Contribution by students of Bachelors of Eastern Medicine and Surgery (BEMS) from Hamdard University, Pakistan.

1. Mirza Farjad Ali Baig

2. • Atonic
Hemorrhage
• Traumatic
Hemorrhage
Categories
of PPH
• Incidence
• Aetiology
Primary
PPH
Secondary
PPH
• Simple adhesion
• Morbid adhesion
Retained
Placenta
Diagnosis
Management

3. Categories of PPH
1. Atonic
O 90% of the cases
O Due to failure of the uterus to contract
2. Traumatic
O 10% of the cases
O Due to damage to genital tract

4. Categories
Atonic Hemorrhage
Traumatic
Hemorrhage
The most common cause of uterus
bleeding is atony, the inability of the
uterus to contract completely after
delivery.
Causes of atony include:
O Retention of placental
fragments
O Inadequate myometrical
activity
O Overdistension of the uterus
with multiple gestations
O Macrosomia
O Polyhydramnios
O Chorioamnionitis
O Prolonged obstructed labor
It is associated with traumatic delivery,
assisted or not, and previous uterine
surgery.

6. Primary Postpartum
Hemorrhage
O Excessive bleeding i.e. >500ml.
O From or into the genital tract within 24 hours of the birth
of the child.
O Ave. blood loss in normal labor is less than 300ml.
O Incidence:
O 2% - 3% of all deliveries.
O 15% are associated with retained placenta requiring manual
removal.

7. Aetiology
Placental Site Trauma to Genital Tract
1. Uterine inertia or uterine
exhaustion as in prolonged
labor.
O Grand multiparity
O Uterine over distension in
multiple pregnancy,
hydramnios.
O Accidental hemorrhage.
O Prolonged anesthesia
O Full bladder.
2. Mechanical factors preventing
retraction of the uterus
O Retention of the placenta.
O Retention of blood clots.
O Uterine fibroids.
1. Lacerations to the perineum,
vagina, cervix
2. Uterine rupture

8. Primary Haemorrhage from
Placental Site
O Causes:
O Ineffective uterine contractions & retraction.
O Mismanagement at Third Stage.
O Abnormally Adherent Placenta:
O Placenta accreta
O Placenta increta
O Placenta percreta
O Disseminated intravascular coagulation.

10. Other Causes
OCoagulation defects such as
hyperfibrinogenaemia.
OMismanagement of third stage (amateur
attempts of expressing placenta)
OHx of previous PPH
OPre-eclampsia
OObesity
OPrimigravida

11. Secondary Postpartum
Haemorrhage
O Occurs after 24 hours of puerperium.
O Uterine haemorrhage occurs within first 2
weeks after delivery up to 6 weeks after
delivery.
O May be severe or life threatening.
O Common causes:
O Delayed involution
O Retained bits of placenta

12. Retained placenta
Retention of placenta takes place under
two circumstances:
1. The placenta is detached but not
completely expelled.
2. Adherent placenta:
 Simple adhesion
 Morbid adhesion

13. Adhesive Placenta
Simple Adhesion Morbid Adhesion
O The placenta remains in
union with the uterine
wall although its
attachments are not
normal.
O The condition tends to
recur in the same patient.
O Pathological attachment
O No line of cleavage
between placenta and
uterine wall.
O Placenta accreta
O Placenta increta
O Placenta percreta

15. Diagnosis
O Loss of blood >500ml.
O Bleeding is external, mostly.
O Sometimes it is hidden or concealed, due to which uterus
becomes distended and vagina shows blood clots.
O Concealed haemorrhage is confirmed by squeezing of the uterus
firmly as there will be a gush of blood immediately.
O CBC for Hb
O Blood clotting test
O Clot observation tests
O Monitoring BP and pulse of the mother.
O Angiography
O U/S LA
O Assessing the time of bleeding.
O <24 hours: Primary PPH
O >24hours: Secondary PPH

17. Postpartum Haemorrhage
Placenta delivered
Uterus flabby
(atonic)
IV Ergometrin, Oxytocin 0.5mg
Start IV inf. 100 units Syntocinon 20 drops/min
Bimanual compression
IM Prostaglandin F 0.25mcg
Bleeding continues
Exploration under Gen. anaesthesia
Retained bits of placenta
Uterus contracted
Inspect cervix and vagina
for local trauma
Repair, if necessary under
anaesthesia
Placenta not
delivered
Normal placental attachment
but retained
Manual removal under GA
Morbid adhesion
Manual removal if separation
possible
Hysterectomy
MANAGEMENT OF PPH
• Beware of coagulation defects.
• Accurate monitoring for blood loss and urinary output
• Timely blood transfusion
• Monitor CVP for adequate replacement of blood.