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Postpartum Hemorrhage Case Report

Hanisah Idris Norfarah Izzati Azman

Identity
Name Sex Age Religion Race Address : Mrs Y : : 34 y.o : Islam : Jawa : Teluk Jambe

Anamnesis (18

th

of January 2014, 0650hrs)

RPS

Menstrual History
First day of LMP Estimated Due Date Gestational Age Menarche Menstrual Cycle Duration Volume Dismenore :: 22-01-2014 (ANC) : 40 wks : 15 thn : regular : 4 days : 2 pads/day : (-)

Past Medical History


HTN (-) , DM(-), asthma (-), Heart Failure (-)

Family History
HTN (-) , DM(-), asthma (-), Heart Failure (-)

Marital Status
Married once at 14 y.o

Past Obstetrics History


G3P2A0 : I : 13yo,, SVD, 3500gr. II : , SVD,3600gr III : This pregnancy Routine antenatal care (ANC)

Contraceptive History
Contraceptive Injection (every 3mo)

Antenatal Care and Immunization

ANC once in every month TT Twice USG (-)

Physical Examination
General Examination Appearance : Tampak sakit ringan Kesadaran : Compos mentis
Vital Sign Blood Pressure Pulse Temperature Respiratory : 130 / 80 mmHg : 84 x /mins, regular : 36,20 C : 18 x /menit

Head Eyes Nose Mouth Neck Thorax Mammae Cor Pulmo Abdomen Ekstrimities

: Normocephali. : Pupil bulat isokor, CA -/-, SI -/: Normosepta, NCH -/-, sekret -/: Karies -, mukosa intak. : KGB tidak teraba membesar, Tiroid tidak teraba.

: Simetris, hiperpigmentasi pada kedua areola, retraksi putting -/: Bunyi jantung I-II regular, murmur -, gallop : Suara nafas vesikuler, rhonki -/-, wheezing -/: membesar sesuai usia kehamilan, striae gravidarum (+) : akral hangat +/+, edema -/-

Obstetrics Examination
I. II. INSPECTION : Distention (+) PALPATION (4 manouvers of Leopold) 1. Examination of uterine fundus Symphysio- fundal height(35cm) 2. Fetal back (right side) 3. Presenting part : vertex 4. Engagement of presenting part (4/5)

III. Auscultation : Fetal heart rate 144bpm

Vaginal Examination
Vulva & vagina Tenang Cervix-dilatation 6cm ,effacement (thin), position (axial) & consistency (soften) Presenting part : Vertex

Hodge : I-II
Membranes (+) Liquor (-)

Pemeriksaan penunjang
Hematologi 18 Januari 2014 Hb : 10,8 Ht : 32,8% Leukosit : 26, 270 Trombosit :299.000 HBsAg : nonreaktif Blood type/ rhesus : B/ + Bleeding time : 2 mins Clotting time GDS mg/dl : 11 mins : 100

USG
BPD FL HC AC EFW ICA : 95,2 mm : 76,4 mm : 324 mm : 351,8 mm : 3712gram :9

JPKTH, plasenta di fundus

Resume
Wanita, 29 tahun, G2P1A0 hamil 39-40 minggu,HPHT : 0904-2013, TP: 16-01-2014 dirujuk bidan dengan keluhan ketuban pecah sejak 1 hari SMRS, mengaku hamil 9 bulan, keluhan keluar air-air sejak 18 jam SMRS. berwarna bening, amis, banyak, tidak disertai lendir bercampur darah. keluar tiba-tiba saat pasien bangun dari tempat tidur untuk kekamar mandi. Keputihan sejak 3 hari SMRS.tidak banyak, putih, gatal. mules-mules hilang timbul sejak 18 SMRS. tidak bertambah kuat. Pasien masih merasakan gerakan janin. Riwayat terbentur/ trauma, demam dan nyeri saat BAK disangkal. Pasien berobat ke bidan terdekat dikatakan oleh bidan ketuban pasien sudah pecah. Kemudian pasien di rujuk ke RSUD Karawang.

Diagnosis
PK1 aktif pada G3P2A0 hamil 38-39minggu, JPKTH

Therapy
Observasi tanda tanda vital, HIS, DJJ dan kemajuan persalinan. Observasi tanda tanda infeksi intrauterin, infeksi intrapartum, maupun tanda tanda gawat janin.

Terapi medikamentosa ;
Ceftriaxone 2 x 1 gram IV bolus Rencana Persalinan Per Vaginam

Prognosis
Mother : dubia ad bonam

Fetus : dubia ad bonam

Follow up (1)

18th of January 2014

1100hrs : Fully dilated Active phase 1120hrs : Lahir bayi perempuan, BBL 3400, PBL 50cm, A/S 5/7, ketuban jernih, jumlah cukup, cacat (-), anus (+), mekonium (+), posisi lahir kepala 1130hrs : Dilakukan PTT. Plasenta lahir spontan lengkap dengan berat 500gr, ukuran 12x12x1,5cm. Dilakukan masasefundus, kontraksi lemah dengan perdarahan aktif 700cc injeksi metergin 1 ampul iv, oksitosin 20iu/500RL, misoprostol 1000mcg dan KBI selama 2 menit perdarahan aktif pervaginam (+) KBI lagi, persiapkan tampon kondom A : HPP ec Atonia Uteri

Planning : Survey

A : Free B : Spontaneous C : BP 100/60mmhg, pulse 110x/m D : -IVFD 2 line, loading1000cc -calcium gluconas 1 ampul IV -D40% II -drip oksitosin 40 IU/500cc + metergin 1 ampul dengan metergin 1 ampul IM Observasi keadaan umum, TTV, kontraksi, perdarahan Pasang monitor Cek DPL cito Pasang tampon kondom kateteri intravakum dengan isi 500cc Asam traneksamat 1000 mg IV

Follow up (2)

(19th of January 2014)

S : Pusing (-), perdarahan aktif (-), O : KU baik, CM Tanda Vital : TD : 110/700mmHg RR : 20x/m N : 88x/m S : 36,4 C Status generalis : dbn Status obstetrikus : TFU sepusat , kontraksi baik, I: v/u tenang, perdarahan aktif (-) Lochia rubra (+) Terpasang DC, terpasang kondom kateter 500cc, tampon bola intravaginal A : Riwayat HPP pada P3 post partus spontan

P : Observasi TTV, kontraksi, perdarahan Diet TKTP Mobilisasi aktif Rawat ruangan Th/ - As. Traneksamat 3 x 500mg IV - Keluarkan kondom kateter 250cc, tersisa 250cc untuk dikeluarkan pada jam 1230
- Cefadroxil 3 x 500mg p.o.

- As. Mefenamat 3 x 500mg - SF 1x1 p.o.

Analisa kasus

Introduction
Postpartum hemorrhage (PPH) is the leading cause of maternal mortality. All women who carry a pregnancy beyond 20 weeks gestation are at risk for PPH and its sequelae. Although maternal mortality rates have declined greatly in the developed world, PPH remains a leading cause of maternal mortality elsewhere.

Major causes of death for pregnancy women (maternal mortality)


Postpartum hemorrhage28%) heart diseases pregnancy-induced hypertension (or Amniotic fluid embolism ) infection

Definition of PPH
PPH is defined as blood loss of more than 500 mL following vaginal delivery or more than 1000 mL following cesarean delivery. A loss of these amounts within 24 hours of delivery is termed early or primary PPH, whereas such losses are termed late or secondary PPH if they occur 24 hours after delivery.

Major causes
Uterine atony (90%) lacerations of the genital tract(6%) retained placenta(3%-4%) coagulation defects (blood dyscrasia)

(4T: tone, tissue,trauma,thrombin)

1. Uterine atony (Tone)


Local factors overdistention of the uterine (hydramnios, multiple pregnancy, macrosomia ) condition that interfere with contraction(leiomyomas) complications(PIH,anaemia, placenta praevia

Systemic factors: nervous drugs(magnesium sulfate,sedative) abnormal labor(prolonged,precipitous) History of previous PPH Preeclampsia, abnormal placentation,

pathology
Contraction constricting the spiral arteries preventing the excessive bleeding from the placenta implantation site the uterine atony give rise to PPH when no contraction occur

Prevention and therapeutic of uterine atony


Administration of medicine: Promotes contraction of the uterine corpus Decreases the likelihood of uterine atony Oxytocin agents Methergine Prostaglandin

Mechanical stimulation of uterine contraction:

Massage of uterus through the abdomen and bimanual compression


intrauterine packing

Surgical methods
If massage and agents are unsuccessful: Ligation of the uterine arteries ligation of the hypogastric arteries selective arterial embolization hysterectomy taking into account the degree of hemorrhage,the overall status of patient,her future childbearing desires

2. Lacerations of the genital tract (Trauma)


Causes: Instrumented delivery (forceps) manipulative delivery(breech extraction,precipitous labor, macrosomia) Types: perineum laceration vaginal laceration cervical laceration

Perineum and Vaginal laceration


The first degree tear: involves only skin and a minor part of the perineal body the second degree tear: involves the perineal body and vagina the third degree tear: involves the anal sphincter and anal canal

management
Vaginal examination soon after delivery
repair: cervical laceration >2cm in length and be actively bleeding laceration of vaginal and perineum

3. Retained placenta (Tissue)


Separation and explosion of placenta is caused by strong uterine contraction Placenta tissue remaining in the uterus prevent adequate contraction and predispose to excessive bleeding

causes: adherence of placenta (previous cesarean delivery,prior uterine curettage) succenturiate placenta placenta accreta (into the decidua) placenta increta(into the myometrium) placenta pericreta(through the myometrium to the peritoneal)

Prevention and treatment


The placenta should be examined to see that it is complete or not part of placenta is missing, removed digitally not separated, manual removal of placenta is done hysterectomy is required for placenta increta(percreta,accreta) uterine contraction drugs

4. Coagulation defects (Thrombin)


Acquired abnormality in blood clotting: abruptio placenta, amniotic fluid embolism severe preclampsia congenital abnormality in blood clotting: thrombocytopenia severe hepatic diseases leukemia

Disseminated intravascular coagulopathy(DIC)


if bleeding persists in spite of all other treatment described, DIC should be suspected the blood passing from the genital tract is not clotting shock: reduction of effective circulation inadequate perfusion of all tissues oxygen depletion depression of functions

Record: pulse blood pressure maternal heart rate central venous pressure urine output

Lab tests: Hb, BT(bleeding time), CT( clotting time), platelets count fibrinogen prothrombin time and patial thromboplastin time FDP womens group and cross-matching

Treatment: the key is correcting the coagulation defect resuscitation must be started as soon as possible infusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusion blood transfusion is essential infusion of platelets, fresh frozen plasma, FDP , clotting factors,

Potential complications of PPH: Postpartum infection Anemia Transfusion hepatitis, Sheehans syndrome Ashermans syndrome

The best management of PPH is prevention

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