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OVERVIEW
Bleeding is a very important issue in the field of obstetrics and gynecology. In
the field of obstetrics, bleeding is almost always fatal to both mother and
fetus. 1.2Postpartum hemorrhage is the leading cause of maternal death in the
world wide and is the sole cause of both maternal death, ranking behind
preeclampsia or eclampsia. Bleeding in obstetrics can occur either during
pregnancy, childbirth, and the postpartum period. Thus, the bleeding that occurs in
these periods should be regarded as a state of acute and serious. Every woman is
pregnant and postpartum bleeding should be treated immediately and determined
the cause, so it can then be given the right help, it is expected to indirectly reduce
maternal mortality. 1,2,3,4
In this world every minute a woman dies from complications related to
pregnancy and childbirth. Where in 1400 women die every day or more than
500,000 women die each year due to pregnancy and childbirth. Based on
Indonesia's health profile, the maternal mortality rate (MMR) in Indonesia still
stands at 228 per 100,000 live births and the birth rate of 17 births per 1000
population then every hour is 1 maternal death due to various causes. 6
Recognizing these conditions, the Ministry of Health since 1990 has
developed a Strategic Plan for long-term efforts to reduce maternal mortality and
neonatal mortality. In this Strategic Plan focused on activities that build on a solid
health system to ensure the implementation of cost-effective interventions based
on scientific evidence that is known as the Safe Motherhood. This movement is
followed by Mothers movement in 1996, and in 2000 the Ministry of Health
launched the "Making Pregnancy Safer (MPS)" through three key messages. The
three key messages that MPS is any births assisted by skilled health personnel,
every obstetric and neonatal complications receive adequate care and every
woman of childbearing age have access to prevention of unwanted pregnancy and
treatment of complications of miscarriage. Then in 2012, the Ministry of Health
launched a program Expanding Maternal and Neonatal Survival (EMAS) 6
Because of its importance in the treatment of bleeding in obstetrics, then this
will be discussed further on the importance of addressing bleeding, especially in
this case the treatment of postpartum hemorrhage.
CHAPTER II
LITERATURE REVIEW
2.1. Definition
Postpartum hemorraghe is blood loss> 500 ml through the birth canal after the
third stage (the placenta) and> 1000 by caesarean section in the first 24 hours after
birth (1).Actually, in normal pregnant women who will have additional blood
volume of about 30-60%, it causes intolerance in women experiencing postpartum
hemorraghe.Additionally approximately 5% of women who give birth with
normal birth bleeding> 1000ml. 1,4,7 Therefore, as a benchmark, after the delivery
is completed, the state is called "safe" when consciousness and vital signs of
mother is good , uterine contractions well, and there is no active bleeding from the
vagina. 1
2.3 etiology 17
1. general anesthesia
2. The uterus is very stretched
3. Myometrium poor perfusion
4. prolonged labor
5. Childbirth is too fast
6. Labor induction / augmentation
7. multiparity
8. History atonic
9. abnormalities of the uterus
10. Preeklampsi - eclampsia
11. Khorioamnionitis
B. retained placenta
Is a condition in which the placenta has not been born within half an
hour after the baby is born. 1.17
Things that cause it are:
Inversio uteri are marked with signs: the shock of pain, bleeding a
lot clotted, in inverted vulva looks endometrium with or without
placenta attached.When a new case, then the prognosis is good, but it
was long enough that narrowed cervical tongs will make the uterus
ischemia, necrosis, and infection.
TONUS
Causes of acute hemorrhage and severe postnatal often caused by a weak
force of contraction of the myometrium, which can lead to more severe
complications which occur hypovolemic shock. Atonic occur for reasons noted
previously.
Lack of muscle contractions of the uterus can also be caused by muscle
fatigue as a result of labor too long or can also be due to stimulation. Can also be
due to medications that can decrease the strength of contraction like; halogen,
nitrate, NSAIDs, MgSO4, and nifedipine. 3
TISSUE
On the basis of the placenta are usually obtained fibrinoid layer of material
called "layer nitabuch". This relates to the release of the placenta uterine
contraction.But the separation of the placenta from this layer can be disturbed
when engaging villous placenta develops downwards into the myometrium that
interfere with the layer. Such as placenta accreta, in which there are these layers
so that the placenta will be attached to the myometrium, so that if despite some
will cause bleeding very much. This is because the myometrium can not contract
properly to stop the bleeding because it is part of the placenta still attached. 3
TRAUMA
At birth the birth canal damage may occur spontaneously or be caused by
the actions in labor. And the labor per abdominal bleeding risk two times greater
than vaginally.
In the former cesarean section, there is increased risk of uterine
rupture. Uterine rupture can also be obtained when previously had a history of rips
or tears in total. The tears are included as a result of fibroidektomi, uteroplasti,
resection of the cervix and uterine perforation caused by stretching, curettage,
biopsy, hysteroscopy, laparoscopy or intra-uterine contraceptive use.
Trauma can also occur in a long labor, especially in patients with
disproportion cephalopelvic relative or absolute and the uterus was stimulated by
oxytocin or prostaglandins. 3
THROMBIN
In the postpartum period abnormalities in coagulation and clotting system
is not always the case in a lot of bleeding, it is emphasized the efficacy of
contraction and retraction to prevent bleeding. The precipitate fibrin at the site of
the placenta, blood clots and supply of blood vessels plays an important role in the
hours and days after delivery in which abnormalities in this area can trigger
secondary postpartum hemorraghe or exacerbation of bleeding due to other causes
which are most often traumatized. The symptoms of a blood clotting disorder can
be hereditary diseases or acquired. Blood clotting disorder can include:
Hypofibrinogenemia, can lead to increased intravascular coagulation.
Disseminated Intravascular Coagulation / consumptive coagulopathy
Thrombocytopenia
Idiopathic Thrombocytopenic Purpura
HELLP syndrome (hemolysis, Elevated Liver enzymes, and Low
Platelet Count)
2.5.Diagnosis
Diagnosis on postpartum hemorraghe to look for the underlying
cause. Diagnosis can be made: 12
Palpitations,
500-1000 mL
Normal tachycardia, Compensated
(10-15%)
dizziness
Weakness,
1000-1500 mL Slight fall (80-100
tachycardia, Mild
(15-25%) mm Hg)
sweating
1500-2000 mL Moderate fall (70- Restlessness,
Moderate
(25-35%) 80 mm Hg) pallor, oliguria
A. Management 13.14
Handling on postpartum hemorraghe intended to restore normal
blood circulation, it is necessary to act quickly and appropriately. The
best treatment is prevention.Therefore we need to do:
Maximum Not more than 3 L 5 doses (Total 1.0 mg) 8 doses (Total 2
dose of IV fluids mg)
containing oxytocin
Actions of supporters: 1
2.8 Complications
Some of the complications that can occur in postpartum hemorraghe is a
patient can fall into a state:
Shock
Anemia
Sheehan's syndrome
2.9 Prognosis
Post partum hemorraghe has recurrence rate of approximately 10% in future
pregnancies. There are limited data on outcome of pregnancies after uterine artery
embolization or B-Lynch suture. It is unknown if these procedures put future
pregnancies at increased risk of complication, although there are case report and
series of uneventful pregnancy outcomes after these procudures.
CHAPTER III
CONCLUSION
Postpartum hemorraghe is one of the important causes of the high
maternal morbidity and mortality. Therefore health professionals are expected to
know what things that can cause bleeding as well as ways of handling. Hopefully,
by the early detection, diagnosis accuracy and speed in the handling of postnatal
hemorrhage, the incidence of maternal hemorrhage can be derived.
BIBLIOGRAPHY
1. Cunningham F, Leveno K, Bloom S, Hauth J, L Gilstrap, Wenstrom Obstetrical
Hemorrhage K. Chapter 25, Section VII; Obstetrical complication, in William
Obstetrics 22th edition. Philadelphia. McGrawHill.2005 p: 635-663
2. Hanifa W. Disturbance In Kala III Labor, in obstetrics. Issue 3.1997 Jakarta:
Yayasan Bina Library Sarwono Prawirohardjo.
3. JR Smith, Postpartum Haemorrhage, updated 23 September 2014. Accessed on
February 27, 2015 from http://emedicine.medscape.com/article/275038-
overview
4. Yaa M and Yiadom YB. Postpartum Hemorrhage in Emergency
Medicine. Accessed on February 27, 2015 from http://www.emedicine.com/
emerg / topic481.htm
6. Ministry of Health. PROFILE HEALTH INDONESIA, 2013. Accessed on
February 27, 2015 from http://www.depkes.go.id .
7. Anonymus, Preventing Postpartum Hemorrhage: Managing the third stage of
labor, September 2001. Accessed on February 24, 2015
fromhttp://www.pphprevention.org/files/PPHEnglish.pdf
8. Prawirohardjo S. PPH in Obstetrics. Jakarta.YBP-SP.2002. it 664-674
9. Jones, DL Disorders Chapter 24 in the puerperal in Fundamentals of Obstetrics
and Gynecologgy seventh edition. London.Mosby. 1999. p: 187-189
10. M. Rustam PPH. in Synopsis of Obstetrics, edition 2. Jakarta: EGC. 1998:
298-312
11. William, FR, Carey JC Postpartum Care, Obstetrics & Gynecology in the first
edition ,. Jakarta: Widya Medika 2001: 200-209
12. Abdul BS Advanced Bleeding Pregnancy and Childbirth. National Reference
books Maternal and Neonatal Health Services. Jakarta.YBP-SP.2000. It 173-
183; 644-674
13. WHO, Managing Complications in Pregnancy and Childbirth. Accessed on
February 24, 2015
from http://whqlibdoc.who.int/publications/2007/9241545879_eng.pdf
14. JNPKKR.POGI. Bleeding After Baby Born, the National Reference Book for
Maternal and Neonatal Health Care second edition. Prawiroharjo S.
Ed.Jakarta.YBP-SP. 2002. M-26 - M-32
15. Neville FH, JG Moore Postpartum Haemorrhage and Sepsis, in Essentials of
Obstetrics and Gynecology. 2nd edition. Philadelphia: WB Saunders
Company. 2001: 319-321
16. Gilstrap. LC Management Post Partum Hemorrhage. in Operative Obstetrics,
2 nd edition. New York, 2002. p: 246; 415-416
17. Made Kornia Cancer, Postpartum Hemorrhage, in obstetrics. Issue 4. Jakarta:
Yayasan Bina Library Sarwono Prawirohardjo. 2008: 522-529.