a briefing on postpartum hemorrhage, a major worldwide health problem especially in the developing world.

1. َ‫ع‬ ‫َا‬‫ن‬ْ‫ب‬َ‫ت‬َ‫ك‬ َ‫ك‬ِ‫ل‬ََٰ‫ذ‬ ِ‫ل‬ْ‫ج‬َ‫أ‬ ْ‫ن‬ِ‫م‬
َ‫ل‬‫ي‬ِ‫ئ‬‫ا‬َ‫ر‬ْ‫س‬ِ‫إ‬ ‫ي‬ِ‫ن‬َ‫ب‬ َٰ
‫ى‬َ‫ل‬
ُ‫ه‬َّ‫ن‬َ‫أ‬
َ‫ن‬ ِ
‫ْر‬‫ي‬َ‫غ‬ِ‫ب‬ ‫ا‬ً‫س‬ْ‫ف‬َ‫ن‬ َ‫ل‬َ‫ت‬َ‫ق‬ ‫ن‬َ‫م‬
‫ي‬ِ‫ف‬ ٍ‫د‬‫ا‬َ‫س‬َ‫ف‬ ْ‫و‬َ‫أ‬ ٍ
‫س‬ْ‫ف‬
‫ال‬ َ‫ل‬َ‫ت‬َ‫ق‬ ‫ا‬َ‫م‬َّ‫ن‬َ‫أ‬َ‫ك‬َ‫ف‬ ِ
‫ض‬ ْ‫ر‬َ ْ
‫اْل‬
‫ا‬ً‫ع‬‫ي‬ِ‫م‬َ‫ج‬ َ‫اس‬َّ‫ن‬
ْ‫ح‬َ‫أ‬ ‫ا‬َ‫م‬َّ‫ن‬َ‫أ‬َ‫ك‬َ‫ف‬ ‫ا‬َ‫ه‬‫ا‬َ‫ي‬ْ‫ح‬َ‫أ‬ ْ‫ن‬َ‫م‬ َ‫و‬
ۚ ‫ا‬ً‫ع‬‫ي‬ِ‫م‬َ‫ج‬ َ
‫اس‬َّ‫ن‬‫ال‬ ‫ا‬َ‫ي‬
ِ‫ب‬ ‫َا‬‫ن‬ُ‫ل‬ُ‫س‬ُ‫ر‬ ْ‫م‬ُ‫ه‬ْ‫ت‬َ‫ء‬‫ا‬َ‫ج‬ ْ‫د‬َ‫ق‬َ‫ل‬ َ‫و‬
ِ‫إ‬ َّ‫م‬ُ‫ث‬ ِ‫ت‬‫َا‬‫ن‬ِ‫ي‬َ‫ب‬ْ‫ال‬
‫ا‬ً‫ير‬ِ‫ث‬َ‫ك‬ َّ‫ن‬
َ ْ
‫اْل‬ ‫ي‬ِ‫ف‬ َ‫ك‬ِ‫ل‬ََٰ‫ذ‬ َ‫د‬ْ‫ع‬َ‫ب‬ ‫م‬ُ‫ه‬ْ‫ن‬ِ‫م‬
﴾َ‫ون‬ُ‫ف‬ ِ
‫ر‬ْ‫س‬ُ‫م‬َ‫ل‬ ِ
‫ض‬ ْ‫ر‬
[
‫المائدة‬
:
32
]

2. POST PARTUM HEMORRHAGE
BY
DR. AHMED BAYOUMI
CONSULTANT OB GYN
NOVEMBER 2023

3. PRIMARY & SECONDARY PPH
• PRIMARY PPH is defined by the ACOG as cumulative
blood loss of >1000 mL (irrespective of route of
delivery) or blood loss accompanied by signs or
symptoms of hypovolemia within 24 hours after the
birth process
• 2ry PPH: any significant uterine bleeding occurring between
24 hours and 12 weeks postpartum
• UAE

4. َ‫أ‬ ‫ا‬َ‫م‬َّ‫ن‬َ‫أ‬َ‫ك‬َ‫ف‬ ‫ا‬َ‫ه‬‫ا‬َ‫ي‬ْ‫ح‬َ‫أ‬ ْ‫ن‬َ‫م‬ َ‫و‬
‫ي‬‫ي‬‫م‬ََ َ
َ‫ا‬ََّّ‫لن‬ ‫ا‬َ‫ي‬ْ‫ح‬
‫ا‬ً‫ع‬
The leading cause of maternal mortality (deaths from pregnancy and
childbirth related complications) is obstetric hemorrhage in which a woman
bleeds heavily, most often immediately after giving birth.
A woman dies every 4 minutes from this kind of complication.
A woman can bleed to death in two hours or less
In rural areas, where hospitals may be TOO FAR away, this leaves little hope
for women suffering from hemorrhage
Major cause of MATERNAL MORBIDITY

5. WE SHOULD TALK ABOUT
1. PPH PREVENTION EMERGENCY TTT ,NON OPERATIVE TTT
2. DETAILED OPERATIVE TECHNIQUES UP TO HYSTERECTOMY
3. PAS
4. DIC
5. COAGULOPATHY
6. HYPOVOLEMIC SHOCK
7. SEPSIS
8. BLOOD & FLUID REPLACEMENT

6. BLOOD SUPPLY OF THE UTERUS

7. DELTA ARTERIES

8. BLOOD VOLUME TO THE PREGNANT
UTERUS

9. HIGH RISK FACTORS

10. LOW RISK VS. “NO RISK”

11. CAUSES : 4T’S

12. PATHOPHYSIOLOGY OF HYPOVOLEMIC
SHOCK
• The pre-shock stage is characterized by compensatory
mechanisms with increased sympathetic tone resulting in
increased heart rate, increased cardiac contractility, and
peripheral vasoconstriction.
• Due to the increased sympathetic activity, the early changes in
vital signs seen in hypovolemic shock with the loss of 10%
blood volume include an increased diastolic blood pressure
with narrowed pulse pressure. The net result is normal or
mildly elevated blood pressure.

13. PATHOPHYSIOLOGY OF HYPOVOLEMIC
SHOCK
• As volume status continues to decrease, specifically when it is 25 to 30% of
the effective blood volume patient gets into a shock state with
1. a drop in systolic blood pressure,
2. tachycardia, and
3. oliguria.
4. As a result, oxygen delivery to vital organs cannot meet oxygen demand.
Here cells switch from aerobic to anaerobic metabolism, resulting in lactic
acidosis.
5. As sympathetic drive increases, blood flow is diverted from other organs
to preserve blood flow to the heart and brain. This blood flow diversion
propagates tissue ischemia and worsens lactic acidosis.
6. If untreated, this will lead to hemodynamic compromise, refractory
acidosis, and a further reduction in cardiac output, leading to
7. multiorgan failure (MOF) and, eventually, death.

14. STAGES OF HYPOVOLEMIC SHOCK

15. CALL FOR HELP
COMMUNICATION AND MULTIDISCIPLINARY CARE
COMMUNICATION WITH THE WOMAN& HER PARTNER

16. PATIENTS NOT AT IMMINENT RISK OF
COLLAPSE
• Uterine tourniquet .
• Intrauterine postpartum hemorrhage-control devices
• Ligation of uterine and utero-ovarian arteries
• Clamp across utero-ovarian ligaments .
• Pelvic packing : to create tamponade pressure exceeding arterial
pressure can control bleeding from small pelvic arteries. It can be
useful as a temporizing measure in the management of broad
ligament or retroperitoneal hematomas, lacerations that are difficult to
repair because of their location or friable tissue, bleeding related to
coagulopathy while clotting factors are being replaced, and post
hysterectomy bleeding.

17. NON OPERATIVE PPH CARE BUNDLES
1.The “first response to PPH bundle” comprises : BLADDER CATHETER,
uterotonics, isotonic crystalloids, tranexamic acid, and uterine massage.
2. The “response to refractory PPH bundle” comprises compressive
measures (aortic or bimanual uterine compression), the non-pneumatic
antishock garment, and intrauterine balloon tamponade (IBT)/ UT PACKING
3. Supporting elements bundle: Advocacy, training, teamwork,
communication, and use of best clinical practices

18. TIMELY DECISION MAKING
•‫جراح‬ DECIDE EARLY: conservative interventions
OR hysterectomy. AGAIN CALL FOR HELP
• ‫تخدير‬ Reversal of any coagulopathy,
hypothermia, acidosis, and lack of clotting
factors. Even if bleeding cannot be completely
controlled initially, keep infusion of blood and
blood products.
•‫ومعمل‬ ‫دم‬ ‫بنك‬

19. CERVICAL TEAR
•Instrumental delivery
•Oxytocin
•Precipitate labor

20. MANAGEMENT APPROACHES REQUIRING
LAPAROTOMY
• EVALUATION OF THE ABDOMEN AT LAPAROTOMY
• TEMPORARY MEASURES FOR STABILIZING HEMODYNAMICALLY UNSTABLE PATIENTS :
TIME IS THE ENEMY
• ETIOLOGY-BASED MANAGEMENT
• POST-LAPAROTOMY INSPECTION
• ROLE OF HYSTERECTOMY
• ROLE OF EMBOLIZATION
• SUMMARY AND RECOMMENDATIONS

21. EVALUATION OF THE ABDOMEN AT
LAPAROTOMY
• THEATRE: RETRACTOR, LIGHT, ASSISTANT, CHROMIC CATGUT,
?C-ARM
• INCISION: MID LINE : when? TRANSVERSE EXTENDED: how?
• The abdominal cavity is irrigated to remove blood and clots and
inspected for the source of bleeding, which is usually from the uterus.
• The source of bleeding is often readily apparent:-
atony, retained placental fragments, uterine laceration, uterine
incision

22. EVALUATION OF THE ABDOMEN AT
LAPAROTOMY
• BUT may not be immediately recognized when it is
1. inside the uterine cavity(after vaginal birth or after closure of CS
incision)
2. retroperitoneal (including vaginal and vulvar hematomas from
trauma to branches of the pudendal or uterine arteries and veins),
or
3. due to a posterior uterine wall rupture.
These sites should be systematically evaluated in patients with
compensated shock (normal blood pressure with increasing
heart rate).
• Intra-abdominal blood without an obvious cause may be due to
hepatic or splenic rupture, or rupture of a visceral artery aneurysm or

23. TEMPORARY MEASURES FOR STABILIZING
HEMODYNAMICALLY UNSTABLE PATIENTS
• Severe bleeding often continues while the surgeon is
preparing to perform and while performing surgical
procedures for controlling hemorrhage.
• Even an intended hysterectomy that the surgeon
thinks will be easy and uncomplicated can be very
difficult to perform if the pelvis or retroperitoneum
fills with blood, especially when structures that were
not bleeding start to bleed because of DIC.

24. TEMPORARY MEASURES FOR STABILIZING
HEMODYNAMICALLY UNSTABLE PATIENTS
• fluid administration : details?
• transfusion of blood products: details?
• The option chosen depends on
1. the urgency to control bleeding,
2. the source of bleeding (intrauterine versus extrauterine), and
3. the surgeon's expertise and preference.

25. PATIENTS AT IMMINENT RISK OF COLLAPSE
• Manual aortic compression
• PELVIC PACKING
• Balloon occlusion of the aorta (REBOA): Resuscitative endovascular balloon occlusion of
the aorta (could also be used prior to surgery for PAS)
A. Through FLUROSCOPY
B. Seldinger technique (initial needle followed by a guidewire over which the balloon
catheter is inserted).
The catheter is advanced up the aorta to position the balloon below the renal arteries,
above the inferior mesenteric arteries and at or above the ovarian arteries

27. IT IS A RACE WITH DEATH

29. CLAMP ACROSS THE UTERO-OVARIAN VESSELS AND
LIGAMENT TO REDUCE UTERINE BLEEDING

30. UTERINE TOURNIQUET

31. ‫قريب‬ ‫هللا‬ ‫نصر‬ ‫لن‬ ‫لال‬
‫الدعاء‬
‫المقاطعة‬

32. MYOMETRIAL LACERATIONS
The angles of a transverse incision should be clearly visualized to ensure that
they, and any retracted vessels, are completely ligated. gentle traction on an
exteriorized uterus to provide adequate visualization of the lateral areas of
the uterus above and below the edges of the incision.
• An enlarging hematoma (or swelling beneath the surface of the broad
ligament) beyond the end of the incision or laceration suggests a retracted
blood vessel with ongoing bleeding.
• Once the ureters can be seen or palpated (stent), the broad ligament may
need to be opened to isolate the bleeding vessel. Alternatively, sutures can
be placed while retracting the ureter safely aside, without opening the
retroperitoneum. Once the hemorrhage has been controlled, the integrity of
the ureter(s) should be ensured.
•

33. LACERATION OF THE UTERINE A. OR UTERO-
OVARIAN A. BRANCHES
• After identification of the ureter, a large curved needle with a #0 polyglycolic acid
suture is passed through the lateral aspect of the lower uterine segment as close to
the cervix as possible and then back through the broad ligament just lateral to the
uterine vessels. If this does not control bleeding, the vessels of the utero-ovarian
arcade are similarly ligated just distal to the cornua by passing a suture ligature
through the myometrium just medial to the vessels, then back through the broad
ligament just lateral to the vessels, and then tying to compress the vessels .
• Bilateral ligation of the arteries and veins (uterine and utero-ovarian) is often
successful in controlling hemorrhage but in some cases may not completely control
it.

34. DRAWBACKS OF UT & UT OV A LIGATION
• Bilateral ligation does not appear to affect future reproductive
function .
• Uterine necrosis and placental insufficiency in a subsequent
pregnancy have not been described as complications. However, there
is a single case report of ovarian failure and development of
intrauterine synechiae after postpartum ligation of the uterine, utero-
ovarian, and ovarian arteries for PPH related to atony .

35. Uterine artery ligation
Sutures are placed to ligate the ascending uterine artery and the anastomotic branch of the
ovarian artery. The procedure should be performed on each side.

36. ATONY
• All patients with PPH related to atony receive uterine massage/manual compression and
administration of uterotonic medications and tranexamic acid.
• Carbetocin 100mic gm. No need to refrigerate, long (100mim) half
• If these measures do not control bleeding, and the patient is hemodynamically stable, we
rapidly move on to placement of uterine compression sutures, which are an effective
method for reducing uterine blood loss related to atony.
• If the patient is hemodynamically unstable, temporizing measures such as placement of a
uterine tourniquet, insertion of an intrauterine balloon for tamponade, and/or ligation of
the uterine and utero-ovarian arteries can reduce ongoing heavy blood loss before placing
compression sutures, and may obviate the need for them.

37. UTERINE COMPRESSION SUTURES
• The B-Lynch suture is the most common technique for uterine
compression; several variations of this technique have been described
and no technique has been proven significantly more effective than
another .
• Generally, longitudinal sutures are easier to place and safer than
transverse sutures, but this may not always be the case
• increase chances of developing Asherman syndrome

38. VERTICAL(?) B-LYNCH TECHNIQUE
• A large Mayo needle with #2 chromic catgut is used to enter and exit the
uterine cavity at A and B. The suture is looped over the fundus and then
reenters the uterine cavity posteriorly at C, which is directly below B. The
suture should be pulled very tight at this point. It then enters the posterior
wall of the uterine cavity at D, is looped back over the fundus, and anchored
by entering the anterior lateral lower uterine segment at E and crossing
through the uterine cavity to exit at F. The free ends at A and F are tied
down securely to compress the uterus.

40. HAYMAN MODIFICATION
• Hayman described a modification of the B-Lynch suture that is
performed without a hysterotomy. Two to 4 vertical compression
sutures are placed, as needed, but in contrast to the B-Lynch
technique, these sutures pass directly from the anterior uterine wall to
the posterior uterine wall. A transverse cervicoisthmic suture can also
be placed, if needed, to control bleeding from the lower uterine
segment.

42. PEREIRA TECHNIQUE
• Pereira described a technique in which a series of transverse and longitudinal
sutures of a delayed absorbable multifilament suture are placed around the uterus
via a series of bites into the submucosal myometrium. Two or 3 rows of these
sutures are placed in each direction to completely envelop and compress the uterus.
When the transverse sutures are brought through the broad ligament, care should
be taken to avoid damaging blood vessels, ureters, and fallopian tubes. The
longitudinal sutures begin and end at the last transverse suture nearest the cervix
and do not enter the uterine cavity. The myometrium should be manually
compressed prior to tying down the sutures to facilitate maximal compression.

44. CHO TECHNIQUE
• Cho described a technique in which a straight number 7 or 8 needle
with #1 chromic catgut is used to place sutures in a small rectangular
array to compress the anterior and posterior uterine walls against
one another at sites of heavy bleeding. The through and through
sutures extend from the serosa of the anterior wall to the serosa of
the posterior wall. After creating a square, the ends are tied down as
tight as possible to compress the myometrium. Two to 5
squares/rectangles are made, as needed.
• Foley’s catheter could be inserted in the uterus for drainage in all
hemostatic compression suture techniques

46. Role of internal iliac (hypogastric) artery ligation
• This technique is challenging even for an experienced pelvic surgeon,
especially when in the setting of a large uterus, limited exposure through a
transverse lower abdominal incision, ongoing pelvic hemorrhage, or obesity.
Successful and safe bilateral internal iliac artery ligation becomes even more
difficult when attempted by a surgeon who rarely operates deep in the pelvic
retroperitoneal space.
• For these reasons, uterine compression sutures, uterine artery ligation, and
arterial embolization have largely replaced this procedure.

47. IIA LIGATION
• Bilateral ligation of the internal iliac arteries reduces the pulse pressure of blood flowing to the
uterus .
• The utility of the procedure may be compromised when there are extensive collateral vessels (e.g.
placenta percreta). Reverse filling of the internal iliac arteries has been reported beyond the
point of ligation via branches of the external iliac artery (inferior epigastric, obturator, deep
circumflex iliac, and superior gluteal arteries)
• Major value in retroperitoneal bleeding
• In trauma surgery, vessel loops or tapes along with vascular clamps or Rummel tourniquets have
been used for temporary reduction of internal iliac blood flow and then released subsequent to
control of distal hemorrhage.

48. ROLE OF INTRAOPERATIVE CELL SALVAGE
• Arranging for cell salvage in patients at high risk for PPH is
economically reasonable, while routine use of cell salvage for
all cesarean births probably is not (ACOG)
• Institutions that offer reinfusion of salvaged blood should have
designated personnel, which may include cross-trained
operating room employee (eg, an anesthesia technician) or a
member of a specialist service (eg, an extracorporeal
technologist or perfusionist). These individuals are called to
manage the cell salvage equipment and follow written policies
and procedures for proper collection, labeling, and storage of
the collected blood.

49. INTRAOPERATIVE CELL SALVAGE
DISADVANTAGES
• Autotransfusion of blood obtained by intraoperative cell salvage (with a
leukocyte filter and washing) can reduce the use of allogeneic blood, but the
reduction may be modest
• Although there is a theoretical concern that reinfusing amniotic fluid may
cause amniotic fluid embolism, this has been documented only once and
may have been prevented by cell washing. Risk of maternal infection from
infusion of bacterial contamination is also minimal. Salvaged blood may
contain fetal erythrocytes , but this is not a major concern, in part because D
alloimmunization in a D-negative mother can be prevented by
administration of anti-D immune globulin.
• Although ABO incompatibility reactions cannot be prevented, they are
unlikely to be serious because the volume of fetal blood contamination is
small and A and B antigens/antibodies are not fully developed at birth.
Alloimmunization from other red blood cell antigens is theoretically
possible. These risks are probably less than or similar to those from

50. DIC
• Is a condition in which small blood clots form
throughout the body, blocking small blood vessels.
• Symptoms may include chest pain, shortness of breath,
leg pain, problems speaking, or problems moving parts
of the body.
• As clotting factors and platelets are used up, bleeding
may occur. This may include blood in the urine, blood in
the stool, or bleeding into the skin.
•BLEEDING IN OPERATIVE FIELD IS OUR MAJOR
ENEMY
• Complications may include organ failure.

52. DIC
• About 1% of people admitted to hospital are affected by the
condition.
• It is there in the 3 major causes of MATERNAL MORTALITY
• abruptio placentae, pre-eclampsia or eclampsia, amniotic fluid
embolism, retained intrauterine fetal demise, septic
abortion, postpartum hemorrhage
• BLOOD TRANSFUSION REACTION
• In those with sepsis, rates are between 20% and 50%.
• ROLE OF TISSUE FACTOR, EXTRINSIC PATHWAY
• NOT IN HELLP, TTP
• The risk of death among those affected varies from 20% to 50%.

53. DIC
•Causes include sepsis, surgery, major trauma,
cancer, and complications of pregnancy. Less
common causes include snake bites, frostbite, and
burns.
• There are two main types: acute (as in amniotic
fluid embolism, or endotoxic shock) and chronic
(as in retained dead fetus).
• Diagnosis is typically based on blood tests.
Findings may include low platelets, low fibrinogen,
high INR, or high D-dimer.

54. DIC
•Treatment is mainly that of the CAUSE.
• Other measures (especially in planned invasive
procedure) may include
1.Platelets
2. cryoprecipitate, or
3. fresh frozen plasma. Evidence to support
these treatments, however, is poor.
• Heparin may be useful in the slowly developing
form.

55. GREEN-TOP GUIDELINE NO. 52
•Prevention and Management of Postpartum
Haemorrhage
•First published: 16 December 2016
•Executive summary of recommendations
•NEXT LECTURE ISA

56. ‫قريب‬ ‫هللا‬ ‫نصر‬ ‫لن‬ ‫لال‬
‫الدعاء‬
‫المقاطعة‬