Postpartum hemorrhage (PPH) is defined as blood loss greater than 500 mL following vaginal delivery or 1000 mL following cesarean delivery. It is one of the leading causes of maternal mortality worldwide. The main causes of PPH can be remembered as the four Ts: tone (uterine atony), trauma, tissue (retained placenta), and thrombin (coagulopathies). Uterine atony accounts for approximately 80% of PPH cases. Initial management of PPH involves calling for help, administering IV fluids and oxytocics, and determining the cause of bleeding in order to provide targeted treatment.

1. by Shanyar Qadir
Shanyar.com

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 Blood loss of:
 > 500 mL during vaginal delivery
 > 1,000 mL following cesarean delivery
 Measurements are subjective and likely inaccurate
 Primary (early): within 24 hrs of delivery
 Secondary (late): from 24 hrs – 12 wks post-
delivery
Definition

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 Defined clinically as excessive bleeding that makes the patient
symptomatic
 10% drop in hematocrit
 Signs/symptoms of blood loss
Objective Criteria

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 One of the most common obstetrical emergencies
 Major cause of maternal morbidity
 One of the top 3 causes of direct maternal death in
both developing and developed countries
 Leading cause of admission to the ICU
 Incidence
 4% after vaginal delivery
 6.5% after C/S delivery
Why is it important?

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Causes of PPH can be remembered as the 4 ‘Ts’
Tone Uterine atony
Trauma Injury to cervix, vagina, perineum
Tissue Retained placenta &/or membranes
Thrombin Clotting disorders
Etiology

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 Call for help, ABCs
 O2 by mask initially
 2 x 14-gauge IV lines
 FBC & clotting studies
 Test for renal function & liver function tests
 Cross-match at least 6 units of blood
 IV fluid resuscitation
 Notify blood bank & consult hematologist
 Foley catheter into the bladder & fluid balance chart
 Blood transfusion asap, O- if not available
 Central venous pressure & arterial lines
 May need FFP, platelets & cryoprecipitate (consult hematologist)
 Eliminate the cause
Initial Management

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 Most common cause of excessive PPH
 Risk Factors:
 Overworked: Rapid or prolonged labor (most common)
 Infected: Chorioamnionitis
 Relaxed: MgSO4, β-agonists, halothane
 Overdistended: Multiple pregnancies, macrosomia,
polyhydramnios
Uterine Atony (80%)

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 Clinical Findings:
 A soft uterus (feels like dough) palpable above the
umbilicus.
 Management:
 Uterine massage
 Uterotonics (oxytocin, ergonovine, misoprostol, carboprost)
 Surgical: Uterine packing or compression balloon,
B-Lynch suture, sequential arterial ligation, selective arterial
embolization, hysterectomy
Uterine Atony (80%)

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Bimanual Uterine Massage

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Compression
Balloons

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B-Lynch Suture

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 Risk Factors:
 Difficult delivery (shoulder dystocia, macrosomia)
 Instrumental delivery (forceps, vacuum extractor)
 Clinical Findings:
 Identifiable lacerations (cervix, vagina, perineum) in
the presence of a contracted uterus.
 Management:
 Surgical repair.
Genital Lacerations (15%)

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Cervical Laceration Repair

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 Risk Factors:
 Accessory placental lobe (most common)
 Abnormal trophoblastic uterine invasion
 Clinical Findings:
 Missing placental cotyledons in the presence of a
contracted uterus.
 Management:
 Manual removal or uterine curettage under US guidance.
Retained Placenta (5%)

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Placenta
Fetal side

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Placenta
Maternal side

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Succenturiate Placental Lobe

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Manual removal of placenta

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Uterine curettage

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 Risk Factors:
 Abruptio placenta (most common)
 Severe preeclampsia
 Amniotic fluid embolism
 Prolonged retention of a dead fetus
 Clinical Findings:
 Generalized oozing
 Bleeding from IV sites or lacerations in the presence of a
contracted uterus.
 Management:
 Removal of pregnancy tissues from the uterus
 Intensive care unit (ICU) support
 Selective blood-product replacement.
DIC (Rare)

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 Risk Factors:
 Fundal placentation
 Excessive cord traction
 Previous uterine inversion.
 Clinical Findings:
 Beefy-appearing bleeding mass in the vagina and failure to
palpate the uterus abdominally.
 Management:
 Elevating the vaginal fornices and lifting the uterus back into
its normal anatomic position
 IV oxytocin.
Inverted Uterus (rare)

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Progressive degrees of inversion

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Manual replacement of uterine inversion

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Clinical Diagnosis Management
Uterus not palpable Inversion (rare) ↑ fornices, IV oxytocin
Uterus like dough Atony (80%) Uterine massage,
oxytocin, ergot, PG
F2α
Tears in vagina, cervix Laceration (15%) Suture & repair
Placenta incomplete Retained placenta (5%) Manual removal or
curettage
Diffuse oozing DIC (rare) Remove POC, ICU
care, blood products
Summary

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Thank You!

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1. Obstetrics by Ten Teachers, 19e - 2011
2. Williams Obstetrics, 24e - 2014
3. A Comprehensive Textbook of Postpartum
Hemorrhage, 2e - 2012
4. Step Up to Obstetrics & Gynecology – 2014
5. Obstetrics & Gynecology Lecture Notes – 2013
6. Postpartum hemorrhage on Wikipedia
(http://en.wikipedia.org/wiki/Postpartum_hemorrhage)
Sources