pph, haemorrhage

1. MANAGEMENT OF POSTMANAGEMENT OF POST
PARTUMHAEMORRHAGEPARTUMHAEMORRHAGE
Dr. Rabinarayan SatapathyDr. Rabinarayan Satapathy
Asst. ProfessorAsst. Professor
Dept. of Obst.& GynaeDept. of Obst.& Gynae
S.C.B. Medical College,CuttackS.C.B. Medical College,Cuttack

2. INTRODUCTION
 The World famous monument “Taj Mahal” was
built in memory of a woman who died of
postpartum haemorrhage during her fourteenth
child birth.
 Postpartum haemorrhage (PPH) is an obstetric
emergency and it is the most challenging
situation to Obstetricians.
 At the end of the last century , 25% of maternal
death was estimated to be due to PPH
according to WHO.
 In developing countries, risk of dying from PPH
is 1 in 1000 deliveries.
 The incidence of PPH varies from 4-6% of all
deliveries.

3. DIAGNOSIS
 PPH is a description of an event and not a
diagnosis.
 Most of the primary PPH occurs within 4 hours
after delivery. In majority of cases, profuse
bleeding at the time of caesarean section and
after vaginal delivery, makes diagnosis
obvious. But rarely bleeding is concealed as
broad ligament haematoma or uterine rupture
where signs and symptoms of hypovolaemic
shock helps in diagnosis of PPH.
 Traumatic haemorrhage – the uterus is well
contracted.
 Atonic haemorrhage – uterus is flabby and
becomes hard on massaging.

4. PREVENTION OF PPH
Antenatal Care :
 Prophylactic iron and folic acid supplementation.
 Detection of anaemia and its treatment
 Identification of high risk cases who are prone to
develop PPH (Placenta previa, Twin pregnancy, PIH,
Obesity, Large baby, prolonged labour) and their
special management.
Intrapartum Care:
 Active management of third stage of labor,
a) Administration of prophylactic oxytocic drugs before
delivery of the placenta.
b) Controlled cord traction decreases the risk of PPH by
40%.
 Oral misoprostol (600mg) is quite effective in
preventing PPH when given after delivery of the baby
(WHO, 1998).
 Routine uterine palpation , massaging and inspection
of both placenta and lower genital tract.
 Adequate antibiotics after operative and manipulative
delivery.

5. PRELIMINARY STEPS IN
MANAGEMENT OF PPH
 Helps of a senior person is always sought.
 Two IV lines with large bore cannula should be
set up
 Assessment: (a) amount of blood loss (b) General
condition (c) Degree of hypovolaemia
 Oxygen to be administered by O2 mask
 Blood sent for: Grouping , cross matching,
Complete haemogram, coagulation profile,
Antibody screening
 Fluid replacement : Crystalloid , Colloid, Blood
 Indwelling urethral catheter.
 Monitoring of vital parameter: Levels of
consciousness, pulse , Blood pressure, Urine
output.

6. MANAGEMENT OF ATONIC PPH
 Uterine atonicity is responsible for 75-90% cases
of PPH.
 In the treatment of atonic PPH, medical methods
are instituted first in a step wise manner before
resorting to surgical methods , one should pass
onto the next step without losing time because
here a minute counts.
MANAGEMENT OF THIRD STAGE BLEEDING
 Massage the uterus if not contracted , oxytocin
should be added to I.V. drip (10 units in 540ml of
fluid).
 If signs of placental separation appear , then
delivered by controlled cord traction.
 If spontaneous separation does not occur and
bleeding continues MROP should done under
anaesthesia.

7. MANAGEMENT OF ATONIC PPH AFTER
DELIVERY OF PLACENTA
 Uterine massage
 Oxytocin in I/V Drip
 Methyl ergometrine ( Methergin)0.2 mg I/V
 Prostaglandin derivatives:
 15 methyl PGF2α - 0.25mg I/M or intramyometrial
repeated every 15-90minutes and maximum dose
of 2 mg or 8 doses.
 PGE2: 20 mg given P/V or P/R route.
 PGE1 (Misoprostol) : 1000 µg used per rectally.
 ‘O’ Brien and Colleagues (1998) reported that
misoprostol 1000 mg given rectally, was effective
in 14 women unresponsive to usual oxytocic.
 Bleeding unresponsive to oxytocic
 Obtain help, Reassess the diagnosis, Begin blood
transfusion, Employ bimanual uterine compression

8. Bimanual uterine compression

9. OTHER TRANSVAGINAL OPTION
 Uterine exploration
 Balloon tamponade :
• Foleys catheter or stomach balloon of a senga
staken- Blackemore tube is inserted within the
uterine cavity and inflated.
• It is left for 24 hours
• A condom introduced inside uterine cavity and
inflated with fluid.
 Uterine Packing
• Done under analgesia or anesthesia
• Pack completely and uniformly
• Prophylactic antibiotics, oxytocic
• Vital signs every 15 minutes
• Removal at 24-36 hours Contd…

10.  It helpful in :
1. Selcted cases of placental site bleeding
2. When surgical treatment is non available
3. When patient is unsuitable for surgery
4. For transfer of a patient to referral center.
 Disadvantage:
• Its mode of action is non-physiological as it
prevents uterine muscle contraction.
• It may mask trauma and ongoing haemorrhage
• May cause infection

11. SELECTIVE ARTERIAL EMBOLISATION
 In 1979 , Brown first reported the method of
angiographically guided arterial embolisation
for the treatment of PPH.
 Usually uterine artery or internal iliac artery
embolisation is done
 Advantages:
• Success rate is high
• Complication rate is low
• Very useful when surgery is difficult like
retroperitoneal haematoma
• Fertility is preserved
• Surgical risk is reduced
• If it fails surgical options remains open.

12. Disadvantages:
• Needs interventional radiological set up
which may not be available in
emergency.
• Haematoma formation at the site of
catheterisation.
• Infection resulting in low grade fever and
pelvic abscess.
• Ischaemic phenomenon due to vascular
injury.
• Radiation exposure
• Sciatic nerve injury

13. UTERINE VESSEL LIGATION
 Uterine artery is ligated first
unilaterally and then
bilaterally at a level of upper
part of lower uterine
segment in LSCS, artery is
ligated 2-3cm below the
level of uterine incision.
 First bladder is pushed
down to avoid injury to
ureter.
 A large atraumatic needle
with absorbable suture is
used.
SURGICAL METHOD
 If the patient continues to bleed inspite of
conservative measures
 Any coagulopathy should be excluded prior to
laparotomy

14. Needle is passed from anterior to posterior ,
2-3 cm & medial to the vessels including full
thickness of myometrium and then brought
back from posterior to anterior through an
avascular area of broad ligament and the
knot is tied.
The step is repeated on the otherside
A second pair of stiches can be placed in the
same way bilaterally 3-5 cm below the upper
ligatures after mobilising the bladder down
wards. These ligatures obliterate most of the
supply of uterine artery to lower uterine
segment and to its cervical branch.

15. Advantage:
 Simple to perform and can be done quickly.
 Lower complication rate.
 As it is a more distal ligation of artery than
internal iliac there is less chance of further
bleeding because of collaterals as compared to
internal iliac.
 No long term vascular effect has been
documented.
 Subsequent pregnancy has been documented.
 Limitation of uterine vessels ligation:
 It is not useful in :
• Myometrial pathology like myoma
• Intramural cervical laceration
• Retained placental fragments.

16. LIGATION OF UTEROOVARIAN
ANASTOMOSIS
It involves identifying an avascular area of
mesovarium near the uteroovarian ligament
and ligating the utero-ovarian vessels by few
interrupted stitches.

17.  Pioneered by Howard Kelly
 Mechanism: By reducing
arterial pulse pressure (85%
reduction in bilateral ligation) by
converting the pelvic arterial
circulation into a venous
system.
 Procedure: Internal iliac artery
is identified and with the help of
aneurysm needle , two silk
sutures are placed around the
artery ½ cm apart and 2 cm
below its origin (to exclude the
posterior division of internal
iliac artery) and tied.
INTERNAL ILIAC ARTERY LIGATION:
 Complication: Injury to internal iliac vein and external
iliac artery.

18. Usefulness:
 It is successful in controlling haemorrhage in
42%.
 It should be done in relatively haemodynamically
stable patient who desire future pregnancy.
 Internal iliac ligation is particularly useful in cases
of traumatic PPH (like rupture uterus), where
hysterectomy has been done but bleeding is still
continuing.
Disadvantages:
 It is more technically challenging than uterine artery
ligation requiring sufficient skill and experience.
 It cannot be done in haemodynamically unstable
patient as it is time consuming.

19. HAEMOSTATIC SUTURE
B-Lynch Procedure:
 Crystopher B Lynch (1997) introduced this
technique of surgical management of PPH where
uterus is conserved.
Mechanism of action:
 The sutures acts by over sewing the uterus to
apply on-going compression.
 Bimanual compression is performed to test the
potential efficacy of the suture.
 If compression controls bleeding , brace suture
can be placed.
Indication:
 It is useful in placental accreta, increta, percreta,
placenta previa bleeding and atonic PPH where
medical treatment fails.

20. B-LYNCH PROCEDURE
Technique:
 Placing an absorbable suture vertically from 3 cm
below the uterine incision to 3 cm above the uterine
incision on the right side of the uterus. The stitch is
then taken vertically over the fundus and placed
horizontally in the posterior uterus at the same level
as the anterior suture.
The suture is threaded
over the left side of the
uterus to place another
stitch on the left from 3
cm above the uterine
incision to 3 cm below
the uterine incision.
The long suture is tied
compressing the fundus.

21. Advantages::
 It is easy to apply, can be done quicker than
hysterectomy and internal iliac ligation.
 Fertility can be conserved.
Disadvantages:
 Hysterotomy is a prerequisite to perform this
procedure.
Modified B-Lynch Procedure:
 No 2 chromic catgut is passed through
anterior and posterior walls of the uterus 3 cm
above the uterine incision, 4 cm medial to
lateral border and passed over fundus to
anterior surface and tied.
 It is repeated on other side.

22. ISTHMIC CERVICAL APPOSITION SUTURE:
 It is particularly helpful in bleeding from lower
uterine segment in cases of placenta previa
and morbid adhesion of placenta.
 No-2 chromic catgut on a straight needle is
passed through anterior wall and posterior
wall of the lower segment , 2 cm medial to the
lateral boarder and 3 cm below the cut margin.
 Then it is brought back through posterior and
anterior walls 1 cm medial to first entry and
tied anteriorly. The same procedure is
repeated on other side.
 A pair of closed artery forceps are passed
between both stutres through the cervical
canal to ensure drainage of uterine collection.

23. HYSTERECTOMY
 Indication:
• Placenta accreta or percreta
• Uterine atony
• Association of placenta previa and prior
LSCS
• Rupture uterus
• Extension of LSCS incision
• Broad ligament haematoma after forceps ,
lacerated cervix/vagina after ventouse
• Severe chorioamniotitis
The principle is to clamp, cut and drop the
pedicles to below the level of uterine
arteries. Contd…

24.  Whether subtotal or total hysterectomy:
• Subtotal hysterectomy is often the choice of
operation to reduce the operation time and
blood loss in cases of atonic PPH.
• If bleeding site is in lower uterine segment or
cervix as in cervical laceration or central
placenta previa bleeding will not be
controlled by subtotal hysterectomy and total
hysterectomy is needed.
 Advantage of hysterectomy:
• It is the definitive treatment and stops
bleeding in atonic and traumatic PPH
• Familiarity of the obstetricians with the
procedure of hysterectomy.
 Disadvantage: Future child bearing capacity is
sacrificed.

26. PLACENTA ACCRETA-INCRETA-PERCRETA
AND POST PARTUM HAEMORRHAGE
 Management depends on the site of implantation,
depth of penetration and extent of the placental
involvement.
 In case of focal placenta accreta- the cotyledon is
either pulled off the myometrium.
 In more extensive involvement as placental removal is
attempted, profuse bleeding occurs demanding
immediate blood transfusion.
 Prompt hysterectomy is the definitive treatment
 When there is total placenta accreta-leaving the
placenta in situ, administration of methotrexate and
regular follow up with serial β-HCG estimation and
USG are suggested by some authorities. Other
conservative approach is manual removal of placenta
as much as possible and then packing of uterus.
 However , leaving the placenta is not universally
acceptable because of the risks of haemorrhage and
infection.Hence the safest t/t is prompt hysterectomy.

27.  Suspected when bleeding
continuing with a firmly
retracted uterus (may also
be associated with atonic
PPH).
 Laceration of cervix and
vagina.
 Repair needs : good light
source, exposure, optimal
instrument , infiltration of
vasopressure at the cut
margins.
 Suturing should start
above the apex
 Interrupted sutures
preferred.
TRAUMATIC PPH

28. PELVIC HAEMATOMA
 Pain, Symptom of pressure, Hypovolaemia
Small haematoma (<5cm): Conservative treatment.
Larger haematoma:
 Should be explored under general anaesthesia.
 Bleeder ligated
 If not found - dead space
obliterated by mattress suture
 Vaginal pack
 Prophylactic antibiotic
 Blood transfusion usually required.
UTERINE RUPTURE
 Simple repair if patient wants to preserve her child
bearing capacity.
 Otherwise hysterectomy is performed.

29. UTERINE INVERSION
 Complete uterine inversion – Iatrogenic
Management:
 Resuscitation
 Assistance including one anaesthesiologist.
 Immediate replacement
 If placenta is still attached , MROP should be done
after the uterus is reposed.
 If manual replacement fails , repeat under
ananesthesia & tocolytic.
 Hydrostatic (O’ Sullivan’s) replacement If fails
then , reposition may be done by abdominal
Haultains operation
 After replacement uterus should be kept
contracted with oxytocic.
 Observe for reinversion.

30. COAGULATION DISORDER
 Consumptive coagulopathy usually acquired can
be reversed by treatment of underlying
pathological process.
 No intervention improves maternal prognosis in
amniotic fluid embolism.
 Heparin and E-aminocapraic acid are dangerous.
 Judicious and rational management with fresh
frozen plasma or even fresh blood may arrest
bleeding and improve patients general condition.
 Aim is to keep clotting factors at safe levels:
 i.e., Fibronogen ≥ 100mg/dl
 Platelets ≥ 40,000/mm3
 FDP < 1 mg/dl

31. SECONDARY POST PARTUM
HAEMORRHAGE:
 Secondary PPH most commonly occurs within 5-
15 days postpartum.
 Common causes are :
Retained and infected products of conception.
Placental polyp
Submucous fibroma
Choriocarcinoma
 Diagnosis :
Other than vaginal bleeding , there may be
evidence of sepsis (pyrexia, lower abdominal
pain, offensive discharge per vagina,
subinvolution of uterus and uterine
tenderness).
Pelvic ultrasound helps in diagnosis

32. Management:
Antibiotics
Intravenous fluid
Oxytocic
Blood transfusion
In presence of product of conception –
evacuation is done
In case of placental bleeding – packing may
be helpful to arrest bleeding
In exceptional cases uterine artery ligation
or hysterectomy is needed.

33. CONCLUSION
Postpartum haemorrhage is still a leading
cause of maternal mortality.
Availability of prostaglandins has greatly
reduced the incidence of severe PPH of
atonic origin.
To deal with PPH , a prompt and effective
action is necessary within a very short
period of time.
When conservative measures fail , early
resort to hysterectomy is life saving.
The best is to save the life and uterus. But,
losing a life in an attempt to preserve the
uterus is the greatest tragedy in an
obstetricians life!