This document summarizes causes, risk factors, diagnosis, and management of postpartum hemorrhage (PPH). PPH is defined as blood loss of 500 ml or more within 24 hours of delivery. Common causes include uterine atony (70%), retained placenta, genital tract trauma, and bleeding disorders. Risk factors include previous uterine surgery, uterine abnormalities, and operative delivery. Diagnosis involves estimating blood loss and identifying the cause. Management involves resuscitation, arresting the bleeding through uterotonic drugs, manual removal of retained placenta, repairing lacerations, and in severe cases, surgical procedures like hysterectomy.

1. Post partum haemorrhage Zhalla Omar Ahmad Soran Hisham Tahir Ra’ad Mhamad Abubakr Sulaimany university – Iraq Department of gynecology and obstetrics 6 th stage seminar

2. Definition Primary Post-Partum Haemorrhage is blood loss from the birth canal of 500 ml or more within 24 hours of delivery. After 24 hours, abnormal bleeding is classed as Secondary Post-Partum Haemorrhage. Incidence Varies with use of oxytocic drugs. From 1% to 8% of all deliveries. Postpartum haemorrhage (PPH) is the leading cause of maternal mortality worldwide with a prevalence rate of approximately 6%; Africa has the highest prevalence rate of about 10.5% “WHO” What is normal blood loss durin delivery? Mean blood loss with vaginal delivery: 500cc Mean blood loss with C/S: 1000cc

3. Causes Tone (atonic uterus) 70% Tissue (Retained tissue--placenta) Trauma (Lacerations and uterine rupture) Thrombin (Bleeding disorders)

4. Risk factors Uterine atony: Over distended uterus (polyhydramnion, multiple gestation) Uterine muscle exhaustion (prolong labor) Uterine abnormality (fibroid, placenta previa) General anesthesia Retained tissue Incomplete delivary of placenta Abnormal placenta (placenta acreta) Previous uterine scar

5. Risk factors Trauma Operative delivery Precipitate labor Malpositioning of fetal head Previous uterine surgery Bleeding abnormality Hemophilia A or B ITP Liver disease Anticoagulant HELLP syndrome DIC

6. CONSEQUENCES OF PPH Bleeding may be very rapid causing circulatory collapse leading to shock and death, Death—about 8% of direct maternal deaths follow PPH; half of these are avoidable. Anemia Damage to the pituitary blood supply leading to pituitary necrosis Sheehan's syndrome. Fear of further pregnancies. Haemorrhage is terrifying for the mother. Renal shutdown and consequent anuria.

7. Prevention Antenatal care and treatment of anemia. Give oxytocin after delivery, or Administration of 600 micrograms (mcg) misoprostol orally or sublingually after the birth of the baby.(if oxytocin is not available) Controlled cord traction. Uterine massage after delivery of placenta.

8. Diagnosis Estimate blood loss accurately. Evaluate all bleeding, including slow bleeds. If mother develops hypotension , tachycardia or abdominal pain …rule out intra-abdominal blood loss. In hypertensive cases the BP may be within normal range… Abdominal or pelvic bleeding may be hidden Measurement of blood loss Blood spilt on bed linen and dressings is often ignored and only blood actually collected in a bowl is measured. The estimated loss is therefore invariably lower than the actual loss. The mother's response will be governed by her haemoglobin level.

9. Diagnosis Uterine atony : soft uterus, patient is in shock Retained tissue : missing part of placenta or membranes, uterus is contracted, fundus is above umbilicus. Genital tract trauma : contracted uterus, no missing part of placenta, bleeding from genital tract or there is hematoma. Uterine rupture : abdominal pain, tender abdomen, shock, sometimes bleeding is concealed. Uterine inversion : Blue-gray mass protruding from vagina.

10. Management Once PPH has been identified, management involves four components, all of which must be undertaken SIMULTANEOUSLY: communication, resuscitation, monitoring and investigation, arresting the bleeding. Identify possible post partum hemorrhage. ABCs. Call for help. Use O2 4L/min. Start two wide bore IV lines. Have blood taken for cross-matching and investigations. Syntocinon 20U/L of IV solution Massage the uterus. Insert Foley’s catheter. Diagnose 4 “T”s and specific treatment accordingly.

11. Resuscitation RCOG guideline for resuscitation: Basic measures for MINOR PPH (blood loss 500–1000 ml, no clinical shock): Intravenous access (14-gauge cannula x 1). Commence crystalloid infusion. Full protocol for MAJOR PPH (blood loss > 1000 ml and continuing to bleed OR clinical shock): Assess airway. Assess breathing. Evaluate circulation

12. Oxygen by mask at 10–15 litres/minute. Intravenous access (14-gauge cannula x 2). Position flat. Keep the woman warm using appropriate available measures. Transfuse blood as soon as possible. Until blood is available, infuse up to 3.5 litres of warmed crystalloid Hartmann’s solution (2 litres) and/or colloid (1–2 litres) as rapidly as required. The best equipment available should be used to achieve RAPID WARMED infusion of fluids. Special blood filters should NOT be used, as they slow infusions.

13. Which fluid you give? Uncross-matched blood of the woman’s group. Up to 2 litres of Hartmann’s solution. Up to 1.5 litres of Gelofusin. Cross-matched blood as soon as available. Give O Rh-negative blood (universal donor) only as a last resort. Give 1 unit of FFP for every 6 units of blood. Be aware of hypothermia, hypocalcemia caused by massive blood transfusion. How to give oxytocin? 20 U (2 ampules) of oxytocin in 1000 ml of ringer lactate or normal saline, and administer it at 10ml/min (200 mU/min). Avoid undiluted bolus dose of oxytocin, it may cause hypotension and cardiac arrhythmia.

14. Uterine atony Massage uterus to stimulate contraction. Syntocinon i.v. by continuous drip (10 i.u./ 500ml fluid). Give IM or IU, not IV Bimanually compress uterus. In most of the cases bleeding will stop, but if it is not? Ergote derivatives (methergine 0.2mg IV or IM) but it causes hypertension. Injection of prostaglandin PGE2a or carboprost directly into uterus. Misoprostol 1000microgram rectally.

15. Surgical option balloon tamponade haemostatic brace suturing ( such as using procedures described by B - Lynch or modifiedcompression sutures ) bilateral ligation of uterine arteries bilateral ligation of internal iliac ( hypogastric ) arteries selective arterial embolisation. Hysterectomy.

16. Fingers of one hand are If not satisfactory, the whole pressed into anterior fornix fist is inserted

18. B-lynch suture

19. Retained placenta Why retained placenta does cause postpartum hemorrhage? Because piece of tissue or clot prevent effective myometrial contraction and retraction, which is normally needed to compress the blood vessels at the site of detached placenta. Routinely after delivery of placent inspect placenta for missing cotyledons, then examine uterine fundus, it should be at level of umbulicus or lower. Immediate PPH is seldom caused by retained small fragment of placenta.

20. Management perform controlled cord traction, being careful not to snap cord. Empty bladder. If placenta still undelivered 20 minutes after birth of the baby, prepare for manual removal it must be done under anesthesia because it is very painful procedure. Try one gentle, sterile vaginal examination; placenta may be trapped by the closing cervix and an edge can sometimes be hooked down and the placenta gently eased out. Give 20U of oxytocin in 1 L normal saline, or misoprostol rectally. If the case presented lately try to do dilation and curettage (immediately after delivery D & C ia contraindicated). Give prophylactic antibiotics afterwards.

23. Very rarely, the placenta may be abnormally adherent: • Placenta accreta: villi just penetrate into myometrium. • Placenta increta: villi penetrate deeply into myometrium. • Placenta percreta: villi penetrate through myometrium to peritoneum. Piecemeal removal is very dangerous and only done for placenta accreta, it causes hemorrhage. Sometimes there is small pieces left, we let them atrophy with antibiotic control of infection provided that the bleeding is stopped. The safest treatment is hysterectomy.

24. Trauma Suspect it in prolong labor, operative delivery. Carefully examine vagina and cervix. Suspect it if the uterus is well contracted and below umbulicus. Repair all lacerations. Uterine Inversion Uterine Rupture

25. Vaginal and cervical laceration: Lacerations in anterior wall of vagina is relatively common, but usually it is superficial and and needs no repair, but if it is deep it needs repair and also put urinary catheter if there is difficulty in voiding. Vulval, vulvovaginal and paravaginal hematomas: there is rounded swelling in the vulva, may cause excruciating pain. Give adequate blood and IV fluid. If it is large and causes discomfort then we have to evacuate it through an incision, evacuate all blood and clots, ligate all bleeding points. Then suture it. Vagina should be packed for 12-24 hours.

26. Uterine Inversion Blue-gray mass protruding from vagina. Usually due to adherent placenta to uterine fundus. Copious bleeding. Hypotension worsened by vaso-vagal reaction. Management: IV fluid, and blood transfusion. Push center of uterus with three fingers into abdominal cavity or make a fist and push it back to its position as soon as possible. Or by hydrostatic repositioning, using about 2L saline infused into vagina. If cervical contraction ring developed? it needs to do laparotomy. give tocolytics to relax the uterus as terbutalin or MgSO4, then reposition the uterus by pushing it throug vagina and pull it from cervix. When completed, treat uterine atony.

28. Uterine Rupture Risk factor: Previous scar Patients Complain 1. Continuous abdominal pain 2. Vaginal blood loss 3. Contractions cease 4. The fetal heart rate pattern becomes abnormal Management ABCs. IV fluids. Surgical correction

29. Clotting defect Check: Platelets. Coagulation studies PT, PTT, bleeding time. Fibrinogen. Management: Adequate preoperative preparation for those cases with coagulation abnormality. Treat appropriately by fresh frozen plasma (FFP) Recombinant activated factor VII, for bleeding related to hemophilia A & B.

30. Secondary PPH Secondary PPH is often associated with endometritis. When antibiotics are clinically indicated, a combination of ampicillin (clindamycin if penicillin allergic) and metronidazole is appropriate. In cases of endomyometritis (tender uterus) or overt sepsis, then the addition of gentamicin is recommended also add uterotonic agent. Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings, insertion of balloon catheter may be effective..

31. Monitoring • Pulse rate every • Blood pressure every 15 minute • Temperature • Respiratory rate • Urine output. • Amount and type of fluids which is given. • Drugs which has received. • Central venous pressure in complicated cases.

32. If still bleeding? Intrauterine tamponade. Uterine artery embolization Laparotomy (hypogastric artery ligation, B-lynch sutures, hysterectomy)

34. Summary ABCs, 2 IVs, O2, T & C, urgent OB consult examine and treat patient simultaneously if bleed is prior to placental delivery, give oxytocin & do manual extraction if bleed is after placental delivery, palpate the uterus. If evidence of atony, massage and treat repair genital tract tears remove retained products foley catheter, CBC, coags. & treat ABNL’s if refractory to medical therapy consider surgical options

35. Thank You…