1. Postpartum Hemorrhage
& Abnormal Placentation
Manuel Fonseca
MSIII
Hospital San Lucas Guayama
OB/GYN
Dr.Miranda

2. PostPartum Hemorrhage
• Bleeding more than 500 ml after vaginal delivery or more
than 1000 mL following cesarean delivery
• Early postpartum bleeding ocurrs within 24 hours of delivery
• Late postpartum bleeding ocurrs 24 hours to 6 weeks later
• The diagnosis is reserved for pregnancies that have more than
20 weeks’ gestation.
• Less than 20 weeks’ gestational age are spontaneous
abortions.

3. Post Partum Hemorrhage
• Uterine Atony
• Risk Factors
- Anesthesia
-Uterine over distention (twins, Polyhydramnios)
-Prolonged labor
• Bimanual examination
• R/O uterine rupture , Retained placenta
• If unresponsive to bimanual massage administer oxytocin

4. PostPartum Hemorrhage
• Retained placenta (Accreta)
• Genital lacerations
• Failure to progress during the second stage of labor
• Large-for-gestational-age (LGA) newborn
• Hypertensive disorders
• Augmentation of labor with oxytocin

5. Sheehan Syndrome
• Massive bleeding and hypotension —->
• Infarction of pituitary —->
• Hypopituitarism
-No lactation
-Amenorrhea
-Cold intolerance
- Loss of pubic hair

6. 4 T’s
• Tone
• Tissue
• Trauma
-Cervical laceration
-Uterine ruptura
-Very prolongad or vigorous labor
-Vaginal sidewall laceración
-Lower vaginal trauma, either spontaneously or because of episiotomy
• Thrombosis
-Thrombocytopenia
idiopathic thrombocytopenic purpura
-acquired secondary to HELLP syndrome
-Abruptio placentae
-(DIC)
-Coagulopathies
-Sepsis

7. Layers of endometrium
• Stratum compactum*
• Stratum spongiosum*
• Stratum basale = Base layer
• Myometrium

9. Placenta Previa
• Implantation of the placenta in the lower uterine segment;
• placenta overlies
cervical os (opening).
• Presents as third-
trimester painless
bleeding

10. Placenta Previa
• Dx.Ultrasound
• Risk Factors:
-Multiparity
-Prior C-section
• Tx: C-section

11. Vasa Previa
• Fetal blood vessels cover cerviz
• Risk of fetal hemorrhage

12. Placenta Accreta
• Improper implantation of placenta into the
myometrium with little or no intervening
decidua(directly to myometrium)
• Presents with difficult delivery of the placenta and
postpartum bleeding ( Cannot detach after delivery)
• Tx. Hysterectomy

13. Placenta increta
• Placenta grows into wall of uterus
Placenta percreta
• Placenta perforates through uterus
• Risk factor : previous c-section

14. Placenta Abruption
• Separation of placenta from the decidua prior to delivery of the
fetus
• Painful Vaginal Bleeding 3rd trimester
• Common cause of stillbirth (fetus dies in utero)
• Can Lead to DIC or fetal death
• Risk Factors
- Trauma, Abuse
-Smoking , HTN , Cocaine
• DX: Kleihauer-Betke test

16. Indicactions for vaginal
delivery and c-section
• C-section
-uncontrollable maternal hemorrhage
-rapidly expanding concealed hemorrhage
-fetal distress
-rapid placenta separation
• Vaginal Delivery
-placental separation is limited
-separation is extensive and fetus is dead