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PPH class for undergraduate

A short, comprehensive and informative lecture on PPH which will help the UG students to understand PPH and prepare for the exams.

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PPH class for undergraduate

  1. 1. Post Partum Hemorrhage (PPH) class for undergradutes Dr. Debraj Mondal MBBS, MS, DNB, MRCOG (1)-UK Asst. Professor, Dept. of OBGY GIMSH, Durgapur, WB, India
  2. 2. Clinical Definition  Any bleeding from or into the genital tract following birth of the baby up to the end of puerperium which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure is called “Post Partum Hemorrhage (PPH)”.
  3. 3. End of puerperium  Previously it was considered as 6 wk.  Now it has extended up to 12 wk following birth of the child.
  4. 4. Quantitative definition  Blood loss >500 ml following vaginal birth of the baby  Or >1000 ml after CS (WHO).  ACOG: Either a 10% drop of Hematocrit of need for Packed RBC transfusion following birth of the baby.
  5. 5. How much time do we have ? It is estimated that, if untreated, Death occurs on average in: 2 hours from Postpartum Hemorrhage 12 hours from Antepartum Hemorrhage 2 days from Obstructed Labor 6 days from Infection
  6. 6. Types Primary PPH  Within 1st 24 hour of delivery of baby. Two types: 1. Third stage bleeding: bleeding during separation of placenta. 2. True primary PPH: After delivery of the placenta. Secondary PPH  Beyond first 24 hours and upto 12 wk (or some say 6 wk).
  7. 7. Causes of PPH 4 ‘T’s  Tonicity- Atonic PPH- most common (75-90%).  Trauma- Traumatic PPH (10-20%)  Tissue- Retained tissues related PPH (Placenta, membranes).  Thromboplastin- Coagulation defect related PPH.
  8. 8. Atonic PPH- Risk Factors 1. Over distended uterus: Multiple pregnancy, hydramnios. 2. Mismanaged third stage of labour. 3. Multi parity 4. Anemia & malnutrition 5. Prolonged labour, precipitate labour 6. APH 7. Abnormal Uterine anatomy- malformation, fibroids. 8. Obesity 9. Drugs- Halothane, tocolytics 10. Prior history of atonic PPH.
  9. 9. Traumatic PPH 1. Laceration of the cervix, vagina, perineum and peri-urethral tear- mostly in instrumental delivery, complicated vaginal delivery. 2. Ruptured uterus 3. Extension of the cesarean section incision- Uterine artery tear. 4. Broad ligament hematoma. 5. Uterine inversion.
  10. 10. Management of PPH 1. Prevention 2. Treatment
  11. 11. Prevention 1. Regular antenatal care 2. Correction of anemia & malnutrition 3. Identify at risk women and deliver them in a hospital where emergency Obstetric care (EmOC) facility available. 4. Emergency referral facility to a tertiary care hospital should be available. & 5. Routine AMTSL
  12. 12. Active Management of Third Stage of Labour (AMTSL)  It is recommended by WHO that AMTSL should be done in all cases. Because: 1. It minimizes the blood loss 2. Cut short the third stage of labour.
  13. 13. WHO Recommendations for Active Management of the Third Stage of Labour (AMTSL), 2012 1. Check the uterus for presence of twin. 2. Uterotonic immediately after the delivery of the baby in all births. 3. Delayed cord clamping. 4. Controlled Cord traction (CCT): is not mandatory. Perform CCT, if required. 5. Postpartum vigilance for uterine tonus.
  14. 14. Uterotonic immediately after the delivery of the baby in all births  The use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the third stage of labour is recommended for all births.  Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH.  Other option is misoprostol.  Ensure a continuous supply of high-quality Oxytocin by maintaining the cool chain.
  15. 15. Delayed cord clamping  Delay clamping the cord for at least 1-3 minutes to reduce rates of infant anaemia. The only indication for Early cord clamping in modern day obstetrics:  Asphyxiated baby who needs immediate neonatal resuscitation.
  16. 16. CCT: is not mandatory. Perform CCT, if required  In settings where skilled birth attendants (SBA) are available, controlled cord traction (CCT) is recommended for vaginal births  In settings where SBA are unavailable, CCT is not recommended.  CCT is the recommended method for removal of the placenta in caesarean section.
  17. 17. Postpartum vigilance for uterine tonus  Immediately assess uterine tone to ensure a contracted uterus; continue to check every 15 minutes for 2 hours.  If there is uterine atony, perform fundal massage and monitor more frequently.  But sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin
  18. 18. Treatment of PPH (HAEMOSTASIS)  Medical mangement. Mnemonic:  HAEMO  Surgical mangement. Mnemonic:  STASIS
  19. 19. HAEMOSTASIS  H= Help-ask for help  A= Asses (Vitals, Blood loss) & resuscitate.  E= Etiology, Ensure availability of blood.  M= Massage uterus  O= Oxytocics.
  20. 20. HAEMOSTASIS  S= Shift to OT,  T= Trauma (to exclude), Temponade  A= Apply compression sutures  S= Stepwise pelvic devascularization  I= Intervention radiology  S= Subtotal Hysterectomy.
  21. 21. H= Help-ask for help  Whenever there is PPH the 1st thing to do is to shout for help.  It is a team effort not a one man’s job.
  22. 22. A= Asses (Vitals, Blood loss) & resuscitate  Monitor Vitals: Pulse, BP, Temp, Respiration & oxygen saturation Put the patient on multi-parameter monitor.
  23. 23. Resuscitate  Make two intra-venous channel with large bore cannula (18G) in both hands.  IV fluids: Crystalloids (RL) and colloids (to be given till the blood is available).  Moist O2 @ 10-15 Lit/min.  Catheterize to monitor urine output.
  24. 24. E= Establish the etiology  Asses the uterus tone- Atonic?  Local examination to exclude Trauma?  Examination of placenta & membranes to exclude retained bits?  Investigations: Complete hemogram, Coagulation profile, electrolytes, blood grouping.
  25. 25. Ensure availability of blood.  Immediately send blood for grouping and cross-matching and arrange for at least two units of WHOLE BLOOD.
  26. 26. Oxytocics  Start oxytocin infusion: 10 units in 500 ml NS @ 15-30 drops/min.  Methergine (Methyle ergometrine): 0.2 mg may be given IV
  27. 27. Oxytocics Drug Dosage Cant be given Oxytocin infusion 10 units in 500 ml NS @ 15-30 drops/min If pt has heart failure Methergine (Methyle ergometrine) 0.2 mg may be given IV Repeat after 15 min, Max 4 doses. If pt has hypertension Carboprost (PGF2α) 250 micro-gram IM Repeat after 15 min, max 8 doses. If pt has asthma Misoprostol Tablets 200 micro-gram sublingual or Per-rectal. Usual dose 600 micro-gram. Nothing significant Tranexamic acid IV injections 500-1000 mg can be repeated after 4 hr. Nothing significant
  28. 28. S= Shift to OT While shifting the patient the following things may be done:  Bimanual compression of the uterus,  NASG: Non-pneumatic anti-shock garments.
  29. 29. Bimanual compression of the uterus
  30. 30. NASG: Non-pneumatic anti-shock garments
  31. 31. NASG: Non-pneumatic anti-shock garments
  32. 32. T= Trauma, Temponade  If any trauma is noted it should be immediately repaired. Temponade:  Bakri baloon  Sengstaken-Blakemore tube  Rusch balloon  Foley's catheter.  Or uterus can be packed with Gauge.
  33. 33. Internal Uterine Tamponade- Bakri baloon
  34. 34. Sengstaken-Blakemore tube
  35. 35. Rusch balloon & Foley's catheter
  36. 36. A= Apply compression sutures  B-Lynch  Modified B-Lynch  Cho sutures
  37. 37. B-Lynch “Brace” Suture
  38. 38. Cho sutures
  39. 39. S= Stepwise pelvic devascularization 1. Uterine artery ligation. 2. Ligation of round ligaments and 3. Internal iliac (Hypogastric) artery ligation
  40. 40. S= Stepwise pelvic devascularization
  41. 41. Hypogastric Artery Ligation
  42. 42. I= Intervention radiology  Selective  uterine artery or  Internal iliac (Hypogastric) artery  embolization with the help of angiographycally guided techniques.
  43. 43. Embolisation
  44. 44. S= Subtotal Hysterectomy  Last resort, if everything fails.  Sometimes total hysterectomy is also done  Ovaries must be preserved at any cost.
  45. 45. Golden Hour  The 1st hour of PPH is taken as the golden hour, coz if management started within 1st hour of onset of PPH, then the patient has the best chance of survival.  Chance of survival decrease sharply after the 1st hour.
  46. 46. Rule of 30 1. SBP drops by 30mmHg 2. Heart rate falls by 30 bpm 3. Resp rate becomes >30/ min 4. Hematocrit/ Hb drops by 30% 5. Urine output becomes <30 ml/hr  It means that the pt has lost >30% of her blood and is in moderate shock.