimanual compression of the uterus. If it is retained placenta – do manual removal of placenta Prevention of Postpartum Haemorrhage Predicting who will have post-partum haemorrhage is not the best approach; rather taking preventive measures can save a lot of lives. Despite efforts of health workers, PPH may still occur, but quick diagnosis and prompt effective treatment can save life. Routine preventive actions should be offered to all women from pregnancy till immediate post-partum period as follows: During Antenatal Care During Labour and Second Stage During Third Stage After Delivery of the Placenta

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Ectopic pregnancy: Causes, Management and prevention

Obstetrics / Tofort Online

What is an ectopic pregnancy? Ectopic pregnancy is otherwise known as extrauterine pregnancy — meaning a pregnancy where implantation occurs at sites other than the uterine cavity. That’s, it is a pregnancy that occurred when the fertilised egg embeds or implants outside the uterus(e.g. ampulla or cervix). It is an emergency obstetric condition that requires prompt and appropriate treatment of the woman. Early diagnosis and treatment tend to reduce its life-threatening outcomes such as uterine tube rupture, haemorrhage or shock, or even deaths. How common is ectopic pregnancy? About 1% of all pregnancies are ectopic or extrauterine. Few other women tend to recur ectopic pregnancy in subsequent pregnancy especially if its underlying cause is not treated or removed. Sites for ectopic pregnancy Types depend on where the ectopic pregnancy is found or site of implantation and may include: In tubal pregnancy, the implantation can occur anywhere along the Fallopian tube but ampulla is the commonest site, followed by the isthmus and interstitial part (least common) respectively. Physiology of tubal pregnancy During normal intrauterine pregnancy, the blastocyst implants or embeds in the deciduae (pregnant endometrium) and the trophoblast invades or erodes the maternal tissues in order to anchor the developing and growing embryo. In tubal pregnancy, the blastocyst rapidly erodes the tubal epithelium and attaches itself in the muscle layer. The blastocyst grows and expands within the wall, thereby distending the uterine tube. The pressure from the pregnancy and penetration of the trophoblast tends to increase until it results in ruptured ectopic pregnancy. Signs & symptoms of ectopic pregnancy Signs of ectopic pregnancy at 6 weeks are: Acute symptoms result from the tubal rupture and the related degree of haemorrhage. These symptoms include: Diagnosis Apart from history-taking and using a pregnancy test kit to detect human gonadotropin hormone (hCG) in a woman’s urine — which is a non-sensitive test of pregnancy, ultrasound ectopic pregnancy is also available in most health facilities. Ultrasound can detect or diagnose it early as five to six weeks gestation thereby confirming or ruling out an ectopic pregnancy. Thus, 6 week ultrasound is readily available in both developed or developing countries. What causes ectopic pregnancy? Its causes and risk factors are multifaceted. But the actual cause of extra-uterine gestation is not properly understood. However, the more you have any of these factors below, the higher your chances of having this form of pregnancy. Note: Untreated infection alters the ciliated lining or peristaltic action of the oviducts. It also leaves adhesions both inside and surrounding the Fallopian tube, thereby restricting its normal functions. Ectopic pregnancy treatment The treatment involves either use of chemotherapy or surgery. I shall consider each more deeply: Chemotherapy Methotrexate remains the main chemotherapy for tubal pregnancy. It takes about 32 days for a single dose of methotrexate or 58 days when receiving two doses or more for ectopic pregnancy to resolve. Methotrexate can be injected once a week at the site of the ectopic pregnancy to dissolve it. What to expect after taking methotrexate ? Methotrexate otherwise known as MTX has a success rate of about 65 to 95% and 67–80.7% fertility rate with delivery after medical treatment for ectopic pregnancy. Common side effects associated with taking methotrexate are: Surgical Interventions If ectopic pregnancy is detected earlier, prompt surgical intervention can be taken to prevent rupture — which is a fatal complication. The surgery are of two types, with aims of removing the trophoblast and preserving the affected tube where possible. The main surgical options are: Partial salpingectomy: salpingectomy remains the treatment option for tubal conception. It involves the removal of part of the tube where ectopic conceptus is found. Salpingostomy: Salpingostomy may be the safest or best choice for ectopic pregnancy, particularly when the obstetrician is making efforts to preserve the affected tube where possible. The surgery involves leaving the tube in a place and removing the ectopic (embryo) through an incision in the wall of the tube with the help of a laparoscope. Laparotomy: This is another surgical intervention for ectopic pregnancy, which usually recommended in obese patients or patients with extensive pelvic adhesion. Success of this surgery depends on the experience and the training of the operator or doctor in laparoscopic surgery. What to expect after the surgery? Once the procedure is carried out under strict aseptic techniques, ectopic pregnancy surgery wounds heals quickly and fertility (ovulation after ectopic pregnancy) is likely to return within 6-8 weeks following the ectopic pregnancy surgery. And unprotected sex within this period is far more likely to result in another pregnancy. The surgery is associated with the increased risk of ectopic pregnancy in subsequent pregnancy especially if the healing process forms scars in the uterine tube. However, women who had this surgery are advised to maintain adequate nutrition, personal hygiene, quit smoking and/or avoid risk factors of ectopic pregnancy, and use safer contraceptives to prevent pregnancy. Tubal abortion: Tubal abortion is more common with ampullary implantation. It occurs when the developing conceptus separates and is expelled through the fimbriated end of the Fallopian tube. Outcomes of tubal pregnancy Bleeding around the embryo results in its demise: The blood clots around the conceptus tend to enclose it, impairing its survival. These products are retained in the uterine tube and may need surgical intervention to remove it. Tubal rupture: The wall of the tube is distended by pregnancy and extensive penetration by the trophoblast results in its rupture. The rupture of the tube may be a gradual or acute episode. Abdominal pregnancy: Abdominal pregnancy is a rare type of ectopic pregnancy— occurring when the fertilized egg embeds in the peritoneal cavity exclusive of tubal, ovarian, or intraligamentary locations. Abdominal pregnancy is a life-threatening condition, characterized by nonspecific symptoms such as nausea and vomiting,abdominal cramps, palpable fetal parts, pain on fetal movement, or displacement of the cervix. It can be situated mainly in the the peritoneal cavity and/or secondary to a ruptured pregnancy (tubal abortion). Life after an Ectopic Pregnancy Early antenatal booking is recommended also for

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5 Hormones of Pregnancy and functions

Obstetrics / Tofort Online

In our previous posts, I have discussed pregnancy: signs and symptoms with diagnostic tips, physiological changes during pregnancy, and complications of pregnancy with their treatments. I will discuss today those hormones of pregnancy responsible for inducing physiological changes in a woman’s systems during pregnancy. Pregnancy hormones play these roles in order to make the woman’s body or uterus conducive for the growing and developing foetus. Without functions of these hormones, miscarriages are likely to result in. Hormones are the biochemical messengers of the body. They are produced by ductless glands, majorly the endocrine system and produce their effects on the targeted organs. Hormones in pregnancy are what produce the physiological and anatomical change in the body of a woman during pregnancy. Here they are: Human chorionic Gonadotropin (hCG) The trophoblast secretes HCG in early pregnancy. This hormone stimulates progesterone and estrogen production by the corpus luteum to maintain the pregnancy until the placenta is developed sufficiently to assume that function. Human Placental Lactogen (hPL) hPL is also called human chorionic somatomammotropin produced by the syncytiotrophoblast. It is an antagonist of insulin. It increases the amount of circulating free fatty acids for maternal metabolic needs and decreases maternal metabolism of glucose to favour fetal growth. Oestrogen It is secreted originally by the corpus luteum, then by the placenta stimulates urine development to provide a suitable environment for the fetus. Oestrogen helps to develop the ductal system of the breasts. Progesterone: It is also produced initially by the corpus luteum, then by the placenta. Progesterone plays the greatest role in maintaining pregnancy. It maintains the endometrium and inhabits spontaneous uterine contractively preventing spontaneous abortion. Also helps to develop the acini cells and lobules of the breast in preparation for lactation. Relaxin Relaxin is a polypeptide hormone weighing about 6000 Da. It is detected in the serum of a pregnant woman at 7-10 weeks gestation and was first described in 1926 by Frederick Hisaw. Its peak occurs within 36-38 weeks of gestation. Relaxin inhibits uterine activity, diminishes the strength of uterine contraction, and aids in softening of the cervix. The hormone relaxes the mother’s muscles, joints and ligaments to make room for the growing baby. The effects of relaxin are highly concentrated around the pelvic region; softening the joints of the pelvis can often lead to pain in the area. In preparation for childbirth, it relaxes the joints and ligaments in the pelvis and softens and widens the cervix. Its primary sources are the corpus luteum of the ovary and placenta. Having the understanding of pregnancy hormones help you to tolerate the minor complaints of pregnancy and to become an expert in your own health. See how pregnancy hormones are causing complications of pregnancy. Thanks for your time. Share to your family and friends.

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Understanding Woman’s Period: Pregnancy, Signs and Diagnosis

Obstetrics / Tofort Online

Definition of Pregnancy This refers to the condition of having a developing embryo or fetus within the body; the state from conception to delivery of the fetus. Medically, it is defined as the union of male and female gametes to zygote which would further undergoes serial cell divisions and be transferred to uterus for implantation and further growth and development. It’s otherwise called conception, gestation or fertilization, The normal duration is 280days (40 weeks or 9 months and 7days) counted from the first day of the last normal menstrual period. Diagnosis of Pregnancy Signs and symptoms of pregnancy are divided into three categories which are: Subjective (Presumptive changes) signs Presumptive signs of pregnancy are symptoms the woman experiences and reports. They can be caused by other conditions, so they cannot be considered as true proof of pregnancy. They include: 6. Quickening: Qickening simply means the mother’s perception of fetal movement. It occurs about 18-20 weeks after the last menstrual period (LMP) in primiparous (a woman in her first pregnancy) and as early as 16weeks in a woman that has been pregnant before (multipara). For the sake of examination and quick remembrance, the subjective signs of pregnancy can be summarized by this acronym, “ANC-QUE”: A: Amenorrhea N: Nausea and vomiting C: Changes in breasts Q: Quickening U: Urinary frequency E: Excessive Fatigue Objective (probable) signs of pregnancy These are non-sensitive indications of conception. They involve changes in the pelvic organs due to increased vascular congestion. They include: Goodell’s signs: softening of the cervix occurring at about six to eight weeks of gestation. Chadwick sign: Bluish, purple or deep red discoloration of the mucous membrane of the cervix vagina and vulva. Hegar’s sign: flexing the body of the uterus against the cervix (i.e. softening of the cervix and the uterine isthmus, occurring at six to 12 weeks of gestation. McDonald’s sign: This is an ease in flexing the body of the uterus against the cervix. Alternative causes are vascular congestion and oral contraceptives Enlargement of the abdomen If it is continuous and accompanied by amenorrhea during the child bearing years, pregnancy might not be the cause. Obesity, ascites, pelvic tumors are alternative causes Braxton Hicks Contractions This is common after the 28 weeks of gestation. Towards term, it may become uncomfortable and is known as false labor. These Braxton Hicks contractions are nature’s way of stimulating or training the uterus for the essential functions it would perform during the time of delivery or labour. Uterine Souffle: It’s heard during auscultation on the abdomen. It is a soft blowing sound that occurs at the same rate as the maternal purse caused by the increased uterine blood flow and blood pulsating through the placenta. Alternative causes are large uterine myomas, large ovarian tumors. Changes in pigmentation of the skin These changes include: Foetal outline: Ballottement: It is the passive fetal movement elicited when the examiner inserts two gloved fingers into the vagina and pushes against the cervix. This action pushes the fetal body up and as it falls back, the examiner feels a rebound. Alternative causes are uterine tumors, polyps, ascites and others. Pregnancy Tests: This detects the presence of HCG (human chorionic gonadotropin) in the maternal blood or urine. Alternative causes are choriocarcinoma, menopause, and hydatidiform mole. Diagnostic (positive) signs of pregnancy: Diagnostic signs are completely objective and cannot be confused with a pathologic state. They offer conclusive proof of pregnancy. The positive or confirmatory signs of pregnancy which the midwife can trust are: This can be detected with an electronic Doppler device as early as weeks 10 to 12th gestation. This is palpable by a trained examiner or midwife after about the 20-22th week. The gestational sac can be observed by 4-6 weeks gestation with aid of ultrasound scan and other imaging techniques that are not detrimental to pregnancy. Fetal parts and movements can be seen as early as 8weeks. Gestational sacs can be detected as early as 10days. The skillful and experienced midwife can palpate fetal parts during abdominal examination. Conclusion In summary, if you notice any of these signs and symptoms related to pregnancy, it is good that you see your doctor prompt ly. This is early antenatal booking helps to save both mother and baby from complications of pregnancy. If you have questions, feel free to reach me. Thanks for reading.

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