Management of Post
DR HUSSEINH AKL
The confidential enquiry into maternal
Why CEMACH is important?
200 million global pregnancies
30 million globally experiences ill health due to pregnancy
8 millions have life threatened condition
Over half million women dies as result of pregnancy &
88-98% of MMR in the world are avoidable with timely
and effective care.
In UK, MMR 14 per 100.000 (2003-2005) live birth
In Malaysia half million deliveries per year.
MMR in Malaysia in 1947 - 700 per 100.000 deliveries
in 1999 – 30 per 100.000 live birth
MMR now 27.4 per 100.000 live birth target according
To MDG5 EXPECTED TO BE 14/100.000 BY 2015
Successes in Maternal Mortality Reduction
1840 1860 1880 1900 1920 1940 1960 1980 2000
Source: England, Wales, Sweden, USA: VanLerberghe and DeBrouwere,
Safe Motherhood Strategies, A Review of the Evidence, 2001
Malaysia, China: Koblinsky, Et al., Issues in Programming for Safe Motherhood, 2000
Causes of Maternal Deaths Malaysia
PPH HDP Embolism Medical Ob trauma Others
What we can do?
Explain to parents
Be vigilant & aggressive management of
massive obstetric haemorrhage
Don’t promise perfect outcome for mother
& the baby
We can identify and treat problems that
arises but we cannot prevent all
PPH is a major cause of maternal morbidity & mortality
world wide accounting for at least 25% of maternal
deaths accounting 30% of MMR in Malaysia
Globally > 125.000 women die of PPH each year
Major cause of maternal deaths in the UK (often after
Incidence is 2-11% in the UK
With a low BMI or low Hb, <500ml loss may cause
heamodynamic disturbances requiring prompt and
PPH is the 2nd
leading cause of pregnancy-related death
in USA accounting 17% of MMR.
WHO shows PPH occurs in 10-15% of births in
14 millions cases of PPH occurs per year globally with
case fatality 1-2%.
PPH creates a great morbidity causing physical/
psychological/ social/ economic impacts on the society.
PPH - definitions
Primary PPH – is defined as blood loss of ≥ 500ml for
vaginal delivery and ≥ 1000ml for caesarean delivery
from the genital tract occurring within 24H of delivery.
Secondary PPH – is defined as excessive loss occurring
between 24H and 6-12 weeks after delivery.
10% change of haematocrite between admission and
post partum period.
Excessive bleeding producing symptoms and requiring
Uterine Atony ( 90%)
Caused by failure of uterus to contract after
over distended uterus with twins or polyhydramnios, big
failure to actively managed 3rd
stage of labour
or rarely due to placenta abruption (diffuse bleeding into
the uterine muscle that prevents contractions)
Genital Tract Trauma (7%)
Vulva, vaginal tears
lacerations of cervix
Rupture of the uterus.
Severe PET, placenta abruption and
sepsis may contribute to PPH.
Autoimmune disease, liver disease,
inherited or acquired coagulation
disorders are rare causes.
Sometimes the patient on heparin can
lead to excessive bleeding.
Abnormal Placental Site
Placenta previa, placenta accreta and
Appropriate preplanning is needed to
avoid morbidity &mortality.
Uterine inversion & rupture are rare
causes of excessive bleeding.
Causes of secondary PPH
Infection - endometritis
Retained placenta parts & membranes
Subinvolution of the placenta site
Rarely trophoblastic disease
Pre-existing uterine lesion like submucous
Very rarely uterine Arterial Venous Malformation
Inherited coagulation defect
Antenatal Risk Factors for PPH
Maternal Hb ≤ 8.5g/dl at
onset of labour.
Para 4 or more
Overdistention of uterus
Maternal age > 35 years
The presence of any risk
factors for PPH should
lead to the woman being
advised to deliver in an
obstetric unit (facilities for
blood transfusion &
surgical management of
Intrapartum Risk Factors for PPH
Induction of labour
Use of oxytocin
Vaginal operative delivery
Massive Obstetric Haemorrhage 2nd
This is an important cause of maternal
morbidity & mortality
Identification of the risk factors , institution
of preventive measures and prompt &
appropriate management of the blood loss
is likely to improve the outcome.
Massive PPH loss of 30-40% of the pt’s
blood volume (about 2L).
Consequences of Massive PPH
Sudden and rapid cardiovascular
Iatrogenic complications associated with
massive blood transfusion
Sheehan’s syndrome (hypopituitarism)
Pathophysiology of Massive Obstetric
Blood volume increased during pregnancy.
Blood flow to pregnant uterus at term 500-
Placenta circulation accounting for 400ml/min.
Loss of 500-1000ml (10-15% of blood volume) is
usually well tolerated by a fit, healthy young
woman as she is able to maintain her
cardiovascular parameters by effective
compensatory mechanism until 30-40% of the
blood volume is loss.
Blood Loss & cardiovascular Parameters
Blood loss HR Systolic
10-15% increased normal Postural
15-30% Increased+ Normal Peripheral
30-40% Increased++ 70-80
40%+ Increased+++ <60
PPH / Massive Obstetric Heamorrhage
Life-threatening emergency requiring swift &
Most units have local guidelines for
management such as local hosp geography,
staff availability, who to contact & agreed
timescales for laboratory results
Activate Red Alert
Management consist of immediate resuscitation,
restore blood volume & rapid treatment of the
underlying cause to stop ongoing blood loss.
Initial measures for Resuscitation
Call for help – senior obstetrician, anaesthetists,
haematologist, midwife, hospital porter, blood bank & OT
High flow facial Oxygen even if the SPO2 is normal.
Assess airway & respiration – intubate to protect the
airway if decreased level of consciousness secondary to
2 large bore IV cannulla (14G)
Take blood for FBC, cross match, U&Es, liver functions,
Start IV cystalloids to correct hypovolemia
Catheterize & measure hourly urine output.
Blood Tx – O-ve blood can be given immediately until
cross matched blood is available.
Replace clotting factors – FFP (4 units every 6 units of
blood), cryoprecipatate, recombinant activated factor VII
As soon as appropriate in the resuscitation process,
transfer the woman to place where there is adequate
place, light & equipment to continue treatment (OT)
Assess for CVP line
V/S, urine output, type & quantity of fluids replaced,
drugs given & timelines of events should be recorded by
Once bleeding has been stopped & pt stable, pt should
be managed in HDU or ICU
Principles For Stopping the Bleeding
Empty uterus (remove the placental /
Treat uterine atony ( physically, medically
Repair genital tract trauma in OT
Medical Mx of uterine atony
Accompanied by physical attempts to
contract uterus – rubbing up the uterus &
500 micrograms of ergometrine IV/ can be
given IM if difficulty in IV access
Start oxytocin infusion 40IU
If bleeding doesn't stop, give oxytocin
10IU IV slowly, not bolus
If atony continues, carboprost 250 micrograms IM given
in the thigh or directly to myometrium & repeated at 15
min interval up to total 4 doses.
If bleeding persist or ergometrine contraindicated then
800 micrograms of misoprostol (tables) is given rectally.
Recent data shows misoprostol can be use as the 1st
drug to control PPH.
If all measures failed, retained tissue must be considered
& the EUA with possible further surgical management is
indicated without delay.
Surgical Management of PPH
A Rusch balloon catheter, Sengstaken-Blakemore tube
or Cooke’s balloon inserted into the uterine cavity & fill
with 100-500ml warm N/S.
If bleeding is controlled and the balloon is left for 24H
Tamponade may be particularly useful to control PPH
secondary to Placenta previa & accreta.
If conservative intervention for uterine tamponade like
uterine packing or balloon tamponade failed then
consideration must be given to perform an exploratory
laparotomy via vertical midline incision
Several procedures may be performed
the choice depends on pt’s desire for
future child bearing/ extent of the
haemorrhage/ experience of the
Intervention after laparotomy
Make sure uterine cavity is empty as small pieces of
tissue can cause atony.
If bleeding from large placental sinuses following CS
then undersewing the placenta bed ± insertion of Rusch
balloon may control bleeding.
If bleeding from uterine atony unresponsive to drug
treatment but ↓ with manual compression, B-Lynch or
vertical compression sutures should be attempted to
provide continuous compression & ↓ blood flow to the
Systematic pelvic devascularization by ligation of uterine,
tubal branch of ovarian or anterior division of internal iliac
Internal iliac ligation will help in controlling both the
uterine & vaginal branch bleeding ( B/L ligation results in
85% reduction of pulse pressure & 50% reduction blood
flow & bleeding reduced by 50%).
Hysterectomy is the last option. Subtotal hysterectomy is
safer & quicker to perform.
If the bleeding is from the lower segment ( placenta
previa, accreta or tears) then total hysterectomy is
The decision for hysterectomy should not be unduely
delayed as this can result in the death of the mother.
1. Compressive suture – B-Lynch suture in 1997 can be effective
in uterine atony
2. B/L uterine artery ligation –safe & effective method, identify the
ureters then ascending branches of uterine artery are ligated at
the level of vesicouterine peritoneal reflection.
3. B/L internal iliac artery ligation
4. Hysterectomy –remain definitive measure for control severe
PPH, should not be delayed.Placenta accreta is the most
common indication for emergency CS hysterectomy.
Arterial Embolization for Massive PPH
Less invasive than laparotomy
Help to preserve fertility
Quicker recovery than laparotomy
Only available in a few centres
May not be possible to get the required equipment to
obstetric OT or transfer a woman to the radiology
Appropriately trained interventional radiologists must be
A catheter is inserted through the femoral
artery and advanced above the bifurcation
of the aorta and a contrast dye is injected
to identify the bleeding vessels.
The catheter is then directed to the
bleeding vessels and embolized with
gelatin sponge which is usually
reabsorbed in 10 days.
Updates of the surgical Mx of PPH
Systematic review of conservative management
of PPH what to do when medical Tx fails
48 studies included in the review 2006
The cumulative outcome showed success rates
of 90.7% ( confidence interval 95%) for arterial
embolization – 84% for ballon tamponade –
91.7% for uterine compression sutures and
84.6% for internal iliac ligation or uterine
At present there is no evidence to suggest
that anyone method is better for the
management for severe PPH.
RCT of various treatment options may be
difficult to perform in practice.
Balloon tamponade is the least invasive
and the most rapid approach, it would be
logical to use this as the 1st
step in the
Case Illustration 1
27 year old G2 P1, had antenatal follow-up and
delivery at private maternity centre. Scanty
information as to what happened had ante-natally,
but was known to have had a ventouse delivery and
subsequently developed uterine atony. Transferred
out to a government hospital and arrived 2 ½ hours
after delivery. By then, patient was moribund and
very pale. Laprotomy decided upon, but patient died
before surgery could be performed.
Q1. What is the risk factor to the mother?
Q2. What are the commonest causes of uterine
Q3. Explain the management of uterine atony in
A1. Ventouse delivery and subsequently developed uterine
A2. Common causes can be divided into 2 main categories:
Predetermined Risk Factors
Uterine over distension
Past obstetric history of PPH
Uterine fibroid/retained products of conception
Controllable Risk Factors
Mismanagement of 3rd
A3. As in lecture.
Case Illustration 2
26 years old G2 P1 admitted to GH for post dates.
Induced with prostin and subsequently had
ventouse extraction. Developed PPH and blood loss
underestimated. Uterus was found to be atonic and
cervical tear noted. MO attempted to suture cervical
tear unsuccessfully. Meanwhile patient continued
bleeding. O&G specialist called in as patient
collapsed. Resuscitation carried out and
hysterectomy performed 1 ¼ hours after delivery. By
then, DIVC had set in. Patient died in ICU 8 hours
Q1. What are the causes of death for this patient?
Q2. Explain the management of PPH secondary to
PPH due to atonic uterus and cervical tear
Secondary to DIVC
Perform general resuscitative measures
Set up a minimum of 2 iv drips for major PPH (>1000cc blood
loss) a 3rd iv line or CV should be considered
Stabilise the patient with crystalloids (Hartman’s) or colloids
Take blood for FBC, GXM, Plt
Place the patient in lithotomy position
Find bleeding point if visible and clamp it
Suture tear immediately
Start broad spectrum antibiotics
Place continuous bladder drainage
Watch out for bleeding