what is the Placental Abnormalities and Hemorrhagic Complications during pregnancy What is PPH and what is the management? what is the ectopic pregnancy?

2. Placental Abnormalities and
Hemorrhagic Complications
1. Antepartum Hemorrhage (APH)
2. Postpartum Hemorrhage (PPH)
3. Ectopic Pregnancy
4. Abortion

3. 2. Postpartum Hemorrhage (PPH)
• Postpartum Hemorrhage (PPH) is a
blood loss after delivery greater than:
- 500 mL for vaginal delivery, and
- 1,000 mL for cesarean delivery,
- with 10% drop in hematocrit
• PPH is responsible for around 25% of
maternal mortality.

4. PPH Classification
• PPH is classified into:
− Primary (early) occurs
within the first 24 hours
after delivery.
− Secondary (late) occurs
after 24 hours post-birth to 6
weeks after delivery.

5. PPH Risk factors
• Antepartum hemorrhage in this pregnancy.
• Enlargement Uterus Due to Macrosomia or Multiple fetuses.
• Pre-eclampsia.
• Previous PPH.
• Maternal obesity.
• Uterine abnormalities and Surgery.
• Maternal age (35 years or older).
• Maternal anemia.
• Operative vaginal delivery (Use of forceps or vacuum).
• Induction of labor.
• Prolonged first and second stage of labor (over 12 hours
labor).
• Infections.
• Anemia

6. Forceps Birth Vacuum Birth

7. PPH Common Causes
The causes of PPH have been described as the
"four T"
1. Tone: uterine atony (“70%” failure of the uterus
to contract properly after delivery).
2. Trauma: lacerations of the uterus, cervix, or
vagina, and uterus inversion.
3. Tissue: retained placenta.
4. Thrombin: Coagulation abnormalities.

8. 1. Tone:
• Once a baby is delivered, the uterus normally continues to
contract (tightening of uterine muscles) and expels the
placenta.
• After the placenta is delivered, these contractions help
compress the bleeding vessels in the area where the
placenta was attached.
• If the uterus does not contract strongly enough, called
uterine atony, these blood vessels bleed freely and
haemorrhage occurs.
• This is the most common cause of postpartum
haemorrhage.

9. 2. Trauma: Lacerations, hematomas, injury, rupture of
the uterus, cervix, or vagina. And uterus inversion.
3. Tissue: If small pieces of the placenta remain
attached, bleeding is also likely. Or placenta tissues
attack and enter the uterine tissues.
4. Thrombin: Coagulation abnormalities due to many
causes as; HELLP Syndrome, Amniotic fluid
embolism, Vitamin K deficiency.

10. PPH Prevention
• Detect any abnormality (anemia, diabetes…) before the
delivery and try to control it.
• Ensure that the bladder of the mother is empty since a full
bladder makes it more difficult for the uterus to contract.
• We should know the mother’s blood type.
• IV access should be maintained.
• Slow IV infusion.
• Oxytocin medication (A drug used to stimulate uterine
contractions and control bleeding).
• Oxytocin should be routinely used in the third stage of labor.
• Massage the mother’s uterus to help it contract.

11. PPH Management
Tone
• Massage
• Drugs (Oxytocin)
Thrombin
• Drugs (according to
the cause)
• Platelet and blood
transfusion
Tissue
• Drugs (Oxytocin)
• Manual removal of retained
placenta
• Uterine curettage
Trauma
• Manual fixation of
uterus inversion
• Repair the rupture
and laceration

12. Uterine
curettage

13. Uterus inversion and how to fix it back

14. Uterine massage
Manual Removal of
the Placenta

15. PPH Management
• Large-bore intravenous access, and increase
oxytocin.
• Uterus Relaxation Agent
• A blood clotting medication.
• Transfuse blood.
• Bakri Balloon.
• Laparotomy: Surgery to open the abdomen to find
the cause of bleeding.
• If the blood doesn’t stop; Hysterectomy should be
Done (This is always a last resort in all condition).

16. Bakri
Balloon

17. 3. Ectopic Pregnancy
• An ectopic pregnancy is the implanting
of the zygote somewhere other than the
inner endometrial lining of the uterus
(pregnancy that occurs outside the
uterus).
• It occurs in 1%-2% of all pregnancies.
• It is life-threatening to the mother.
17

18. 3. Ectopic Pregnancy
• The vast majority of ectopic
pregnancies occur in the fallopian
tube “tubal pregnancy’’ (95%), but the
fertilized ovum can also implant in
the ovary, cervix, or abdominal cavity
(5%).
• Doctors usually discover it between
week 5 and week 14 of pregnancy . 18

19. 19

20. Sites of ectopic pregnancy
20

21. 21
Bleeding due to ectopic pregnancy

22. Ectopic Pregnancy symptoms
• The first warning sign of an ectopic pregnancy is pelvic
pain.
• Abnormal vaginal bleeding.
• Abdominal pain, typically just in one side, which can
range from mild to severe.
• An absent of menstruation (amenorrhea), and other
symptoms of pregnancy.
• Shoulder pain (unknown why).
• If the fallopian tube ruptures, the pain and bleeding
could be severe enough to cause fainting.
• Rectal pressure.
22

23. Ectopic Pregnancy Causes
• The most common cause is damaged fallopian tube.
• Zygote abnormality.
• Previous ectopic pregnancy.
• Sexual diseases (typically chlamydia).
• Reproductive organs infections and inflammations.
• Smoking.
• Endometriosis (abnormal uterus lining).
• Using fertility drugs.
• Getting pregnant while having an intrauterine device
(IUD).
23

24. Intrauterine
device (IUD)
24

25. Ectopic Pregnancy Complications
• The major health risk of ectopic
pregnancy is rupture leading to
internal bleeding.
• Decreased fertility related to removal
of fallopian tube.
25

26. Ectopic Pregnancy Management
• In early stage; a medication used to stop
the egg developing. The pregnancy
tissue is then absorbed into the woman’s
body.
• In more advanced stage; a surgery is
required to remove the egg or Embryo.
26

27. Ectopic Pregnancy Management
• If the fallopian tube has ruptured,
emergency surgery is necessary to
stop the bleeding and fix the tube.
• In some cases, the fallopian tube and
ovary may be damaged and will have
to be removed.
27

28. Ectopic Pregnancy Management
• The hCG level will need to be rechecked
on a regular basis until it reaches zero if
the entire fallopian tube did not removed.
• An hCG level that remains high could
indicate that the ectopic tissue was not
entirely removed, which would require
another surgery or medical management.
28