MANAGING POSTPARTUM 


HEMORRHAGE
( PPH )

Wisnu Prabowo dr SpOG (KFM)

MATERNAL - FETAL MEDICINE DIVISION

MOEWARDI HOSPITAL/ SEBELAS MARET UNIVERSITY

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PLASENTA
AKRETA
Skrining USG Kehamilan Trimester 1-2
( 11-14 minggu )
Riwayat Sesaria !!!!
Deteksi dini PLASENTA AKRETA
 Why do we care?

Major obstetric haemorrhage

more than 1000ml

Very rapidly lead to maternal death

 Risk Factors
Most cases have no risk factors

• Previous PPH
• Antepartum haemorrhage
• Grand multiparity
• Multiple pregnancy
• Polyhydramnios
• Fibroids
• Placenta praevia
• Prolonged labour (&oxytocin)
DEFINITION OF POSTPARTUM HEMORRHAGES

• PERVAGINAM : 500 ml
• SEKSIO SESARIA : 1000 ml
• CESAREAN HYSTEREKTOMI : 1500 ml

Physical Response to Hemorrhage

class Blood loss % loss Physiologic Respon

I 1000-1200 15 asymptomatic
II 1200-1800 25 Tachycardia, orthostatic hypotensi
III 1800-2400 30 Worsening tachycardia, hypotensi
IV > 2400 40 Shock, oluguria

Gina Connely MD, Arizona 2014

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 BLEEDING CAUSES

EARLY (<24 HRS)

• Uterine Atony (80% of cases )

• Coagulopathy : Abruption , Previa

• Lacerations : Retained products

• Invasive placentation : Accreta,percreta,increta

• Uterine rupture

• Uterine inversion

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BLEEDING CAUSES ….............

LATE (>24 HOURS-6 WEEKS)

• 0.5-2% deliveries

• Infection

• Retained products

• Placental site subinvolution

• Coagulopathy

• Rare = AVM

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 Diagnosis 5T - PPH

• TONE
• TISSUE
• TRAUMA
• TROMBINE
• TRACTION
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Management

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algorithm of ‘HAEMOSTASIS’ :

• H – ask for Help

• A – Assess (vital parameters, blood loss) and resuscitate

• E – Establish the cause, ensure availability of blood

• M – Massage uterus

• O – Oxytocin infusion

• S – Shift to theatre/anti-shock garment – bimanual compression

• T – Tamponade test

• A – Apply compression sutures

• S – Systematic pelvic devascularisation

• I – Interventional radiologist – if appropriate, uterine artery embolisation

• S – Subtotal/total abdominal hysterectomy RCOG, 2014

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 ACTIVE MANAGEMENT 

THIRD STAGE OF LABOR

(AMTSL)

• administration of 10 IU of OXYTOCIN/ 0.2 mg,

• ERGOMETRINE within one minute following the
delivery of the fetus,
• CONTROLLED CORD TRACTION,
• mmediate UTERINE MASSAGE following
delivery of the placenta and palpation of uterus
every 15 minutes.
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 DRUGS in PPH
Agent Dose Cautions
Oxytocin 10 IU i.m/i.v. Followed by i.v. Hypotension if given by rapid i.v.
Infusion of 20 IU in 500 ml Bolus. Water intoxication with
crystalloid titrated vs response large volumes
(e.g. 250 ml/h)
Ergometrine 0,25 mg i.m/ i.v Contraindicated in hypertensive
patients. Can cause nausea/
vomiting/ dizziness)
Misoprostol 600- 1000 µg p.r./ intracavitary Gastrointestinal disturbance,
shivering, pyrexia

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 CALCIUM FOR PPH

UTERINE
CONTRACTION

COAGULOPHATY

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 Calcium Gluconate For Uterine Atony Therapy
• Several literatures stated that Ca gluconate intravena is able to be
given for post partum hemorrhage caused by uterine atony because
of magnesium or nifedipin excess.

• Magnesium work as Ca2+ competitor so with the Mg2+ presence,

normal activities of muscle contraction will not occur.

• Nifedipin is the drug that inhibit calcium channel, inhibit the entry of
Ca2+ ion intracellular, so prevent the threshold achievement of Ca2+ to
cause muscle contraction.

• Ca gluconate work as the Ca2+ source.

• The increase of Ca2+ concentration give muscle contraction signal

through protein precursor movement that is bound at the actin
filament: tropomyosin and troponin.

(Brown, 2011)
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Calcium Gluconate For Uterine Atony Therapy…..
• Because concentration of Ca2+ increase (from Ca
gluconate), reticulum sarcoplasma will open quickly and
release Ca2+ into sarcoplasma.
• Concentration of Ca2+ ion in the sarcoplasma increase
quickly up to 105 mol/L. The binding place of Ca2+ at
TpC in thin filament quickly filled by Ca2+. Complex of
TpC-4Ca2+ interacts with Tpl and TPT to change the
interaction with tropomyosin ! lead to muscle
contraction

The used dosage at several research:

drip 10 ml calcium gluconate 10% in 100 ml glucose 10%

(Brown, 2011)
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• The sample taking randomly from 116 birth by using control group.
• At the sample group, at the cervical opening 10 cm ! intravenous
infusion of 100 ml glucose 10% add with 10 ml ca gluconate 10%.
• Control group withaout drug
• At both group still given oxytocin injection after baby delivery 10 IU
and intravenous infusion of oxytocin 20 IU. 30
 Role of Calcium in Cross-Bridge Formation
• Excited

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Human physiology by Lauralee Sherwood, 7th edition
When atony is due to tocolytic therapy, that is,
those medications that impair calcium entry
into the cell (magnesium sulfate, nifedipine),
an additional agent to employ is calcium
gluconate.

Given as an intravenous push, one ampule of

calcium gluconate can effectively improve
!34
Calcium Gluconat Doses
• Calcium Channel Blocker Overdose (Off-label)

• 60-120 mg/kg/hr IV or 60 mg/kg IV over 5 minutes every

10-20 minutes PRN up to 3-4 doses; not to exceed 3-4 g/
dose

Pregnant or breastfeeding patient :

Calcium : 1000/day PO divided q8-12hr,

preferably 1-2 hours after meals

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Conclusion

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Non Surgery
Surgery
Jangan berharap masalah
menjadi lebih mudah

BERHARAPLAH BAHWA ANDA

MEMPUNYAI KEMAMPUAN
LEBIH BAIK
TERIMA KASIH