Post partum hemorrhage in pregnancy

1. Postpartum haemorrhage
MbChB 4.1
Kiryandongo teaching hospital

2. Topic Outline
• Definition
• Clinical features
• Risk factors for PPH
• Aetiology/Causes of PPH
• Complications
• management

3. Definition
• PPH-(Post Partum Hemorrhage) . Any amount of bleeding from or into
the genital tract following birth of the baby up to the end of the puerperium,
which adversely affects the general condition of the patient evidenced by rise
in pulse rate and falling blood pressure is called postpartum hemorrhage.
• PPH refers to the average blood loss following vaginal delivery, cesarean
delivery and cesarean hysterectomy which is 500 mL, 1000 mL and 1500 mL
respectively

4. TYPES:
 Primary Secondary
• Primary: Hemorrhage occurs within 24 hours following the birth of the
baby. In the majority, hemorrhage occurs within two hours following
delivery.
These are of two types:
• Third stage hemorrhage—Bleeding occurs before expulsion of placenta.
• True postpartum hemorrhage—Bleeding occurs subsequent to expulsion of
placenta (majority)
• Secondary: Hemorrhage occurs beyond 24 hours and within puerperium,

5. Clinical presentation
• Lightheadedness or fatigue
• Massive loss of blood, passing large clots
• P/A :Uterus may be soft or well contracted
• V/E :There may be evidence of retained placenta,perineal tears, cervical
tears
• She may be in shock

6. presentation
• Pulse >100bpm
• B.P less <90 mmhg
N.B increased pulse and drop in BP occurs when 1500ml or more is lost
• Deteriorating general condition of mother
• Pale, cold extremities, Increased RR
• reduced brain perfusion e.g confusion, drowsiness, restlessness
• Tears or swelling in the genital tract

7. Risk factors for PPH
•Maternal risk factors
-Uterine fibroids
-infections

8. • Fetal risk factors
-Multiple pregnancy
-Polyhydramnios
-Shoulder dystocia
-Fetal macrosomia

9. Aetiology /causes of PPH
Causes of primary postpartum hemorrhage
The causes of PPH involves the four ‘Ts’:
 Tone (atonicity)
 Tissue (retained bits, blood clots)
 Trauma (genital tract injury)
 Thrombin (coagulopathy).

10. 1. TONE: Uterine atony (80%) causes:
Retained placental fragments and membranes
Prolonged labour or Precipitate labor
Over-distended uterus (e.g., polyhydramnios or multiple pregnancy, big
baby)
Full bladder
Grand multiparity
Uterine inversion
 Anaesthetics agents (e.g., halothane) Drug( uterine relaxants, Halothane, MgSo4)
Uterine fibroids

11. TRAUMA: Soft Birth Canal
Trauma to the genital tract (vaginal, cervical or uterine)
 Ruptured uterus·
Precipitate labour
 Incision: episiotomy, cesarean section
Caesarean section
Assisted vaginal delivery
 Big baby

12. TISSUE: Retained product of conception)
 Retained placenta: Normally or abnormally attached (Placenta acreta)
 Retained membranes
 Blood clots
Thrombin:
• Blood coagulation disorders, acquired or congenital, are less common causes of postpartum
hemorrhage. The blood coagulopathy may be due to diminished procoagulants, or increased
fibrinolytic activity. The conditions where such disorders may occur are
• abruptio placentae,
• jaundice in pregnancy,
• thrombocytopenic purpura,
• severe preeclampsia, or
• IUD.

13. Causes of secondary PPH
• Retained bits of cotyledon or membranes
• Infection
• Cervico-vaginal laceration
• Endometritis
• Subinvolution of the placental site
• Secondary hemorrhage from caesarean section

14. Differential diagnosis
Uterine atony
lacerations
uterine inversion
retained placenta
uterine rupture

15. Investigations
• CBC/Haemoglobin grouping and cross matching
• High vaginal or cervical swab for microscopy, culture and sensitivity when
infection is suspected
• Ultrasound scan to exclude retained products of conception
• Serum HCG to exclude GTDs( Gestational trophoblastic disease)
• Prothrombin time and activated partial thromboplastin time (aPTT)

16. Complications of PPH
• Shock: hypovolemic
• Renal failure
• Respiratory distress syndrome
• Coagulopathy
• Anaemia
• Sheehan’s syndrome (Pituitary necrosis)
• Infertility
• Maternal death

17. Prevention of PPH
Antenatal
 Improvement of the health status of the woman and to keep the
hemoglobin level normal (> 10 g/dL)
 Blood grouping should be done for all womenn so that no time is wasted
during emergency
 Placental localization must be done in all women with previous cesarean
delivery
 High-risk patients(such as twins, hydramnios, grand multipara, history of
previous PPH, severe anemia) are to be screened and delivered in a well-
equipped hospital

18. Intranatal
• Active management of the third stage, for all women in labor should be a
routine as it reduces PPH by 60%
• Women delivered by cesarean section, oxytocin 5 IU slow IV is to be given to
reduce blood loss
• Exploration of the uterovaginal canal for evidence of trauma following
difficult labor
• Observation for about two hours after delivery to make sure that the uterus
is hard and well contracted
• Expert obstetric anesthetist is needed when the delivery is conducted under
general anesthesia.
• Examination of the placenta and membranes should be a routine to detect at
the earliest any missing part.

19. Management of PPH
1. Empty the bladder by catheterisation
2. Uterine FUNDAL MASSAGE and BIMANUAL MASSAGE to encourage contraction.
3. Set up 2 large bore IV lines with 16G (GREY) canullae and start IV crystalloids
(e.g., normal saline or Ringers lactate). Set up drip and allow to run fast and add
oxytocin 20 IU in 1000ml of NS(60 drops per minute for the first 1L of NS then
40 drops per minute for the next 2L of NS containing oxytocin)
4. Order for a minimum of 2 units of crossmatched packed red cells or whole
blood
5. Give IV oxytocin 10 IU IV or misoprostol 800mcg sublingual or IM ergometrine
0.2 mg (in a non-hypertensive mother). Maintain with oxytocin 20 units/I L
normal saline
6. TXA(Tranexamic acid) should be administered at a fixed dose of 1 g in 10 mL
(100 mg/mL) IV at 1 mL per minute.

20. Mgt (contn)
 Deliver the placenta by controlled cord traction if not yet delivered.
 Expel clots from the vagina.
 If placenta is already delivered, look for cause, manage bleeding and treat (e.g., if tears/lacerations, suture
them).
 Give antibiotics (Ampicillin 2 g and Metronidazole 500 mg IV).
If placenta is retained:
I. Perform a manual removal under anaesthesia
II. If bleeding persist, continue oxytocin drip (20 units in 1L normal saline) total maximum dose of
Oxytocin is 40 IU in normal saline as infusion not boluses
III. Massage the uterine fundus.

21. Bimanual Uterus Massage
The fist of one hand is placed deep into the vagina while the other hand firmly
compresses the uterine fundus in an effort to control bleeding

22. Refferences
DC Dutta's Textbook of Obstetrics, 7E REVISED (Complete)(2014)
[PDF] [UnitedVRG].
Langman’s medical embryology 10th Edition
UpTodate Online.