2. INTRODUCTION
Around 300,000 maternal mortality occur allover
the world each year according to WHO
Out of this hemorrhage contributed to 27% most
which is due to PPH
It is the leading cause of maternal mortality in both
high and low income countries
PPH occurs in 1 to 5% of deliveries and is an
obstetric emergency.
It the most preventable cause of maternal mortality.
Timely diagnosis, appropriate resources, and
appropriate management are critical for preventing
death
2
3. Global cause of maternal death(2015)
27
14
11
8
3
10
28
percent
Hemorhage
Hypertension
Sepsis
Abortion
Embolism
other direct
idirect cau.
3
4. Cont ….
• The potential for massive hemorrhage after
delivery is high
• Hemostasis occurs upon placental separation by
a combination of two mechanisms:
1. Contraction of the myometrium
2. Local decidual hemostatic factors and systemic
coagulation factors
• The pathogenesis of most cases of PPH is a
disturbance in one or both of these
mechanisms
4
6. Definition of PPH
• Definition/diagnosis: PPH is classically defined by
the volume of blood loss (ie, estimated blood loss
≥500 mL after vaginal birth or ≥1000 mL after
cesarean delivery)
• ACOG revised their definition of PPH:
1,cumulative blood loss ≥1000 mL or
2,bleeding associated with signs/symptoms of
hypovolemia within 24 hours of the birth process
regardless of delivery route
• In order to reduce the number of women
inappropriately labeled with PPH
6
7. Classification of PPH
Classification of PPH:
1. PPH occurring in the first 24 hours after
delivery is called primary or early PPH, and
2. PPH occurring from 24 hours to 12 weeks
after delivery is called secondary, late, or
delayed PPH
7
8. Etiology and Risk Factors
• Causes of primary and secondary PPH
Primary PPH Secondary PPH
•Uterine atony
•Genital tract lacerations
(perineal, vaginal, cervical,
,broad ligament, Uterine
rupture)
•Retained products of
conception
•Coagulopathy
•Infection
•Retained products of
conception
•Placental site subinvolution
•Coagulopathy
8
9. Cont…..
The 4 Ts of PPH and their prevalence
• TONE 70%
• TRAUMA 20%
• TISSUE 10%
• THROMBIN 1%
9
3.2
10. Risk Factors
• Risk factors do not strongly predict PPH
Over two-thirds have no identifiable risk factors
• EVERY CHILDBIRTH CARRIES RISKS but, presence of
risk factors makes it more likely.
• For women with risk factors, consideration should be given
to extra precautions such as:
– IV access
– Coagulation studies
– Crossmatching of blood
– Anaesthesia backup
– Referral to a tertiary center
• Prevention and early interventions are key to survival
10
11. Cont…..
Risk factors for uterine atony
11
Etiology process Clinical risk factors
Over distended uterus
polyhydraminos
Multiple gestation
Macrosomia
Uterine muscle exhaustion
Rapid labor
Prolonged labor
High parity
Induction/ augumentation
Intra-amniotic infection Fever
Prolonged ROM
Functional/ anatomic distortion of the
uterus
Fibroid uterus
Placenta previa
Uterine anomalies
others Drugs, GA( halothane), prior Hx…
13. Cont…
• Risk factors for retained placenta:
-midtrimester delivery,
-chorioamnionitis,
-accessory placental lobes,
-morbidly adherent placenta,
-placenta previa
-miss management of 3rd stage of labor
13
14. Con …
• Risk factors for coagulopathy:
• Inherited( hemophilia A, von willebrand’s
disease….)
• Acquired (amniotic fluid embolism, APH, SPE, or
HELLP syndrome,IUFD, septic abortion and AFLP)
• Coagulopathy can also be a consequence of
Hemorrhage: when there is a severe reduction of
clotting factors due to persistent heavy bleeding
and hemodilution of the remaining clotting factors
14
15. Clinical Presentation
• Effect of hemorrhage depends on
nonpregnant blood volume, magnitude of
pregnancy induced hypervolemia, and degree
of anemia at the time of delivery
• On history the patient may have excessive
vaginal bleeding following delivery
• Palpitations, lightheadedness, Weakness and
sweating
15
16. Cont ….
• On examination:-
BP –low, PR-fast & feeble, RR- fast or air hunger
,T0 –hypothermic/cold extrimitis
Pallor, anxious/, sweating
Atonic uterus- boggy, non contracted uterus
above the umblicus
Uterine rupture- easily felt uterine defect
Retained placenta-evidenced by visible/palpable
cord or placenta in the vagina or in the uterus
Vaginal, cervical laceration
Oliguria or anuria
Confusion, Lethargy or coma
16
17. Con …
Assessment of severity of hemorrhage
Blood loss, %(mL)
Systolic Blood pressure,
mmHg
Signs and symptoms
10 to 15 (500 to 1000) Normal
Palpitations,
lightheadedness, mild
increase in heart rate
15 to 25 (1000 to 1500) Slightly low
Weakness, sweating,
tachycardia (100 to 120
beats/minute),tachypenia(
30bpm),
25 to 35 (1500 to 2000) 70 to 80
Restlessness, confusion,
pallor, oliguria, tachycardia
(120 to 140 beats/minute)
35 to 45 (2000 to 3000) 50 to 70
Lethargy, air hunger,
anuria, collapse,
tachycardia (>140
beats/minute)
17
18. Management of PPH
• Treatment goals are to:
• Restore or maintain adequate circulatory
volume
• Restore or maintain adequate tissue
oxygenation
• Reverse or prevent coagulopathy
• Eliminate the obstetric cause of PPH
18
19. Cont…
General management:
• SHOUT FOR HELP !!!!!
• ABCs of life
• Secure large bore double IV line and start resuscitation with
crystalloid,
• If the hemodynamic status doesn’t respond to crystaloid
start transfusion
• It also is important to maintain adequate oxygenation and
normothermia.
• Do Hct, B.group, rh ,x-match blood and coagulation study
• Catheterize and monitor UOP
• The initial steps of management are nonspecific to the cause
of PPH.
• While doing the above search for the cause
19
20. Con….
As more time elapses between the point of
severe shock and the start of resuscitation the
percentage of surviving patients decreases
The golden hour is the time in which
resuscitation must begin to achieve maximal
survival
20
22. Cont ….
Blood Component Therapy
PRODUCT CONTENTS VOLUME ANTICIPATED EFFECT (PER UNIT)
Whole blood All
components
500 mL Used only in emergencies*
Packed red
blood cells
Red blood cells 300 mL Increase hemoglobin by 1 g/dL
Increase hematocrit by 3%
platelet(single
donor pooled)
Platelets 300 mL (6 U) Increase platelet count by 30,000
to 60,000/mm3
Fresh frozen
plasma
All clotting
factors
250 mL Increase fibrinogen by 5-10 mg/dL
Cryoprecipitate Fibrinogen,
vWF, factors
VIII and XIII
10-15 mL Increase fibrinogen by 5-10 mg/dL
22
24. Cont….
• Focal or diffuse atony :lack of effective contraction
of the uterus after delivery
• It complicates 1 in 40 births
• Atony is dignosed when the uterus does not
become firm after routine management of the 3rd
stage of labor(AMTSL)
• If preventive measures are unsuccessful, medical
management for uterine atony should be initiated.
• This treatment includes bimanual uterine massage
and uterotonic therapy.
24
26. Cont…..
• UTEROTONIC THERAPY: represent the mainstay of drug
therapy for uterine atony.
• Oxytocin is usually given as a first-line agent.
• IV is the preferred route , but IM and IU is possible.
• Initial with 20 to 30 units of oxytocin in 500 to 1000 mL
of crystalloid solution
• Higher doses (80 units in 500 to 1000 mL) have proved
safe and efficacious
• When oxytocin fails to produce adequate uterine tone,
second-line therapy must be initiated.
• The choice of a second-line agent depends on its side-
effect profile as well as its contraindication
26
27. Cont….
AGENT DOSE ROUTE DOSING
INTERVAL
CONTRAINDICATION
Oxytocin 10 to 80 U in
500-1000
mL
crystalloid
solution
First line: IV
Second line:
IM or IU
Continuous None
Misoprostol 600-1000 μg First line: PR
Second line:
PO or SL
Single dose None
Methylergonovi
ne
0.2 mg First line: IM
Second line:
IU or PO
Every 2-4 hr Hypertension,
migraines,
scleroderma,
Raynaud
syndrome
27
28. AGENT DOSE ROUTE DOSING
INTERVAL
CONTRAINDICATION
Prostaglandin
F2α
(carboprost)
0.25 mg First line: IM
Second line: IU
Every 15-90 min
(maximum of 8
doses)
Active cardiac,
pulmonary,
renal, or hepatic
disease
Prostaglandin E2
(Dinoprostone)
20 mg PR Every 2 hr Hypotension
28
29. Cont ..
• If pharmacologic methods fail to control
atony-related hemorrhage, alternative
measures must be undertaken.
These measures include:
• Uterine tamponade,
• Selective arterial embolization, and
• Surgical intervention
29
30. Cont ..
• UTERINE TAMPONADE: is a safe, simple, and effective
way to control PPH by providing tamponade to the
bleeding uterine surface
• It is effective in many patients with atony or lower
segment bleeding.
Tamponade works by reduction in uterine artery
perfusion pressure :
• direct compression of the uterine artery in the lower
segment or
• due to changes in the uterine wall conformation
• If you use chemical impregnated pack it also provide
additional clot formation and uterotonic effect
30
31. • Options used for uterine tamponade
1.long, continuous gauze
2.intrauterine tamponade balloons
• While the patient is on uterine tamponade the
bladder should be catheterized , broad
spectrum antibiotics must be provided and
vital sign monitored.
• Tamponade should stay for 12-24 hour
31
32. Cont..
• SELECTIVE ARTERIAL EMBOLIZATION:is an increasingly
common therapeutic option for hemodynamically stable
patients with PPH.
• The procedure can be performed alone or after failed
surgical intervention.
• Diagnostic pelvic angiography is used to visualize bleeding
vessels, and gelatin (e.g., Gelfoam]) pledgets are placed
into the vessels for occlusion.
• Cumulative success rates of 90% to 97%
• Selective arterial embolization has several advantages over
surgical intervention.
1. First, it allows for selective occlusion of bleeding vessels
2. Second, the uterus and potential future fertility are
preserved
32
33. Cont….
• When uterine atony is unresponsive to conservative
management, surgical intervention by laparotomy is
necessary.
• Possible interventions include arterial ligation, uterine
compression sutures, and hysterectomy.
• The goal of arterial ligation is to decrease uterine
perfusion
• Success rates have varied from 40% to 95%
• Arterial ligation may be performed on the ascending
uterine arteries, the uteroovarian arteries,
infundibulopelvic vessels and the internal iliac
(hypogastric) arteries.
• Because internal iliac arterial ligation can be technically
challenging and time consuming, it is not advised as a
first-line technique 33
34. Cont…..
• Instead, a stepwise progression of bilaterl uterine
vessel ligation (O’Leary stitch) is recommended.
• Unilateral artery ligation will control hemorrhage
in 10% to 15% of cases, whereas bilateral ligation
will control hemorrhage in over 90% of cases.
• If bleeding persists, the uteroovarian and
infundibulopelvic vessels should be ligated.
• Although the ovarian blood supply may be
decreased with an infundibulopelvic vessel
ligation, successful pregnancy has been reported
following this procedure.
34
36. Cont…..
• uterine compression sutures:
• Have been described for atony control.
• Several techniques have evolved over the past two
decades, including the B-Lynch Suture , Hayman
vertical sutures, Pereira transverse and vertical
sutures, and multiple square sutures.
• Large absorbable suture is typically anchored within
the uterine myometrium both anteriorly and
posteriorly.
• The final surgical intervention for refractory bleeding
due to atony is hysterectomy,
36
38. Cont…..
• Retained Products of Conception - result in PPH because it
inhibit effective uterine contraction, either focally or diffusely
• It complicate 0.5% to 1% of deliveries.
• The diagnosis is made when spontaneous expulsion of the
tissue has not occurred within 30 to 60 minutes of delivery.
• Retained products of conception typically present with
uterine bleeding and associated atony.
• To assess the uterus for retained products of conception, the
uterine cavity needs to be explored.
• Manual exploration is not only diagnostic but is also often
therapeutic .
• Transabdominal or transvaginal ultrasound can also be used
• Once a diagnosed therapeutic options include manual
extraction, or uterine curettage.
38
39. Cont…
• Trauma :Genital tract lacerations are the 2nd leading
cause of PPH.
• It may occur with both vaginal and cesarean
deliveries
• It should be suspected if bleeding persists despite
adequate uterine tone.
• The most common lower genital tract lacerations are
perineal, vulvar, vaginal, and cervical
• Cervical and vaginal lacerations may develop as a
result of the natural processes of delivery or may be
related to provider interventions.
39
40. Cont….
• At cesarean delivery, hemorrhage is caused by lateral
extension of the incision
• Uterine rupture may be complete or incomplete
lacerations of the myometrium
• Retroperitoneal enlargement and bulging of the broad
ligament at cesarean delivery can be signs of
retroperitoneal hemorrhage.
• Adequate exposure and retraction are essential for
identification of many of these lacerations.
• Once a genital tract laceration is identified, management
is to repair depending on its severity and location
40
41. Cont….
• Coagulopathy :represents an imbalance between the
clotting and fibrinolytic systems
• It is a cause of PPH in women with an inherited or
acquired bleeding diathesis
• Primary manifestations include:
Bleeding,
hypotension out of proportion to blood loss,
microangiopathic hemolytic anemia,
acute lung injury,
acute renal failure, and
ischemic end-organ tissue damage.
41
42. Cont…
• Coagulopathy is a clinical diagnosis that is
confirmed with laboratory data
• When timely laboratory assessment is
unavailable, bed side clotting test with 5ml of
blood
• If a clot is not visible within 6-8 minutes or
forms and lyses within 30 minutes, the
fibrinogen level is usually less than 150 mg/dL.
42
43. Cont …..
• The most important factor in the successful treatment
of coagulopathy is identifying and correcting the
underlying etiology
• In addition, rapid replacement of blood products and
clotting factors should occur simultaneously.
• Laboratory studies should be drawn serially every 4
hours until resolution of the coagulopathy
• The obstetrician should attempt to achieve:
1. a hematocrit greater than 21%,
2. a platelet count greater than 50,000/mm3,
3. a fibrinogen level greater than 100 mg/dL, and
4. PT and aPTT less than 1.5 times control
43
44. Prevention
Management of risk — Women with risk factors for PPH
should be identified and counseled as appropriate for
their level of risk
• Planning for these patients involves ensuring availability of
resources that might be needed, including personnel,
medication, equipment, adequate intravenous access, and
blood products.
• Intrapartum, blood should be typed and screened for
women with a medium risk factor for PPH and typed and
crossmatched for those at high risk of PPH
• However, for most patients, knowledge of risk factors for
PPH is not useful clinically because only a small proportion
of at-risk women develop PPH and many women without
risk factors experience PPH
44
45. Risk assessment for PPH
The incidence of severe PPH (ie, necessitating transfusion) in the low, midium and
high riskgroups was 0.8, 2.0, and 7.3%, respectively, and only 22%of severe PPH
cases occurred in the high-risk group
the California quality improvement toolkit
Low risk Medium risk High risk
•Singleton pregnancy
•Fewer than four previous
deliveries
•No previous uterine surgery
•No history of PPH
•Prior uterine surgery
•More than four previous
deliveries
•Multiple gestation
•Large fibroids
•Chorioamnionitis
•Magnesium sulfate or
prolonged oxytocin infusion
•Morbidly adherent placenta
•Hematocrit <30 percent
•Bleeding at admission
•Bleeding
diathesis/coagulation defect
•History of PPH
•Tachycardia, hypotension
45
46. Cont..
Preventive methods for atony associated PPH
1. AMTSL- for all laboring mothers
it prevents PPH by over 60%
Components of AMTSL are;
1Administering uterotonic agent(oxytocin 10 IU IM)
2Controlled cord traction (CCT), and
3Uterine massage.
2. Spontaneous placental separation during cesarean
delivery (reduce blood loss by 30% and
endometritis 7 fold as compared with manual
removal), and
3. Prolonged postpartum oxytocin infusion(for 4-
8hours)
46
47. Cont….
To prevent trauma associated PPH:
• Where episiotomy is indicated, the mediolateral
technique is recommended, with careful attention to
ensure that the angle is 60 degrees away from the
midline when the perineum is distended.
• Perineal protection at crowning can be protective.
• Warm compression of the perineum during the
second stage of labour reduces the risk of anal
sphincter injuries
47
48. Complications of PPH
Hypovolemic shock and organ failure:
- renal failure,
- stroke,
-myocardial infarction,
-postpartum hypopituitarism (Sheehan syndrome)
Fluid overload (pulmonary edema, dilutional coagulopathy)
Anemia
Transfusion (54%) and its related complications
Anesthesia-related complications
Sepsis, wound infection, pneumonia
Venous thrombosis or embolism (0.3%)
Unplanned sterilization due to need for hysterectomy (2.5-3.5%)
Asherman syndrome (related to curettage if performed for retained
products of conception)
Death ( 0.6-20%) 48
