PPH by final yr student IGGMC Nagpur

1. POSTPARTUM
HEMORRHAGE
BY DHIRAJ P. DHOTE

2. QUANTITATIVE DEFINITION -
AMOUNT OF BLOOD LOSS IN EXCESS OF
500 ML FOLLOWING BIRTH OF THE BABY
(WHO).
DEFINITION:

3. CLINICAL DEFINITION
Any amount of bleeding from or into the genital
tract following birth of the baby upto the end of the
puerperium, which adversely affects the general
condition of the patient evidenced by - rise in pulse
rate
- fall in blood pressure

4. RCOG(2016) DEFINITION
AVERAGE BLOOD LOSS:
VAGINAL DELIVERY – 500ML
CESAREAN DELIVERY- 1000ML
CESAREAN HYSTERECTOMY- 1500ML
ACCORDING TO ACOG( American
college of obg. & gynac.)
DROP IN HEMATOCRIT OF 10 %

5. INCIDENCE
4 TO 6 % OF ALL DELIVERIES.

6. TYPES
Depending upon the amount of loss PPH can
be
- MINOR(<1L)
- MAJOR(>1L)
- SEVERE(>2L)
PRIMARY SECONDARY

7. PRIMARY PPH
 Hemorrhage occurs within 24hrs
following the birth of the baby.
 Most common cause
 Atonic uterus These are of two types
 1. THIRD STAGE HG: Bleeding
occurs before expulsion of placenta.
 2.TRUE PPH : Bleeding occurs
subsequent to expulsion of placenta.
SECONDARY PPH
 Hemorrhage occurs between 24hrs to
12 weeks.
 Retained placenta

8. CAUSES OF PRIMARY PPH
FOUR T”S
TONIC (ATONIC PPH) It is the mcc of primary PPH-90%. With the separation
of the placenta , Uterine sinuses which are torn after placental separation,
cannot be compressed effectively d/t imperfect contraction and retraction of
uterine musculature and bleeding continues.
TRAUMA(TRAUMATIC PPH)
THROMBIN(COAGULOPATHY)
TISSUE(RETAINED BITS, BLOOD CLOTS)

9.  ATONIC UTERUS
 Grand multipara
 Overdistension of the uterus as in multiple pregnancy,
hydraminos, big baby
 Malnutrition & Anemia(<9.0g/dl)
 APH (Placenta previa & abruption)
 Prolonged labour (>12hr)
 Anesthesia (Ether, halothane)
 Initiation of delivery by oxytocin
 Malformation of uterus
 Uterine fibroid
 Mismanaged third stage labour
• Too rapid delivery of baby • Pulling the cord
• Premature attempt to remove placenta

10.  Placenta: Morbidly adherent placenta(accrete ,percreta)
 Partially or completely separated placenta
 OTHER cause of atonic HG.
 Obesity(BMI>35)
 Previous PPH
 Age(>40yrs)
 Drugs: Tocolytic agent like Ritodrine, MgSO4, Nifedipine.

11. TRAUMATIC PPH
• Trauma involves usually cervix, vagina, perineum (episiotomy wound,
lacerations)
para urethral region and rarely uterine rupture
• Bleeding is usually revealed but may be concealed ( vulvo vaginal or broad
ligament hematoma)
Trauma to the genital tract occurs following
Operative delivery
Episiotomy
Blood loss in casarean section

12. RETAINED TISSUE
Bits of placenta
Blood clots
THROMBIN
• DUE TO diminished procoagulants(washout phenomenon) or increased
fibrinolytic activity.
• The condition:
abruptio placentae,
severe pre eclampsia,
HELLP ,
thrombocytopenic purpura

13. DIAGNOSIS & CLINICAL
EFFECTS
SHOCK INDEX- SI = HR/ SYSTOLIC BP
Normal- 0.5-0.7
-This has been used in intensive treatment units& trauma centre as a guide to
estimate the amount of blood loss.
-If it increases above 0.9-1.1, then intensive resuscitation may be required.
TRAUMATIC PPH ATONIC PPH
UTERUS; Well contracted Flabby & become hard on massaging

14. 1. In PPH, the vaginal bleeding is visible as a slow
trickle.
2.The effect of blood loss depends on
 -Pre delivery haemoglobin level
 - Degree of pregnancy induced
hypervolemia
 - Speed at which blood loss occurs.

15. Table 8.4 SA

16. PROGNOSIS
1. It is one of the life threatening emergencies.
2. It is one of the major causes of maternal death in developing and developed
countries.
3. INCREASED morbidity sequelae include-
- Shock
- Transfusion reaction
- Puerperal sepsis
- Falling lactation
- Pulmonary embolism
- Thrombosis & thrombophlebitis
Late sequelae include- Sheehan’s syndrome ( Selective hypopituitarism)
Rarely, Diabetes insipidus.

17. MANAGEMENT OF THIRD STAGE
BLEEDING PLACENTAL SITE BLEEDING
a. Palpate the fundus and massage: It is done by placing the four
fingers behind the uterus & thumb in front.
b. Start crystalloid solution (NS or RL) with oxytocin (1L with 20
units) at 60 drops per min
c. Oxytocin 10U IM or Methergine 0.2 mg iv
d. Catheterize the bladder
e. Antibiotics ( ampicillin 2g and metronidazole 500 mg iv)
TRAUMATIC BLEEDING : explore uterovaginal canal under GA
after expulsion of placenta and place hemostatic sutures.

18. MANUAL REMOVAL OF PLACENTA

19. COMPLICATION
1. Hemorrahge
2. Shock
3. Injury to the uterus
4. Infection
5. Inversion
6. Subinvolution
7. Thromboembolism
8. Embolism

20. MANAGEMENT OF TRUE PPH
PRINCIPLES: Simultaneous approach
- Communication
- Resuscitation
- Monitoring
- Arrest of bleeding
MANAGEMENT: 1.Immediate measures
- Call for extra help.
- Put in 2 large bore IV cannulas.
- Send blood for CBC, grouping, cross matching,RFT,LFT, Coagulation
screening.
- Check vitals.
- Infuse rapidly 2 L OF NS or Colloids.
- Give Oxygen by mask 10-15 L/min.

21. ACTUAL MANAGEMENT
ATONIC UTERUS :
Management: It includes-
1. Medical methods
2. Mechanical methods
3. Surgical methods

22. MEDICAL MANAGEMENT
PHOTOS

23. 2. MECHANICAL METHODS
1. Uterine massage & bimanual compression:
- It is now recommended by WHO as a measure to treat PPH.

24. 2.UTERINE TAMPONADE
A. TIGHT UTERINE PACKING:
- 5m long strip of gauge, 8cm wide folded is twice is required.
Gauze soak with antiseptic cream
Gauze placed high up & placed into the fundal area first
while, uterus is steadied by external hand.
Then, gradually the rest of the cavity is packed .

25. ACTION:
IUP acts by 1. Stimulating uterine contraction.
2. Exerts direct hemostatic pressure to the open
- uterine sinuses.
NOTE: Antibiotics should be given and the plug removed after 24hrs.
B. BALOON TAMPONADE :

26. CONSIDER FIRST LINE SURGICAL INTERVENTION
FOR MOST WOMEN WITH ATONIC UTERUS.
Mechanism of action: ~ TIUP
Ex. 1. Foleys catheter
2. Bakri balloon
3. Condom catheter
4. Sengsten- Blakemore
Inserted into uterine cavity & balloon inflamed with
NORMAL SALINE(200- 500 ml)
Kepts for 4-6hours
This can avoid hysterectomy in 78% of cases.

28. OTHER MEASURES
1. Non pneumatic antishock garment
2. Compression of abdominal aorta.

29. 3. SURGICAL METHODS
SURGICAL METHODS
If family is not complete If family is completed
1. B-Lynch suture& multiple square - hysterectomy
2. Ligation of uterine arteries
3. L. of ovarian & UA anastomosis
4. L. of ant. Division of internal iliac A.
5. Embolization

30. A. B LYNCH COMPRESSION &
MULTIPLE SQUARE METHOD
Use of vertical brace suture
Appose ANTERIOR & POSTERIOR walls of the uterus
Compression of FUNDUS & LUS
Controlling the hg.
Main adv.: 1. Very easy to perform.
2. It can avoid hysterectomy
3. Success rate 80%.

31. B.LIGATION OF UTERINE ARTERIES
Ascending branch
At lateral border betn upper & lower US
The sutures is passed into the myometrium 2cm
medial to the artery.

32. C.LIGATION OF THE OVARIAN & UTERINE
ARTERY ANASTOMOSIS
At the infundibulo-pelvic ligament by rubber
sleeved clamps.

33. OTHER METHODS
D. Ligation of Anterior division of internal iliac
artery
E. Angiographic selective arterial embolization-
Under fluoroscopy Using gel foam
F. Hysterectomy.

34. TRAUMATIC PPH
1. The trauma to the perineum, vagina & the cervix is to be
searched under good light by speculum examination.
2. Hemeostasis is achieved by appropriate CATGUT SUTURES.
COAGULATION DISORDERS
• FRESH blood transfusion
• Plasma expander (Haemaccel) should be avoided
• single donor platelet / FFP transfusion
• recombinant activated factor VII (rFVIIa)

35. RETAINED TISSUE
•Retained placenta with shock but no hemorrhage- first treat shock
and then manual removal of placenta
•Retained placenta with hemorrhage- treat as third stage hemorrhage
•Retained placenta with sepsis -antibiotics and manual removal after
improvement.

36. SECONDARY PPH
USUALLY OCCURS BETN 8TH TO 14 TH DOD.

37. A.CAUSES
1.Retained bits of cotyledon or membranes(MC)
2 .Infection and seperation of slough over deep cervicovaginal
laceration
3. Endometritis and subinvolution of placental site due to delayed
healing process.
4 .Secondary hemorrhage from CS wound usually betn 10 and 14
days. Due to (A) Separation of slough exposing a bleeding vessels.
(B)From granulation tissue.
5. Withdrawl Bleeding following estrogen therapy for suppression of
lactation.

38. RARE CAUSES
- Chorioepithelioma
- Carcinoma cervix
- Placental polyp
- Infected fibroid
- Uterine AV fistula

39. DIAGNOSIS
1. Bleeding- bright red
2. Signs of sepsis , varying degree of anemia
Internal examination-
- - Subinvolution of uterus
- Sepsis
- Patulous cervical os
USG : Detects the bits of placenta inside the
uterine cavity.

40. MANAGEMENT
1. Supportive therapy:
- Blood transfusion
- Methergine 0.2mg IM, if bleeding is uterine in origin -
- Antibiotics: Clindamycin & Metronidazole
2. Active treatment:
- Explore uterus urgently under GA and remove retained bits by ovum
forceps.
- Gentle curettage with flushing curette and the materials removed are
send for histological examination.
- Methergine 0.2 mg IM
- Secondary haemorrhage following CS require LAPAROTOMY.

41. - Bleeding from uterine wound is controlled by hemostatic
sutures:
-Uterine artery embolization ,
- Ligation of Internal iliac artery
- Hysterectomy

42. MCQ^S
1. The most common cause of PPH....
A. Uterine atony B. Retained products
C. Trauma D. Bledding disorders
2. The atonic uterus is more common in
a. Casarean section
b. Multigravida
c. Primigravida
d. Breech delivery
3. All of the following are used in the treatment of PPH except
a. Misoprostol
b. Mifepristone
c.Carboprost
d. Methyl ergometrine

43. 4. B LYNCH SUTURE IS APPLIED ON
A.Cervix
b. Uterus
c. Fallopian tube
d.Ovaries
5. SHOCK INDEX IS-
A. HR. SBP
B. HR/ SBP
C. HR-SBP
D.HR/DBP

44. 6. THE doses of Misoprostol in management of atonic uterus is-
A. 600-1000 Mcg
B. 60-100 Mcg
C. 600-1000 Mg
D. 1100-2000 Mg
7. The route of administration of Misoprostol is...
A. IV
B. IM
c.Per rectal
D. Sublingual
E. Both C & D

45. 8.Which of the following is not used in management of true PPH?
a. NPASG
b. Compression of abdominal aorta
c. Balloon tamponade
d. OCPs
9. The 1st line mechanical intervention for Atonic PPH.....
a. NPASG
b. Bimanual compression
c. Ballon tamponade
d. Tight intra uterine packing