has been greatly reduced by the prophylactic use of antibiotics, Dr. Gilmandyar noted. Treatment can include not only antibiotic regimens, but also surgical debriding and packing, if needed. Generally the treatment chosen will be guided by the severity of the infection and the clinical response of the patient. one of the top causes of maternal mortality. minute by the time a woman is in her third trimester of pregnancy. As a result, a patient can lose more than a quart of blood every minute at term if there is a significant hemorrhage. And, since there may be no maternal signs until up to 15 percent to 20 percent of the blood volume is lost, a patient can lose a significant amount of blood before exhibiting well-recognized PPH symptoms, Dr. Gilmandyar warned. Symptoms include mild hypotension, peripheral vasoconstriction, and tachycardia (100 to 120 bpm) at between 20 percent and 25 percent blood loss; hypotension (SPB 80 to 100 mmHg), restlessness, oliguria, and tachycardia (>120 bpm) at 25 percent to 35 percent blood loss; and hypotension (SBP <60 mmHg), altered consciousness, and anuria, at blood loss greater than 35 percent. stage), placenta accreta (placenta abnormally attached to the inside of the uterus), lacerations, hypertensive disorders, and a fetus who is large, such as when the mother has gestational diabetes. fail to contract normally after delivery), retained placenta, trauma from birth, and a coagulopathy. result of an overdistended, fatigued uterus that cannot contract normally, said Dr. Gilmandyar. The first step in this case is to alert the entire obstetrical team in a stat manner and have them on standby if further intervention is necessary. Another part of the initial management approach, especially if the bleeding does not appear to be slowing down, is to quickly transport the patient to the operating room. Once in the operating room, the obstetrical team focuses on: helpful here). the source of bleeding. should be manually explored and the retained placental fragments removed. If manual extraction of the placental fragments is not possible, then a suction and curettage must be performed to empty the endometrial cavity. Because the postpartum uterus is much more likely to perforate, ultrasound guidance is useful, Dr. Gilmandyar advised. (perineal, vaginal, and cervical), hematomas, and hysterotomy/ uterine rupture, while those caused by coagulopathy can be related to maternal conditions or pregnancy-related conditions. uterine massage and uterotonic drugs, such as oxytocin, methyler- gonovine, carboprost, dinoprostone and misoprostol. More invasive therapies include arterial embolization, uterine compression sutures, uterine artery ligation, and, ultimately, if all other measures fail, hysterectomy. to help control the hemorrhage. The tamponade may be created using packs or balloons, Dr. Gilmandyar said. The balloon is inserted into the uterus and filled, exerting pressure on the uterine wall until the bleeding stops. Once the tamponade is in place (inflated), it can be left in place for 12 to 24 hours. The balloon can be deflated gradually over several hours, or all at once, depending on the situation. hemodynamically stable and interventional radiology is available. The femoral artery is used for access, and gelfoam is used for embolization. This procedure has a success rate of 89 percent to 97 percent, Dr. Gilmandyar said. The gelfoam used is typically reabsorbed by the body within weeks; this procedure is not the same as Uterine Artery Embolization (UAE) for fibroids, which is permanent, she noted. disciplinary team must be available for the most consistent and the best outcomes, Dr. Gilmandyar said. This team usually includes the obstetrician, nursing staff, anesthesiologists, surgical assistance, and other health professionals or departments (e.g., blood bank). Protocols and drills, as noted by Dr. Chervenak, have been shown to improve outcomes, and to help reduce not only the time to diagnosis, but also the response times of the health care team for acting on the condition, she said. |