* The postpartum haemorrhage is blood loss originating in the placental site, occurring at the time of issue or within 24 hours after birth, abnormal by their abundance (> 500 ml) and / or their impact on the general state.
There is loss of security world, the uterus becomes soft and flabby, the fundus back, expression brought uterine blood flow.
Think of the differential diagnosis: uterine rupture, cervical vaginal lesions.
* The retained placenta is the most common etiology, defined by the persistence of some or all of the placenta into the uterine cavity.
It may be total (not peel) or partial (often aberrant cotyledon).
The adherent zone prevents the hemostatic uterine retraction. The retention may be due to alterations of the mucosa: infectious, traumatic (curettage, uterine scar), submucosal fibroids; Placental abnormalities: Insertion anomalies (double uterus, placenta previa or accreta) or abnormal conformation (large placenta, placenta abnormal form of: accessories cotyledon placenta bipartita); the contraction of uterine abnormalities: uterine inertia (prolonged or very fast, high parity, multiple pregnancy, polyhydramnios, drug: halogenated anesthetics, betamimetics, oxytocin overdose);localized hypertension (incarcerated placenta retained by the ring of Bandl, enchatonnée placenta retained by a horn).
* Other causes: secondary uterine inertia that occurs after delivery and is due to the same reasons mentioned above.
Coagulation disorders caused by obstetric pathologies by DIC (HRP, HELLP syndrome), amniotic fluid embolism, shock-borne infectious or hemorrhagic …) or medical condition (thrombocytopenia …).
Note: PDF have an inhibitory action on the uterine contraction.
PRINCIPLES OF TREATMENT:
* A placenta should be performed if the placenta has not been expelled naturally, then performs a uterus.
Oxytocics ensure and maintain good retraction soon as the uterus is empty; uterine contraction will be monitored regularly and will be driven by uterine mas-wise as required.
If these treatments are ineffective, oxytocin is put back by a prostaglandin synthesis (sulprostone: Naladon®).
If unsuccessful a tamponade may be proposed by vaginal roving or traction on the cervix by the clamps Museux with 180 ° rotation on the clamps.
Otherwise it is surgery: ligation hypogastric (internal iliac artery) or subtotal hysterectomy hemostasis representing the last resort.
* Preventive treatment should reduce the risk of postpartum hemorrhage.
The physiology of the issue must be respected. A uterus should be performed if the placenta incomplete.
Placenta and uterine exploration is done routinely if obstetric conditions favor uterine inertia or retained placenta.
These gestures are also made when there is a risk of damage to soft tissue or the uterus (cesarean and instrumental applications and obstetric maneuvers).
Uterus and placenta Review
Formal Indications: Multiple pregnancies, large egg and polyhydramnios, placenta previa, uterine fibroid very, hemostasis disorders.
Indication: abnormalities of labor, abnormalities of the issuance history.