clinical detail of pph causes types medical management surgical management

1. Post Partum Hemorrhage

2. According to WHO it is define as the amount of blood
loss in excess of 500ml following birth of baby
Any amount of bleeding from or into the genital tract
following birth up to the end of the 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

3. Obstetrics emergency
leading cause of maternal death world wide
Occurs in up to 18% of total births
Among different factors, PPH due to uterine atony
is the primary and direct cause of maternal
mortality comprising about 90%

4. Depending upon the amount of blood loss, PPH
can be
1. Minor PPH (estimated blood loss of up to 1000 mls.)
2. Major PPH (estimated blood loss over 1000 mls.)
3. Severe PPH (estimated blood loss over 2000 mls.)
The average blood loss following vaginal delivery, cesarean
delivery and cesarean hysterectomy is 500 ml, 1000 ml and 1500
ml respectively.

5. Types
1. Primary PPH(within 24hrs following birth of baby)
a. Third stage hemorrhage(before expulsion of placenta)
b. True post partum haemorrhage(subsequent to expulsion of placenta)
2. Secondary PPH(beyond 24 hrs & within puerperium)
. Also k/a delayed or late puerperal hemorrhage

6. CAUSE OF PRIMARY
POSTPARTUM HEMORRHAGE
Four basic pathologies are expressed as the four
Ts’
Tone-uterine atony
Tissue-retained placenta ,blood clots
Trauma-genital tract injury
thrombin-coagulopathy

7. ATONIC UTERUS(80%)
• Commonest cause of PPH
• As long as placenta remains unseparated ; bleeding is unlikely.
• with separation of the placenta , the uterine sinuses torn, which
cannot be compressed effectively due to the imperfect contraction
and retraction of uterus and bleeding continues.

8. Predisposing factors
1.Grand multipara
• Inadequate retraction and frequent adherent
contribute to it.
2. Overdistension of the uterus
-multiple pregnancy
-hydramnios
-big baby(>4kg)
3.Malnutrition and anemia(<9g/dl)

9. 4.Antepartum hemorrhage
-placenta previa
-abruptio placenta
5.Prolonged labor(>12 hours)
-dehydration
-infection
-poor retraction
6.Anesthesia
-anesthetic agent like ether , halothane

10. 7.Initiation and agumentation of delivery by oxytocin
-if oxytocin is contine for at least one hour following delivery.
8.Malformation of uterus
-implantation of the placenta inuterine septum of septate uterus or in cornual
region of bicornute uterus.
9.Uterine fibroid

11. 10.Mismanaged third stage of labour
-too rapid delivery of the baby preventing the uterine wall to adapt to the
diminising content
-premature attempt to deliver the placenta before it separate
-pulling the cord
-manual separation of placenta increase blood loss during cesarean delivery
11.Placenta
-morbidly adherent (accreta,percreta)
-partially or compeletly seprated
12.precipitate labor

12. • Other causes of atonic hemorrhage are;
-obesity(BMI>35)
-previous PPH
-age(>40 years)
-drugs; ritodrine,mgso4,nifidepine

13. TRAUMATIC
• Trauma to genital tract due to
-operative delivery
-episitomy
-cesarean section

14. RETAINED TISSUE
-bits of placenta
-blood clots
THROMBIN
-blood coagulation disorder ; acquired or congenital
-blood coagulopathy; diminised procoagulant or increase fibrinolytic
activity

15. CAUSE OF SECONDARY POSTPARTUM
HEMORRHAGE
1.Retained bits of cotyledon or membranes
2.Infection and separation of slough over a deep
cervicovaginal laceration
3.Endometritis and subinvolution of placental sites-due to
delayed healing process
4.Secondary hemorrhage from cesarean section wound
usually occurs between 10 and 40 days
5.Withdrawal bleeding following estrogen therapy for
suppression of lactation
6.Other cause are; chorionepithelioma,carcinoma of
cervix,placental polyp,infected fibroid, uterine
arteriovenous fistula formation and puerperal inversion

16. Management of PPH
Medical management

17. Communication
Resuscitation
Monitoring
Arrest the bleeding

18. 1. Communication
• Alert all relevant professionals
• Involve the obstetric registrar on call
• Communicate with patient and partner

19. 2. Resuscitation
• Access airway, breathing and circulation
• Give oxygen 10-15L/min via mask
• Two wide bore cannula is inserted and crystalloid is
infused

20. •Send blood for full count, group, cross
matching, coagulation screen and ask for 2
unit of blood

21. 3. Monitoring
•Continuous monitoring of pulse, BP,
temperature and respiratory rate
•Put foley catheter to monitor urine output

22. 4. Arrest the bleeding
• Bleeding can be treated
I. Mechanically
II. Pharmacologically
III. Surgically

23. Step 1
•Uterine massage: to make uterus hard and express
blood clot
•I.V Methergine 0.2 mg
•Inj. Oxytocin
•To examine expelled placenta and membrane

24. Step 2
• The uterus is explored under general anesthesia to
exclude coexisting bleeding site from injured area
• In refractory cases
Misopristol 1000mcg per rectum
Calcium gluconate 1gm I.V slowly

25. Step 3
•Bimanual compression of uterus: it stimulates the
uterus to contract.

26. •In spite of this therapy bleeding continues
then it is due to coagulation disorders.
Massive blood transfusion is done until
special measure can be taken.
•Almost all cases respond well with oxytocin
and blood transfusion

27. Management of secondary PPH
• For retained bits of placenta: removal by ovum
forceps. Curettage is done by using flushing
curette
• I.M methergine 0.2mg
• Blood transfusion
• To administer antibiotic (clindamycin and
metronidazole)

28. MD FIROZ ALI

29. It is the final method when all the other methods fail to control post partum
haemorrhage.
It includes two steps,
Devascularisation procedure
a) B lynch compression suture
b) Ligaton of uterine artery
c) Ligation of utero-ovarian artery anastomosis
d) Ligation of ant. Div. of Internal iliac artery
e) Angiograhic arterial embolisation
 Hysterectomy

30. B lynch suture
Christopher B Lynch developed it in 1997
 Objective-To compress the uterus without occluding the UA or the
uterine cavity.
 Ind: Atonic PPH,PPH with coagulopathy
 Suture: absorbable-Polyglactin ,Chromic .
Procedure: A compression test is done and if the uterus responds this
suture is attempted

31. Bimanual compression
Wearing hld gloves, insert hand into
vagina; form fist
Place fist into anterior fornix and apply
pressure against anterior wall of uterus.
With other hand, press deeply into
abdomen behind uerus, appling pressure
against posterior wall of uterus
Maintain compression for 20-30 min or
until bleeding is controlled and uterus
contracts

32. B-Lynch suture Procedure:Take a suture 3cm below the incision line
and come out 3cm above the line.
Take the suture over the fundus and come posteriorly.
Now take a horizontal suture in the lower segment of uterus posteriorly.
Take this suture over the fundus and come anteriorly.
Insert a suture again 3cm above the incision ,then come out 3cm below
the incision .
Tell the assistant to compress the uterus while you tie the knot.
SR-80% , Avoid hysterectomy

33. 1
2
3 4
5
6
4 3
1
2 5
6
B-lynch “Brace” suture
Anterior view
Posterior view

35. Ligation of arteries

36. B)Ligation of uterine arteries
 Ascending branch of uterine artery is ligated at
the lateral border b/n upper and lower uterine
segment.
 No.1. chromic catgut is used.
If bleeding continues.
C) Ligation of ovarian & uterine artery
anastamosis
 Done just below the ovarian ligament.
 Some times, temporary occlusion of
ovarian vessels at infundibulopelvic ligament
is done by rubber sleeved clamps.

37. D)Ligation of anterior division of internal iliac artery
 Done unilaterally or bilaterally.
 Reduces distal blood flow. It helps stable clot formation by reducing pp up to 85%.
 Due to extensive collateral circulation, there is no pelvic tissue necrosis.
 Bilateral ligation avoids hysterectomy in 50% of the cases.
E)Angiographic arterial embolization
Under fluroscopy using gel foam as embolus
>90% sucess rate
Avoids hysterectomy

38. Hysterectomy
Final most step.
Rarely indicated.
 Only if uterus fails to contract & bleeding continues.
If mother is parous, decision is taken earlier. It may be total or
subtotal depending on the case.

39. MM of traumatic causes
Exploration
And suturing of vaginal tears, paraurethral tears, cx tears
Hemostasis is achieved by appropriate catgut sutures.
Repair is done under GA if necessary.

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who gives
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