Post-partum hemorrhage

1. Postpartum
Haemorrhage
Presented by:
Dr.Redwan Mahmud
Intern doctor , 250 Bedded General Hospital, Noakhali

2. Learning Objectives
● Definition (Quantitative & Clinical)
● Types ( Primary & Secondary)
● Causes of primary PPH
● Clinical presentation
● Investigation
● Immediate management
● Mechanical method
● Surgical interventions
● Prevention
● Secondary PPH and management

3. PPH is still a major killer of mothers
Percentage distribution of causes of maternal death,Bangladesh, 2016

4. Incidence
● 1 death every 4 min!!!!
● Death due to PPH occurs within 2 hours if no
active intervention taken , as compared to APH –
12 hours , obstructed labor - 2 days , infection –
6 days

6. 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)”

7. Quantitative definition
● Quantitative definition is arbitrary and related
to amount of blood loss in excess of 500 ml
following birth of the baby(WHO)
● Average amount of blood loss:
⮚ Following vaginal delivery : 500 ml
⮚ Following caesarean section : 1000 ml
⮚Following caesarean hysterectomy : 1500ml

9. Causes of primary PPH

10. Atonic Uterus (80%): Risk factors
⮚ Grand multipara
⮚ Over distended Uterus: multiple pg, hydroamnion, big baby(>4kg)
⮚ Malnutrition & Anemia (<9.0g/dl)
⮚ APH( Both placenta previa & abruptio placenta)
⮚ Prolong labor(>12 hr): poor retraction, amnionitis
⮚ Anesthesia: ether, halothane
⮚ Malformation of Uterus
⮚ Fibroid : Causes imperfect retraction
⮚ Mismanaged Third stage of labor
⮚ Placenta (accreta, percreta)
⮚ Others: obesity(BMI>35), drugs(MgSO4,nifedipine) age(>40y)

11. Traumatic(20%)
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

12. Thrombin(Blood coagulopathy)
Due to diminished procoagulant or increased fibrinolytic activity.
Condition where such disorders occurs:
⮚ Abruptio placenta
⮚ Jaundice in pregnancy
⮚ Thrombocytopenic purpura
⮚ Severe pre eclampsia
⮚ HELLP syndrome
⮚ IUD

13. Clinical Presentation
Symptoms:
PV bleeding with or without visible blood loss within 24 hr following birth of the baby
Signs :
Pallor
Features of shock
Altered level of conciousness
Well contracted uterus ( Tramatic)
Flabby uterus & hard on massaging ( atonic cause)

14. Investigations
Blood:
Blood grouping & Rh typing , Hb%
Coagulation Profile:
BT,CT & PT time
USG :
for any retained bits of placenta (After resuscitation of patient )

15. Immediate management
Shout for help
↓
Monitoring of vital signs
↓
Monitoring urine output (continuous catheterization)
↓
Palpate the uterus & massaging the uterus
↓
Look placenta is expelled out or not
↓
Opening up of IV channel by two large bore cannula(18G)
↓
Blood grouping & Rh typing and Ask for at least 2 unit FHB
↓
Give O2 by oxygen mask 10-15L/min
↓
Infuse 2L normal saline or plasma substitute
↓

16. Continue………
Start 20 unit of oxytocin in 1L normal saline IV @ 60 d/min
Or , single dose Carbitocin 100mcg IV as an alternative to oxytocin
⮚ Inj Ergometrine 0.5mg IM or IV . Maximum dose 1.25mg (contraindicated when BP high)
⮚ Transfuse blood as soon as it is available

17. In Refractory cases
Tab: Misoprostol ( prostaglandin E1) 800mcg per rectally
is to be administered .
Inj tranexamic acid 0.5gm or 1gm given in addition to
oxytocin
Uterine atony due to tocolytic agent → Calcium
gluconate 1g IV slowly should be given to neutrilize the
calcium blocking effect of drugs.

18. In management of PPH due to uterine inertia
we usually give Inj Oxytocin, Inj Ergometrin, Inj
Carbetocin, Inj Trannexamic acid & Tab
Misoprostol 800 to 1000 micro gm per rectally.
Carbetocin is preferred to Oxytocin.
Carbetocin is heat stable. But Oxytocin is heat
sensitive & for this reason most of the time PPH
due to uterine atony can not be controlled by
Oxytocin.
On the other hand there is delayed
absorption of Misoprostol when it is given

19. Recent guideline suggests the following drugs to manage
PPH due to uterine atony :-
● 1.Inj Carbetocin 1 amp slow i/v
● 2. Inj Trannexamic acid 2gm slow i/v
● 3. Tab Misoprostol 800 micro gm S/L.
● 4. Inj Ergometrin or Inj Syntometrin may also be given if necessary

20. Mechanical method
1. Bimanual uterine compression
2. Compression of the Aorta
3. Uterine temponade
4. Intrauterine packing

21. Mechanical method

22. Condom Tamponade
It is successful in atonic PPH.
This can avoid Hysterectomy in 78% cases
Inflate the condom with 250-500ml of running
normal saline
Uterine contraction is maintained by oxytocin
drip for at least 6 hrs after the procedure
The condom catheter kept for 24-48 hrs then
deflate gradually over 10-15 min
Patient kept under triple antibiotic coverage
(Amoxicilline + Gentamicin+ metronidazole)

23. Surgical Interventions
⮚ B-Lynch compression suture and multiple square suture
(success rate 80% )
⮚ Ligation of uterine arteries
⮚ Bilateral internal iliac artery ligation
⮚ Arterial Embolization
⮚ Total or Subtotal abdominal hysterectomy

24. B-Lynch compression suture

25. Ligation of uterine artery
Ascending branch of
the uterine artery is
ligated at the lateral
border between upper
and lower uterine
segment. In atonic
hemorrhage, bilateral
ligation is effective in
about 75%

26. Bilateral internal iliac artery ligation
Reduces the distal blood flow. It helps stable
clot formation by reducing the pulse pressure up
to 85%. Due to extensive collateral circulation,
there is no pelvic tissue necrosis. Bilateral
ligation (not division) can avoid hysterectomy in
about 50% of the cases

27. Prevention
1. Regular antenatal care
2. Correction of anemia and malnutrition
3. Identify the risk women and deliver them in a
hospital where emergency obstetric facility
available
4. By doing active management of third stage of
labor( AMTSL)

28. Antenatal care
● Improvement of the health status of the women
● Keep the Hb level >10g/dl
● Screening the high risk patient ( Twin, grand multipara, severe
anemia, H/O PPH,APH)
● Blood grouping & Rh Typing
● Placental Localization by USG
● Women with morbid adherent placenta are high risk of PPH. Such
case should be delivered by senior obstetrician.

29. Intranatal care
● Active management of third stage of labor reduce PPH 60%
● Women delivered by C/S oxytocin 5 IU IV slowly given to
reduce blood loss. Long acting carbitocin is very useful to
prevent PPH
● Observation of uterovaginal canal to find out any trauma
● Examination of placenta and membrane to detect any
missing part
● Observation for two hours after delivery to make sure that
uterus is hard and contracted

30. Management of third stage bleeding
● The principles in the management are :
Toemptytheuterus
Toreplacetheblood
Toensureeffectivehemostasis

31. Steps of third stage management
1. After delivery of the baby ,first
we should exclude twin present
or not . If twin present ,don’t
give oxytocin .
2. After exclude twin pregnancy,
then Inj Oxytocin 10 IU IM is to
given within one minute of
delivery of the baby .
3. The placenta is to be delivered
by CCT & CT
4. Immediate massage the fundus
of uterus until the uterus
contracted . Massaging every 15
min later upto one hour. So, 4
times an hour.

32. PPH bundle Approach
● First approach:
❑ 1. AMTSL
❑ 2. Open IV fluid channel by Green cannula
❑ 3 Oxytocin 20 IU in 1 litter
❑ 4. tranexamic acid ( we give it when pt come within 3 hrs.
after that it will not work)
❑ 5. ORRT ( Obs rapid response team)
● Second approach : (supportive measure) :
❑ Treat tear
❑ Empty bladder
❑ Empty uterus

33. ● Third approach ; ( Refractory PPH intervention)
❑ Bimanual uterine compression
❑ Aortic compression – only for stoppage bleeding , it is
temporary
❑ Ballon tamponade
❑ Anti shock garments
● Referral
● Surgery

34. Secondary PPH
● Bleeding occuring after 24 hours upto the end of puerperium is callled
secondary PPH
Causes :
● Retained bits of cotyledon , membrane & blood clot
● Infection and separation of slough
● Endometritis & Subinvolution of placenta site
● Haemorrhage from C/S wound
● Inversion of uterus , fibroid ,placental polyp

35. Clinical Manifestation
❖ The lochia are heavier then normal and bright red in color.
❖ Lochia is offensive if associated with infection.
❖ Sub involution of the uterus.
❖ Abdominal cramp
❖ Pyrexia and tachycardia.
❖ Open cervical OS
❖ Anemia proportionate to blood loss.

36. Investigations
● a. Blood grouping and cross matching
● b. Full blood count
● c. Coagulation test
● d. Increased C-reactive protein indicate infection
● e. Vaginal swab for aeorobic and anaerobic bacterial growth
● f. Urine for C/S
● g. Blood culture (if maternal temperature is very high)
● h. USG of pelvis for retained placental tissue

37. Management
Supportive therapy:
Blood transfusion if necessary
ergometrine 0.5 mg IM if bleeding uterine origin
Antibiotic
Conservative theraphy :
bed rest and observation for 24hrs if bleeding is mild

38. Active management
❑ - Exploration of uterus is to be done under general anesthesia.
❑ Gentle curettage is done by flushing curette and sent materials for
histological examination.
❑ Ergometrine 0.5mg IM.
❑ Secondary hemorrhage following cesarean section may at times require
laparotomy. The bleeding from uterine wound can be controlled by
haemostatic sutures, may rarely require ligation of the internal iliac artery
or hysterectomy

39. Complications
● Hypovolumic shock
● Renal failure
● Hepatic failure
● Adult respiratory distress syndrome
● DIC
● Sheehan’s syndrome
● Maternal death