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Antepartum &
     Postpartum
Hemorrhage (APH &PPH)
     Al-Momtan
Antepartum & Postpartum Hemorrhage

• Obstetrics is "bloody business."

• Death from hemorrhage still remains a leading
  cause of maternal mortality.

• Hemorrhage was a direct cause of more than
  18 percent of 3201 pregnancy-related
  maternal deaths.
Postpartum Hemorrhage
• In spite of marked improvements in management, PPH
  remains a significant contributor to maternal morbidity and
  mortality both in developing and developed countries.

• One of the most challenging complications a clinician will face.

• Prevention, early recognition and prompt appropriate
  intervention are the keys to minimizing its impact.
DEFINITION:

          The loss of >500ml of blood from the genital tract in
the first 24 hrs after delivery

                                      (or)

     < 500 ml with haemodynamic changes in the mother.

                                      (or)

     >1000 ml – cesarean section within 24 hrs.

                                      (or)

     > 1400 ml – Elective cesarean hysterectomy

                                      (or)

     > 3000 ml – Emergency cesarean hysterectomy
- In a recent ACOG study PPH is defined as Haematocrit       change of 10% or the
need for red cell transfusion.



  Severe PPH -                   > 1500ml blood loss
                                       or
                             Drop in Hb concentration 40g/l.
                                       or
                              units of blood transfusion.
                              4
Secondary PPH - Blood loss between 24 hrs and 6 weeks
                             Post-delivery.
In general, early PPH involves heavier bleeding and greater morbidity.
Incidence:
       Subjective : 2 – 11%
       Objective : 20%
Classification of primary PPH
       Atonic PPH – 80%
       Traumatic PPH – 15%
       Retained placenta, membranes,
       coagulation failure – 5%
Haematological Changes in Pregnancy
• 40% expansion of blood volume by 30 weeks

• 600 ml/min of blood flows through intervillous space

• Appreciable increase in concentration of Factors I (fibrinogen),
  VII, VIII, IX, X

• Plasminogen appreciably increased

• Plasmin activity decreased

• Decreased colloid oncotic pressure secondary to 25%
  reduction in serum albumin
Reduced Maternal Blood Volume

• Small stature

• Severe preeclampsia/eclampsia

• Early gestational age
PPH
PPH
• The etiologies of early PPH are most easily understood as abnormalities of
  one or more of four basic processes.

• The four “T” processes.

• Previous PPH!!
The Four “T”

    Tone
   Tissue
  Trauma
 Thrombin
PPH Risk Factors
• Many factors affect a woman’s risk of PPH.

• Each of these risk factors can be understood
  as predisposing her to one or more of the four
  “T” processes.
PPH Risk Factors
PPH Risk Factors
PPH Risk Factors
PPH Risk Factors
PREVENTION OF PPH
• Although any woman can experience a PPH, the
  presence of risk factors makes it more likely.

• For women with such risk factors, consideration
  should be given to extra precautions such as:
   –   IV access
   –   Coagulation studies
   –   Crossmatching of blood
   –   Anaesthesia backup
   –   Referral to a tertiary centre
PREVENTION OF PPH
• UTEROTONIC DRUGS

  – Routine oxytocic administration in the third stage of labour
    can reduce the risk of PPH by more than 40%

  – The routine prophylaxis with oxytocics results in a reduced
    need to use these drugs therapeutically

  – Management of the third stage of labour should therefore
    include the administration of oxytocin after the delivery of
    the anterior shoulder.
Intranatal:

• Hasty delivery of the baby is to be avoided.

• Adequate amount of blood should be cross matched and
  available when haemorrhage is anticipated.

• Coagulation studies are done in cases of Abruptio
  placenta and retained dead fetus.
Active Management of 3rd Stage of Labour:
1. Uterotonic Agents:
  •   10 units of oxytocin IM or
  •   Syntometrine (5 units of oxytocin and 0.5mg
      ergonovine maleate).
  • Misoprostol, a prostaglandin E1 analogue, 600g
   orally.
2. Early cord clamping
3. Controlled cord traction.
MANAGEMENT OF PPH
• Early recognition of PPH is a very important factor in
  management.

• An established plan of action for the management of
  PPH is of great value when the preventative
  measures have failed.
• Lab:
-   CBC / BG / Cross match of 4-6 units of blood
-   KFT / Coagulation profile
-   Give FFP / cryoprecipitate if coagulation test results are abnormal
-   Give platelet concentrates if the platelet count is < 50 X 109/L & bleeding continues
MANAGEMENT OF PPH
MANAGEMENT OF PPH
DRUG THERAPY FOR PPH
MANAGEMENT OF PPH
MANAGEMENT OF PPH
MANAGEMENT OF PPH
Evaluation of response
- Monitor pulse, blood pressure, blood gas status, &
acid-base status + monitoring central venous pressure.
- Measure urine output using an indwelling catheter
- Order regular FBC counts and coagulation tests to
guide blood component therapy
Summary: remember 4 Ts
• “TONE”                   •   Palpate fundus.
• Rule out Uterine Atony   •   Massage uterus.
                           •   Oxytocin
                           •   Methergine
                           •   Hemabate
Summary: remember 4 Ts
• “Tissue”                • Inspect placenta for
• R/O retained placenta     missing cotyledons.
                          • Explore uterus.
                          • Treat abnormal
                            implantation.
Summary: remember 4 Ts
• “TRAUMA”                  • Obtain good exposure.
• R/O cervical or vaginal   • Inspect cervix and
  lacerations.                vagina.
                            • Worry about slow
                              bleeders.
                            • Treat haematomas.
Summary: remember 4 Ts
• “THROMBIN”    • Check labs if suspicious.
Thank you..

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Overview management of postpartum haemorrhage

  • 1. Antepartum & Postpartum Hemorrhage (APH &PPH) Al-Momtan
  • 2. Antepartum & Postpartum Hemorrhage • Obstetrics is "bloody business." • Death from hemorrhage still remains a leading cause of maternal mortality. • Hemorrhage was a direct cause of more than 18 percent of 3201 pregnancy-related maternal deaths.
  • 3. Postpartum Hemorrhage • In spite of marked improvements in management, PPH remains a significant contributor to maternal morbidity and mortality both in developing and developed countries. • One of the most challenging complications a clinician will face. • Prevention, early recognition and prompt appropriate intervention are the keys to minimizing its impact.
  • 4. DEFINITION: The loss of >500ml of blood from the genital tract in the first 24 hrs after delivery (or) < 500 ml with haemodynamic changes in the mother. (or) >1000 ml – cesarean section within 24 hrs. (or) > 1400 ml – Elective cesarean hysterectomy (or) > 3000 ml – Emergency cesarean hysterectomy
  • 5. - In a recent ACOG study PPH is defined as Haematocrit change of 10% or the need for red cell transfusion. Severe PPH - > 1500ml blood loss or Drop in Hb concentration 40g/l. or  units of blood transfusion. 4 Secondary PPH - Blood loss between 24 hrs and 6 weeks Post-delivery. In general, early PPH involves heavier bleeding and greater morbidity.
  • 6. Incidence: Subjective : 2 – 11% Objective : 20% Classification of primary PPH Atonic PPH – 80% Traumatic PPH – 15% Retained placenta, membranes, coagulation failure – 5%
  • 7. Haematological Changes in Pregnancy • 40% expansion of blood volume by 30 weeks • 600 ml/min of blood flows through intervillous space • Appreciable increase in concentration of Factors I (fibrinogen), VII, VIII, IX, X • Plasminogen appreciably increased • Plasmin activity decreased • Decreased colloid oncotic pressure secondary to 25% reduction in serum albumin
  • 8. Reduced Maternal Blood Volume • Small stature • Severe preeclampsia/eclampsia • Early gestational age
  • 9. PPH
  • 10. PPH • The etiologies of early PPH are most easily understood as abnormalities of one or more of four basic processes. • The four “T” processes. • Previous PPH!!
  • 11. The Four “T” Tone Tissue Trauma Thrombin
  • 12. PPH Risk Factors • Many factors affect a woman’s risk of PPH. • Each of these risk factors can be understood as predisposing her to one or more of the four “T” processes.
  • 17. PREVENTION OF PPH • Although any woman can experience a PPH, the presence of risk factors makes it more likely. • For women with such risk factors, consideration should be given to extra precautions such as: – IV access – Coagulation studies – Crossmatching of blood – Anaesthesia backup – Referral to a tertiary centre
  • 18. PREVENTION OF PPH • UTEROTONIC DRUGS – Routine oxytocic administration in the third stage of labour can reduce the risk of PPH by more than 40% – The routine prophylaxis with oxytocics results in a reduced need to use these drugs therapeutically – Management of the third stage of labour should therefore include the administration of oxytocin after the delivery of the anterior shoulder.
  • 19. Intranatal: • Hasty delivery of the baby is to be avoided. • Adequate amount of blood should be cross matched and available when haemorrhage is anticipated. • Coagulation studies are done in cases of Abruptio placenta and retained dead fetus.
  • 20. Active Management of 3rd Stage of Labour: 1. Uterotonic Agents: • 10 units of oxytocin IM or • Syntometrine (5 units of oxytocin and 0.5mg ergonovine maleate). • Misoprostol, a prostaglandin E1 analogue, 600g orally. 2. Early cord clamping 3. Controlled cord traction.
  • 21. MANAGEMENT OF PPH • Early recognition of PPH is a very important factor in management. • An established plan of action for the management of PPH is of great value when the preventative measures have failed. • Lab: - CBC / BG / Cross match of 4-6 units of blood - KFT / Coagulation profile - Give FFP / cryoprecipitate if coagulation test results are abnormal - Give platelet concentrates if the platelet count is < 50 X 109/L & bleeding continues
  • 24.
  • 26.
  • 29.
  • 30.
  • 31.
  • 33. Evaluation of response - Monitor pulse, blood pressure, blood gas status, & acid-base status + monitoring central venous pressure. - Measure urine output using an indwelling catheter - Order regular FBC counts and coagulation tests to guide blood component therapy
  • 34. Summary: remember 4 Ts • “TONE” • Palpate fundus. • Rule out Uterine Atony • Massage uterus. • Oxytocin • Methergine • Hemabate
  • 35. Summary: remember 4 Ts • “Tissue” • Inspect placenta for • R/O retained placenta missing cotyledons. • Explore uterus. • Treat abnormal implantation.
  • 36. Summary: remember 4 Ts • “TRAUMA” • Obtain good exposure. • R/O cervical or vaginal • Inspect cervix and lacerations. vagina. • Worry about slow bleeders. • Treat haematomas.
  • 37. Summary: remember 4 Ts • “THROMBIN” • Check labs if suspicious.