2. Introduction
PPH is an obstetrical emergency that can follow
vaginal or cesarean delivery.
It is one of the top five causes of maternal
mortality in both high and low per capital
income countries
Timely diagnosis, appropriate resources, and
appropriate management are critical for
preventing death.
3. Definition of PPH
1. PPH is best defined and diagnosed clinically
as excessive bleeding that makes the patient
symptomatic (e.g. lightheadedness,
weakness, palpitations, diaphoresis,
restlessness, confusion, air hunger, syncope)
and/or results in signs of hypovolemia (e.g.
hypotension, tachycardia, oliguria, low oxygen
saturation [<95%]) 4/27/2024
3
4. Definition …
2) EBL ≥500 mL after vaginal birth or ≥1000 mL
after C/ delivery, or
3) 10 % decline in postpartum Hgb concentration
from antepartum levels , or
4) 10 % decline in postpartum maternal blood
volume from antepartum levels, and/or
5) Need for blood transfusion following post
partum bleeding. 4/27/2024
4
5. Types of PPH
1) Primary PPH ( early PPH)
occurs within 24 hours after delivery
2) Secondary PPH (late PPH)
occurs 24 hours to 6 weeks after delivery
4/27/2024
5
6. Incidence
The incidence of excessive blood loss following vaginal
delivery is 5–8%
Most common cause of excessive blood loss in pregnancy
Most transfusions in pregnant women are performed to
replace blood lost after delivery
Leading cause of maternal death
Every pregnant mother is at risk
4/27/2024
6
7. Etiology and risk factors
Bleeding after delivery is controlled by a
combination of
1. Contraction of the myometrium, which constricts
the blood vessels supplying the placental bed,
and
2. local decidual hemostatic factors, including tissue
factor , type-1 plasminogen activator inhibitor ,
and systemic coagulation factors (eg, platelet and
circulating clotting factors).
4/27/2024
7
8. Etiology cont…..
The 4 Ts of PPH
TONE 70%
TRAUMA 20%
TISSUE 10%
THROMBIN 1%
3.2
4/27/2024
8
9. Etiology cont…..
1)Uterine Atony
Inability of the uterine myometrium to contract
effectively.
Is the most common cause of primary PPH
(70% )
Complicates 1 in 20 births
4/27/2024
9
10. Risk factors for uterine atony
Etiology process Clinical risk factors
Over distended uterus
Polyhydramnios
Multiple gestation
Macrosomia
Uterine muscle exhaustion
Rapid or Prolonged labor
High parity
Induction/ augmentation
Intra-amniotic infection Fever
Prolonged ROM
Functional/ anatomic distortion
of the uterus
Fibroid uterus
Placenta previa
Uterine anomalies
others Drugs, GA( halothane), PA, prior
History.
4/27/2024
10
11. Etiology cont …..
2) Trauma (genital tract)
Genital tract lacerations are the second leading cause of
postpartum hemorrhage.
Trauma related bleeding can be due to;
Lacerations (perineal, vaginal, cervical, uterine),
Incisions ( hysterotomy , episiotomy),
Uterine rupture, or
Uterine inversion.
Risk factors for Genital tract laceration????:
4/27/2024
11
12. Etiology cont…..
3) RPOC( placental tissue and amniotic membranes) can
inhibit the uterus from adequate contraction and result in
hemorrhage
Risk factors include:
Midtrimester delivery
Chorioamnionitis
Accessory placental lobes
Abnormally adherent placenta
Accreta ….80%
Increta …...15%
Percreta ………..5%
• Retained blood clots
• Mismanagement of third stage of labor
4/27/2024
12
13. Etiology cont…..
4) Coagulation defects
Acquired and congenital bleeding.
Pre-existing states resulting in coagulation defects includes:
hemophilia A
Acquired causes of coagulopathy include ;
severe preeclampsia and eclampsia,
HELLP syndrome,
Abruption placentae,
Fetal demise (IUFD),
Amniotic fluid embolism (AFE),
Sepsis,
Transfusion of more than 8 U of blood in itself may induce a
dilutional coagulopathy.
Consumptive coagulopathy may develop in women with
severe hemorrhage.
4/27/2024
13
14. 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-related complications
Anesthesia-related complications
Sepsis, wound infection, pneumonia
Venous thrombosis or embolism
Unplanned sterilization due to need for hysterectomy
Asherman syndrome
Death
4/27/2024
14
15. Prevention of PPH
Identify high risk factors for PPH & do proper investigation and
preparation,
Iron supplementation during px to build up iron store in high
risk women,
Seek and treat anemia in pregnancy
Family planning/child spacing
AMTSL for all delivering mothers.
Spontaneous placental separation during cesarean delivery, and
Prolonged postpartum oxytocin infusion.
4/27/2024
15
16. Prevention cont…
AMTSL- for all laboring mothers
Active management of the third stage of labour prevents
PPH by over 60%
Components of AMTSL are;
1. administering uterotonic agent, oxytocin 10 IU IM with
in 1 min after delivery
2. Controlled cord traction (CCT),
3. Uterine massage and.
4. Early cord clamping
4/27/2024
16
17. Uterotonic Selection for Prevention of PPH
Uterotonic Advantages/Disadvantag
es
Doses for
Preventio
n
Storage
Requirements
Oxytocin
(IM
injection)
• Effective 2-3 minutes
after injection.
• Can only be given
intramuscularly.
• Can be used in all
women.
• Reduces length of
third stage of labor.
• Used ONLY after the
delivery of the baby.
• Minimal side effects.
• Inexpensive.
10 IU • Store between
15C & 25C (59-
77 F).
• Delivery room
stock may be
kept at room
temperature—
30C—for up to
one year with an
expected loss of
about 14
percent.
• Light does not
destabilize
oxytocin.
3.3
4/27/2024
17
18. Uterotonic Selection for Prevention of PPH
Uterotonic Advantages/Disadvantages Doses for
Prevention
Storage
Requirements
Ergometrine
(IM Injection)
• Effective 6-7 minutes after
injection.
• Effects may last 2-4 hours.
• Inexpensive.
• Contraindicated in women
with PE, Eclampsia, and
high BP.
• Can cause nausea and
vomiting.
• Requires stringent
handling and storage
conditions.
0.2mg-0.4mg
(use local
standards as
dosage may
range from 0.2
mg – 4 mg)
• Store between 2°C
– 8°C.
• Protect from light
and freezing.
• Requires stringent
handling and
storage conditions.
3.4
4/27/2024
18
19. Uterotonic Selection for Prevention of PPH
Uterotonic Advantages/Disadvantage
s
Doses for
Prevention
Storage
Requirements
Misoprostol
(tablet)
• Effective 9-12 minutes
after ingestion.
• Shivering, nausea and
elevated temperature.
Oral or SL: 600µg
Rectal: 800-
1000µg
• Store at room
temperature in a
closed container.
3.5
4/27/2024
19
21. Management of PPH
4/27/2024
21
Early recognition of PPH is a very important
factor in mgt.
An established plan of action for the
management of PPH is of great value when
the preventative measures have failed.
Treatment goals
Restore or maintain adequate circulatory
volume to prevent hypo perfusion of vital
organs
Restore or maintain adequate tissue
oxygenation
Reverse or prevent coagulopathy
Eliminate the obstetric cause of PPH
22. GENEERAL MEASURES
SHOUT FOR HELP!!!!!! (Get assistance)
ABCs of life
Oxygenate (intranasal)
Open 2 IV lines (large bore cannula) and resuscitate
with crystalloids fast to restore circulatory volume.
Send blood sample to laboratory
Massage uterus and Give oxytocin 10 IU IM
Catheterize and monitor UOP
Evaluate the possible cause of the PPH
4/27/2024
22
24. Specific measures…Uterine Atony
Remove clots
Avoid distended bladder
Medical therapy
Oxytocin 20 units in 1000 ml 0f NS Or RL 60
drops/min (>125ml/hr) IV (not more than 3 lit.)
Misoprostol 800-1000 μg PR, SL route allows for
lower dosing (400 μg) with higher bioavailability
Methylergometrine 0.2mg can be repeated every 2-4 hr
IM or IV ergometrine (maximum 5 doses)
4/27/2024
24
25. Options if medical treatment fails for uterine atony
If bleeding continues:
Explore the uterine cavity
Check placenta again for completeness
Inspect the cervix and the lower genitalia for laceration
If bleeding continues in spite of the above:
Perform bimanual compression of the uterus or compress
abdominal aorta until surgical intervention is amenable.
4/27/2024
25
27. Uterine Tamponade
4/27/2024
27
Uterine packing
Transurethral Foley
catheter placement and
prophylactic antibiotic
A tamponade-balloon
Inserted into the uterus
and inflated with 500ml
of saline
32. Management cont…
3) RPC
Retained Products of
Conceptions
Different methods of removal
of RPCs.
Manual removal
Uterine Curettage
Hysterectomy
4/27/2024
32
33. Management cont…
4) Coagulation defects
Lab investigations: platelet count, PT, PTT, fibrinogen level,
clotting time
Treatment
Use blood products to control hemorrhage
Give fresh whole blood if available.
Otherwise choose fresh frozen plasma, packed RBC,
cryoprecipitate or platelet concetrate based on the major disorder
recognized
4/27/2024
33
