PPH is one of the major killers of women during delivery. timely management can save mothers

1. POST PARTUM HEMORRHAGE
- MEDICAL MANAGEMENT
VEERENDRAKUMAR C. M
.
MD.,DNB
PROFESSOR & UNIT CHIE
F
DEPT. OF OB
G
VIMS , BALLARI, KARNATAKA

2. Obstetrics
lBloody business…

4. PPH Problem:
Living in the shadow of The Taj Mahal
● The majority of these deaths occur within 4 hours of
delivery
.
● Probably accounts for more than 30-38% of all
maternal deaths
.
● Deaths from hemorrhage could often be
avoided.

5. ● PPH is generally defined as blood loss greater than
or equal to 500 ml within 24 hours after birth
.
● Severe PPH is blood loss greater than or equal to
1000 ml within 24 hours.

6. ● When I gave birth to my 4th child, I suffered PPH. I
almost lost my life. I was lucky to be under the care of
trained health care personnel.
Then I started wondering what was happening to rural
women.
- Joyce Bonda
Malawian President

8. PPH - PREDICT
● Prior postpartu
m
● hemorrhag
e
● Advanced maternal
ag
e
● Multifetal gestation
s
● Prolonged labo
r
● Polyhydramnio
s
● Instrumental deliver
y
● Fetal demis
e
● Placental abruption
● Anticoagulation therap
y
● Multiparit
y
● Fibroid
s
● Prolonged use of
oxytoci
n
● Macrosomi
a
● Cesarean deliver
y
● Placenta previa an
d
● accret
a
● Chorioamnioniti
s
● General anesthesia

9. Causes of Postpartum Hemorrhage
Primary causes
-
● Uterine atony
● Genital tract laceration
s
● Retained product
s
● Abnormal placentatio
n
● Coagulopathies and anticoagulatio
n
● Uterine inversio
n
● Amniotic fluid embolis
m
Secondary causes
-
● Retained product
s
● Uterine infectio
n
● Subinvolutio
n
● Anticoagulation

10. 80% OF CASES OF PPH ARE
DUE TO UTERINE ATONY

11. EXPECT PPH IN THE
MOST UNEXPECTED
SITUATION !
NEVERTHELESS…

13. PPH - PREPARE
“Perhaps the most important aspect in the management of PP
H
is the attitude of the attendant in charge. It is critical to maintain equanimity in what
can be a chaotic and stressful environment”.

14. PPH is an emergency which kills fast..
(golden hour)so we have to be ready and prepared
● I- Infrastructure preparednes
s
● D- Drugs and injections and iv fluid
s
● E- Emergency trays and trolley
s
● A- All together (Staff and team work)

15. Infrastructure

16. Drug kit, injections & iv fluids

17. Emergency trays and trolleys

18. ● PPH may occur in women without identifiable
clinical or historical risk factors.
Active management of the third stage of labour
be offered to all women during childbirth to prevent
PPH.
PPH—HANDLE

19. (i) Administration of a uterotonic soon after the birth of the baby;
(ii) Clamping of the cord following the observation of uterine contraction (at
around 3mins
)
(iii) Delivery of the placenta by controlled cord traction, followed by uterine
massage
(i) (ii) (iii)

20. Benefits of AMTSL
● Uterine atony accounts for 70-90% of all PPH cases
AMTSL reduces
:
- Incidence of PPH by 60
%

21. 2018

22. To effectively prevent PPH, only one of the
following uterotonics should be used
:
• Oxytoci
n
• Carbetocin (Newer molecule
)
• Misoprosto
l
• Ergometrine/methylergometrin
e
• Oxytocin(5U) and ergometrine(0.5mg) fixed-dose
combination.

23. Oxytocin : current standard of care.
● Route : IM, Infusion,
● Dose: 5-10 units in 500 ml crystalloid
.
● Max dose : 40 units.
● Intravenous (IV): almost immediate action with peak
concentration after 30 minute
s
● Intramuscular (IM): slower onset of action, taking 3–
7 minutes, but produces a longer lasting clinical
effect of up to 1 hour.

24. Continued..
● Short plasma half life : 1-6 mins
.
● Continuous IV infusion required at LSCS.
Side effects: Hypotension(rapid iv bolus),water
intoxication(large doses)
● Storage at 2–8 °C to prolong shelf
life
.
● Requires protection from light,

25. Oxytocin Ban !

26. Methergine
● Sustained tonic uterine contraction
.
● Route : IM/slow IV.
● Dose : 0.2 mg repeat 15 min followed by 4th hourly
.
● max dose : 5 doses( 1 mg).
● IV: onset of action within 1 minute, lasting 45
minutes (although rhythmic contractions may persist
for up to3 hours)
● IM: onset of action within 2–3 minutes
● Half-life: 30–120 minutes
● Contraindications : hypertension, heart disease.
● Side effects : nausea , vomiting
.
● Storage : 2-8 degrees.

27. Carboprost
● 15 methyl PGF2 alpha
.
● Route : IM/Intra myometrial.
● Dose : 250 mcg once in 15 min
● Max dose : 8 doses(2 mg).
● Onset of action IM: 15–60 minutes to peak plasma
concentration.
● Half-life: 8 minute
s
● Contraindications : bronchial asthma , cardiac disease.
● side effects : nausea,vomiting,diarrhoea
.
● Storage : 4 degrees
.
Injectable prostaglandins (carboprost or sulprostone)
are not recommended for the prevention of PPH
Carboprost should not be given IV- can be fatal.**

28. Misoprostol
● Synthetic analogue of PGE1
● Dose : 400-600 mcg.
● Max : 1000 mcg.
● Half-life: 20–40 minutes.
● Absorbed 9–15 minutes after sublingual, oral, vaginal
or rectal use
● No clear evidence of which dose is superior, but higher
doses have more side effects.
● Can be used in hospital or community
● Side effects : shivering, fever ,diarrhea.
● Stable at room temperature , easy to administer ,
cheap.

29. Carbetocin
● Sold as Duratocin. Rate varies from
18-40 euros. (Approx. 1500 - 3400 INR.)
It is a patented drug researched and developed by
Ferring. The company has committed to the WHO to
make the product available in the market at same
price as oxytocin.

30. Carbetocin (Newer ; heat stable formulation)
● Long acting , synthetic , octapeptide analogue of
oxytocin.
● MOA: Binds to oxytocin receptors in the uterine
smooth muscle, resulting in
-rhythmic contractions
-increased frequency of existing contractions
-increased uterine tone
● Dose : iv bolus 100mcg , acts within 2 min.
● IV: sustained uterine contractions within 2 minutes,
lasting for about 6 minutes and followed by rhythmic
contractions for 60 minutes
● IM: sustained uterine contractions lasting for about
11 minutes and rhythmic contractions for 120
minutes

31. Continued..
● Peak concentration < 30 min
.
● Longer half life : 80-90 min. 80% bioavailability
.
● Carbetocin is intended for single administration only.
No further doses of carbetocin should be administered
for prevention of PPH
.
● Storage:
-It is in heat stable formulation
,
-does not require cold chain transport and storage
.
-can stay at room temperature for a long period of
time
30°C for 3 years
,
40°C for 6 months,
50°C for 3 months,
60°C for 1 month.

32. Continued..
● Carbetocin has similar desirable effects compared with
oxytocin though it may likely be superior to oxytocin in
reducing
-PPH of at least 500 m
l
-use of additional uterotonic
s
Based on the WHO CHAMPION trial results
Carbetocin is recommended for PPH prevention,
especially in those settings where the cold storage
of oxytocin is not possible

34. Tranexamic acid
● Tranexamic acid is an antifibrinolytic agent.
● During elective surgery tranexamic acid reduced the risk
of blood transfusion by 39%
.
● WHO Recommendations:
Tranexamic acid may be offered as a treatment for PPH
ONLY if:
(i) oxytocin, followed by second-line treatment options
and prostaglandins, has failed to or
(ii) it is thought that the bleeding may be partly due to
trauma

35. Recombinant factor VII a
● It involves enhancement of rate of thrombin
generation
.
● Resistant to premature lysis
.
● Effective in severe obstetic hemorrhage
.
● Use of rFVIIa could be life-saving, but is high rates of
thrombotic events
.
● r factor VIIa is expensive and difficult to administer
.
● Cost is 20000 -30000 Rs

36. Hemorrhage is often not recognized
● Blood loss is underestimated because in pregnancy
signs of hypovolaemia do not show until the losses are
large
● Mother can lose up to 30-35% of
circulating blood volume (2000 ml) before
showing signs of hypovolaemia.
● Slow steady bleeding can be fatal.
● Most deaths from hemorrhage seen after 5h

37. MANAGEMENT OF PPH

38. Initial Steps for PPH
● Empty bladder
● Give Oxytocics
● Check for placenta completeness
● genital tract injury
● Massage uterus
● Bimanual compression
● Aortic compression
● Uterine tamponade

41. Q mat/ blood collection mat
• Named after - Dr. Md.
Abdul Quaiyum, is placed
under a woman immediately
after the delivery of a baby.
•The mat can retain 448±58
ml of blood when fully
soaked, signaling the
woman is hemorrhaging.

42. Bimanual Compression of Uterus

43. Compression of Abdominal Aorta
Apply downward pressure wit
h
closed fist over abdominal aort
a
directly through abdominal wall
.
-With other hand, palpate femora
l
pulse to check adequacy o
f
Compressio
n
Pulse palpable = inadequat
e
Pulse not palpable = adequat
e
Maintain compression until bleeding is
controlled.

44. Signs in hemorrhagic shock-
● Pallo
r
● Confusio
n
● Increased HR (1st sign )
● Reduced BP (late sign)
● Tachypnoe
a
● Cold clammy extremitie
s
● Reduced urine outpu
t
● Obvious or hidden bleeding

45. Severity of shock-
A fit woman , who has delivered recently will not usually
decompensate untill 35%
of total blood volume has lost.

46. Rule of 30 and Shock Index
● 30% blood loss >moderate shock
● Pulse rate – increase >30 bp
● Respiratory rate >30/min
● Systolic BP – drop by 30 mm Hg
● Urinary output < 30 ml/hour
● Hematocrit drop > 30% & to be kept at an absolute
value of > 30
● Shock Index = Pulse rate / Systolic BP
Normal = 0.5 to 0.7 : >0.9 indicates state of
shock that needs urgent resuscitation

47. Acute Postpartum Blood Loss
PROBLEMS
:
Loss of circulatory Volum
e
Loss of O2 carrying capacit
y
Restore SaO2 O2 carrying capacit
y
Volum
e
1 – Crystalloid Supplemental O2 Transfusio
n
2 - Colloid

48. Fluid resuscitation-
How much fluid, How fast
?
● Volume of 3x the estimated loss as crystalloid
s
(up to 4L) then as colloid
s
● Give blood early – mistake often
is too little too late!
● Replace as quickly as you can if patient shocke
d
● Be guided by the patients signs and respons
e
(e.g. Pulse rate, BP,level of consciousness)

49. Volume replacement
● Aggressive fluid replacement should commence
to ‘catch up’ for any losses
.
● Fluid of choice- Crystalloids over colloids
.
● Crystalloid of choice- Ringer lactate, N
S
● Fluid input & output charting
.
● Loss of 1 L of blood requires 4-5 L of
crystalloids untill cross matched blood is available.

50. ● Synthetic colloids are a ‘warning’ in modern
practice
.
● No added benefits of colloids over crystalloids
seen. Even suggest possible worsening when
administered too early
.
● But ideal choice- “Blood for Blood”

51. Medical Anti-Shock Trousers –MAST
(Pneumatic Anti-Shock Garments) -
● MAST are used to increase venous return to the
heart until definitive care could be given.
● MOA- combined with compression of blood
vessels, is believed to cause the movement of
blood from the lower body to the brain, heart
and lungs.

52. MAST-

54. Non-pneumatic anti-shock garment
(NASG)
● Low-technology first-aid device for stabilizing
women suffering hypovolemic shock secondary to
obstetric hemorrhage.
● It is a lightweight, re-usable lower-body
compression garment made of neoprene and Velcro

55. NASG
● MOA in hemorrhage & shock-
-Reversing shock and decreasing blood los
s
thereby stabilizing the woman until definitive care is
accessed.
-Increases blood pressure by decreasing the
vascular volume and increasing vascular resistance
within the compressed region of the body, but does
not exert pressure sufficient for tissue ischemia

56. ● The NASG is recommended as a temporizing measure
for PPH by the WHO and FIGO.
● It aids transport of hemorrhaging wome
n
from rural areas to urban treatment centers, or while
awaiting procedures or surgery.

57. NASG

59. Panicker’s/Samartha Ramadas Vacuum Suction Hemostatic
Device for Treating Post-Partum Hemorrhage
● A specially made stainless steel or plastic cannula of
12 mm in diameter and 25 cm in length with multiple
holes of 4 mm diameter at the distal 12 cm of the
cannula.
● When introduced into the uterine cavity through the vagina
to reach the fundus.
● Cannula connected to a suction apparatus, and a negative
pressure of 700 mm Hg produced.

60. ● Negative suction resulted in aspiration of all the blood
collected in the uterine cavity.
● Quantity of blood sucked varied from 50–300 ml. Collected
blood when completely sucked out, the bleeding ceased.
● Suction maintained for 30 min.
● Then the cannula taken out slowly after releasing the
suction after 20-30 minutes.
● No further bleeding from the uterine cavity, noted and the
uterus well contracted.

61. Panicker’s Vacuum Suction Hemostatic
Device

64. What next?
● If all these measures concurrently/sequentially
fail to control PPH, resort to :
1. Tamponade procedures
2. Surgical intervention

65. Thank You