PPH

DEFINTION
Postpartum Hemorrhage: bleeding
from genital tract in excess of 500 ml after
delivery
Or any bleeding that cause a drop in
hematocrit of 10%
Types:-
*Primary PPH occur within first 24 h
* Secondary PPH occur between24h and 6-
12w postpartum
 ASSESSMENT OF BLOOD LOSS AFTER
DELIVERY
• Difficult, mostly visual & subjective.
• For this reason it is more important to
take into account any blood loss that
causes a haemodynamic change.
• As the risk of dying from PPH depend
not only on the amount and rate of
blood loss but also on the health of
women.
 Physiology of 3rd stage
• Once the baby is born myometrial contraction is the main
driving force for placental separation & blood vessel
constriction .This haemostatic mechanism is known as
Physiological suture or living ligature.
• If the uterus does not contract normally, the blood vessels
at the placental site stay open & hemorrhage results.
• Because the estimated blood flow to the uterus is 500 –
800 ml/min at term a severe postpartum hemorrhage can
happen within just a few minutes.
 Etiology of PPH

The causes of postpartum hemorrhage can be

thought of as the four Ts:

➢tone,
➢tissue,
➢trauma,
➢thrombin
 Tone
Uterine atony

➢Multiple gestation polyhydramnios

➢high parity,
➢prolonged labor
➢chorioamnionitis,
➢augmented, instrumental delivery
 Tissue
1-Retained uterine
contents

➢Placenta &products of conception,

➢blood clots
 Tissue
2-Placental abnormalities

Location Attachment Peripartum

Placenta Accreta Placental

previa abruption
(Leiomyoa,
previous
surgery)
 Trauma
Lacerations and trauma

Unplanned
Planned
•Vaginal/cervical tear,
•Cesarean section, •Perennial tear
•episiotomy •Uterine rupture
•Haematoma
 Thrombin
Coagulation disorders

Acquired
Congenital DIC(AP,IUD,AFE)
PET,HELLP
syndrome
Heparin
Von Willebrand's disease
Massive transfusion
 PREVENTION
1-Regular ANC-
Correction of anaemia

2-Identification of high risk cases, who should deliver

in hospital with facility for Emergency Obstetric Care.

3-ACTIVE MANAGEMENT OF 3RD STAGE :-

• Placenta delivered by controlled cord traction (CCT)
• Fundal massage.
Prophylactic oxytocics should be offered routinely
Oxytocin 5 u iv, 10 u im
Syentometrin (5 u syentocinon+0.5 mg ergometrin)
 SYMPTOMS & SIGNS
Blood loss Systolic BP Signs & Symptoms
(% B Vol) ( mm of Hg)
10-15 Normal postural hypotension
15-30 slight fall PR, thirst, weakness
30-40 60-80 pallor,oliguria,
confusion
40+ 40-60 anuria, air hunger,
coma, death
 A-RESUSCITATE
• TEAM(call for help)- Obstetrician, Anaesthetist
,midwife ,haematologist and Blood Bank
• IV access with 14 G cannula X 2,Oxygen, head down
• Transfuse •Crystalloid (eg Hartmann’s)
•Colloid (eg Gelofusine)
• GIVE ‘O NEG’ OR uncross-matched own-
group If no cross-matched blood available .

PR,BP,Foley catheter for UOP,CVP ,oximeter

Monitor
•Cross match 6 units of blood
Investigate
•FBC ,Clotting screen
•RFT,LFT
 B-STOP THE BLEEDING
First step(if placenta delivered)
Examine uterus for atonia, or inversion
ENSURE UTERINE CONTRACTION.
1- Ensure empty bladder
2-Give uterotonics(medical management)
*IV oxytocin 10 units bolus followed by 40U in500ml NS
infusion 125ml/hr
*IV ergometrine 0.2-0.5 mg
*IV Syntometrine (5 unit oxytocin +ergometrine)
*IM or inramyometrial Carboprost or haemabate(PG F2 *
*Misoprostol (PG E1).(800 Mcg rectally or orally)
bronchoconstrive C.I. in asthma SE diarrhea,v omiting
,fever ,headache & flushing
*3-(uterine massage, Bimanual compression)
Second step
SURGICAL TREATMENT
If family is not completed:
UTERINE PACKING
UTERINE TAMPONADE
Uterine A. ligation
Internal Iliac A. Ligation
Brace suturing of Uterus(B- Lynch)
Angiographic embolisation of U.A.
If family is completed
Hysterectomy
 Third step
Exclude causes other than uterine atony
(EUA)
▪Explore the uterine cavity for integrity , placenta
debris and exclude clot retention
*Examine lower genital tract for possible
cervical,vaginal and perineal tears.
Repair of trauma if any

Exclude coagulopathies: bed side clotting test,

clotting profile,fibrinogen and FDP
 IF Placenta not delivered
EUA & MANUAL REMOVAL OF PLACENTA
External hand steadies the uterine fundus

Uterus

Placenta

Internal hand along plane of cleavage

Anaesthesia
Antibiotics Check placenta is complete
IV line Check the uterus is empty
Oxytocics Check for trauma of GT
 Placenta Accreta
(1) Accreta vera, in which the placenta adheres
to the superficial myometrium without invasion .
(2) Increta, in which it invades into the
myometrium.
(3) Percreta, in which it invades the full
thickness of the uterine wall up to serosa and
possibly other pelvic structures, most frequently
the bladder.
21
 Risk factors
1-History of operative interference e.g •
previous c/s ,curettage , myomectomy.
2- Placenta previa in present pregnancy . •
3-Multiparity. •
4-Advanced maternal age >35y. •
 UTERINE RUPTURE

Rupture of the uterus is described

as complete or incomplete and
dehiscence of a cesarean section
scar.
Management of Rupture Uterus
➢At this point, a decision must be made to
perform hysterectomy or to repair the rupture
site. In most cases, hysterectomy should be
performed.
➢ repair of the rupture can be attempted in
dehiscent scar following C/S.
MORBIDITY & MORTALITY from PPH
(Complications)
1-Shock & DIC
2-Renal Failure
3-Puerperal sepsis
4-Blood transfusion reaction
5- Sheehan’s syndrome
6- >25% Maternal deaths are due to PPH
 WEL COME TO

Taj Mahal

Taj Mahal-One of the seven wonders of the world, One of the Greatest
monuments, dedicated to the memory of “Queen Mumtaz” who died in
child birth, by her husband “Emperor Sahajahan”, is a testimony and a
grim reminder of the tragedy of maternal mortality, that can befall any
women in childbirth.