Introduction

Postpartum hemorrhage (PPH) is an

obstetrical emergency that can follow
vaginal or cesarean delivery.
It is a major cause of maternal
morbidity, and one of the top three
causes of maternal mortality.
Incidence

The incidence of postpartum hemorrhage

varies widely, depending upon criteria used
to define the disorder.

A reasonable estimate is 1 - 5 % of
deliveries.
Definition
primary PPH occurs in
the first 24 hours after
delivery (also called early
PPH).
PPH is defined as
primary or secondary:
secondary PPH occurs 24
hours to 12 weeks after
delivery (also called late
or delayed PPH).
Definition (cont…)

The most • estimated blood loss ≥500

common ml after vaginal delivery.
• estimated blood loss
definition ≥1000 ml after cesarean
is: delivery.
Definition (cont…)

PPH is best defined/diagnosed clinically as

excessive bleeding that makes the patient
symptomatic (eg, pallor, lightheadedness,
weakness, palpitations, diaphoresis,
restlessness, confusion, air hunger,
syncope) and/or results in signs of hypovolemia
(eg, hypotension, tachycardia, oliguria, oxygen
saturation <95 percent).
The Royal College of Obstetricians and
Gynaecologists (RCOG) classifies PPH as:

Minor hemorrhage Major hemorrhage

(500 to 1000 mLs). (>1000 mLs).
Moderate
hemorrhage (1000 to
2000 mLs).

Severe hemorrhage
(>2000 mLs).
 Causes of PPH

Tone Tissue Trauma Thrombosis

 Etiology Process Clinical Risk Factors

Overdistended Uterus Polyhydramnios, Multiple Gestation

Macrosomia
Uterine Muscle Fatigue Rapid Labor, Prolonged Labor .High Parity
Tone Intra Amniotic Infection Fever, Prolonged ROM

Functional/Anatomic Fibroid Uterus

Distortion of the Uterus Placenta Previa Uterine Anomalies

Retained Products Incomplete Placenta at Delivery .Previous Uterine

Scar High Parity
Tissue Abnormal Placenta
Retained Blood Clots Atonic Uterus

Lacerations Precipitous or Operative Delivery

Extensions at C/S Malposition, Deep Engagement

Trauma Uterine Rupture Previous Uterine Surgery

Uterine Inversion High Parity, Fundal Placenta

Pre-existing Coagulopaties, Liver Disease

Thrombin Acquired in Pregnancy ITP, DIC

Therapeutic Anti-coag History of clots
Etiology

PPH • defective myometrial contraction

(atony),

can
• defective decidual hemostasis due
to inadequate decidualization (eg,
placenta accreta), resulting in RPOC

result
• trauma
• bleeding diatheses (eg, acquired or
inherited factor deficiencies,

from thrombocytopenia, drugs that affect

coagulation)
Although
uterine •it is often
atony is
the most responsive
common to therapy
cause,
the most common etiologies of
massive transfusion in PPH

≥10 units red blood cells or whole

blood) during hospitalization for delivery

abnormal
coagulopathy
placentation atony (21 % abruption (17
(15 % of
(27 % of of cases) % of cases)
cases)
cases)
Pathophysiology

Over the course of a pregnancy, maternal blood volume

increases by approximately 50% (from 4 L to 6 L).

The plasma volume increases somewhat more than the

total RBC volume, leading to a fall in the hemoglobin
concentration and hematocrit value.

The increase in blood volume serves to fulfill the

perfusion demands of the low-resistance uteroplacental
unit and to provide a reserve for the blood loss that
occurs at delivery.
At term, the uterus and placenta receive 500-
800 ml of blood per minute through their low
resistance network of vessels.

This high flow predisposes a gravid uterus to

significant bleeding if not well physiologically or
medically controlled.

By the third trimester, maternal blood volume

increases by 50%, which increases the body's
tolerance of blood loss during delivery.
Following delivery of the fetus, the gravid uterus is able to
contract down significantly given the reduction in volume.

This allows the placenta to separate from the uterine interface,

exposing maternal blood vessels that interface with the
placental surface.

After separation and delivery of the placenta, the uterus

initiates a process of contraction and retraction, shortening its
fiber and kinking the supplying blood vessels, like physiologic
sutures or "living ligatures“.
The traditional pneumonic "4Ts: tone, tissue, trauma, and
thrombosis" can be used to remember the potential causes.
Here, a 5th is added; “T” for uterine inversion that will be
called “traction.”

Uterine atony, or diminished myometrial

contractility, accounts for 80% of postpartum
hemorrhage.
abnormal placental attachment or retained placental
tissue,
laceration of tissues or blood vessels in the
pelvis and genital tract
inversion of the uterus during placental delivery.

maternal coagulopathies.
risk factors .. Ask about it in the history .
Uterine atony – most common

• Precipitous labor
• Multiparity
• General anesthesia (Halthane anaesthtic gas)
• Oxytocin use in labor
• Prolonged labor
• Macrosomia
• Hydramnios
• Twins
• Amnionitis
• Amniotic fluid embolism
Lacerations in genital tract

• Instrumental delivery
• Manipulative delivery, i.e. breech extraction
• Precipitous labor
• Macrosomia

Retained placenta

• Prior cesarean
• Uterine leiomyomas
• Prior uterine curettage
• Succenturiate lobe of placenta

Coagulation defects

Amniotic fluid embolism

Uterine inversion
ِExamination

Soft large uterus

Utrine atony
ِExamination

Bright red bleeding before placental

delivery

Trauma
ِExamination

Mass increasing

hematoma
 ِExamination

Sever bleeding

Uterus is contracted

Coagulopathy
ِExamination

Fever and signs of infection

Endometritis
chorioamionitis
 Complication :

PPH is a major cause of maternal morbidity, including

catastrophic sequelae:

●Death

●Hypovolemic shock and organ failure: renal failure, stroke,

myocardial infarction, postpartum hypopituitarism (Sheehan
syndrome)

●Fluid overload (pulmonary edema, dilutional coagulopathy)

 Complication :

●Anemia

●Transfusion-related complications,
including severe electrolyte
abnormalities (predominantly
hyperkalemia and hypocalcemia)
 Complication :

●Acute respiratory ●Anesthesia-related ●Sepsis, wound

distress syndrome complications infection, pneumonia

●Asherman syndrome
●Unplanned (related to curettage if
●Venous thrombosis
sterilization due to performed for retained
and embolism
need for hysterectomy products of
conception)
 Risk Factors of PPH:
1- prolonged third stage of labor

2- multiple delivery

3- fetal macrosomia

4-history of postpartum hemorrhage

5- chorioamnionitis

6- magnesium sulfate use

7- placenta accreta

8- induction of labor

9- obesity

However, postpartum hemorrhage also occurs in women with no risk factors

Etiology
 Causes of
PPH

Tone Tissue Trauma Thrombosis

 Tone
Uterine atony and failure of contraction and retraction of myometrial muscle
fibers can lead to rapid and severe hemorrhage and hypovolemic shock

Causes of Atony:

1- Overdistension of the uterus which is caused by:

multifetal gestation:

fetal macrosomia

Polyhydramnios

fetal abnormality

uterine structural abnormality

failure to deliver the placenta

2- Fatigue due to:

- Prolonged labor or rapid forceful labor, especially if stimulated

- Inhibition of contractions by drugs such as halogenated

anesthetic agents, nitrates, nonsteroidal anti-inflammatory
drugs, magnesium sulfate, beta-sympathomimetics, and
nifedipine

- placental implantation site in the lower uterine segment

bacterial toxins (eg, chorioamnionitis, endomyometritis,

septicemia)

hypoxia due to hypoperfusion

 Tissue
•Retention of a portion of the placenta is more common if the
placenta has developed with a succenturiate or accessory lobe. a

• Failure of complete separation of the placenta occurs in

placenta accreta and its variants.

• All patients with placenta previa should be informed of the risk

of severe PPH, including the possible need for transfusion and
hysterectomy.

• Retained blood may cause uterine distension and prevent

effective contraction.
Manual removal of placenta is accomplished as the fingers are swept from side
to side and advanced (A) until the placenta is detached, grasped, and removed
(B).
 Trauma
Damage to the genital tract may occur spontaneously or through
manipulations used to deliver the baby, which can be:

1- Uterine rupture:most common in patients with previous cesarean delivery

scars, or any uterine scar(Any uterus that has undergone a procedure resulting in
a total or thick partial disruption of the uterine wall )

2- Trauma may occur following very prolonged or vigorous labor

3- Extrauterine or intrauterine manipulation of the fetus

4- secondary to attempts to remove a retained placenta manually or with

instrumentation.

5- Instrumental delivery
 Uterine rupture:

Risk factors
• Prior uterine surgery (including myomectomy,
vigorous curettage, manual removal of the
placenta). However, the most frequent cause of a
uterine scar is a previous Caesarean section.
Classical vertical and T-shaped incisions carry a
higher risk of later uterine rupture than the
standard modern low transverse approach.
 Uterine rupture:

Risk factors
• Uterine anomalies (eg undeveloped uterine horn).
• Trauma, eg vehicle accident.
• Use of rotational forceps.
• Obstructed labour.
• Induction of labour (suspected association only) -
prostaglandins should be used with caution
during a trial of labour.
• Cervical laceration.
 Uterine rupture:
Risk factors.
• Placenta percreta or increta.
• Hydramnios.
• Macrosomia and fetal anomaly, eg hydrocephalus.
• Malpresentation (brow or face).
• Choriocarcinoma.
 Thrombosis
Preexistent
•Idiopathic thrombocytopenic purpura
•familial hypofibrinogenemia
•von Willebrand disease
Acquired
•DIC related to abruptio placentae
•HELLP syndrome
•amniotic fluid embolism
•and sepsis
Dilutional coagulopathy may occur
•following massive PPH and resuscitation with crystalloid and packed red blood
cells (PRBCs).
Clinical Picture
•The usual presentation of PPH is one of heavy
vaginal bleeding that can quickly lead to signs and
symptoms of hypovolemic shock

• This rapid blood loss reflects the combination of

high uterine blood flow and the most common cause
of PPH, ie, uterine atony.

• Bleeding from trauma may be concealed in the

form of hematomas of the retroperitoneum, broad
ligament or lower genital tract, or abdominal cavity
The clinical findings in hypovolemia are
Most important step in management
of PPH is identification of those who
are at risk & starting prophylactic
measures during labor to minimize
maternal mortality.
The treatment of patients with
PPH has 2 major components:
resuscitation and management of obstetric
hemorrhage and, possibly, hypovolemic
shock

identification and management of the

underlying cause(s) of the hemorrhage.
Fluid resuscitation
Fluid resuscitation of women experiencing obstetric
hemorrhage is sometimes overly conservative. Possible
reasons for this include:

blood loss being generally underestimated both in volume and

rapidity

women initially compensating well for losses because of their

good health and the hypervolemia of pregnancy

concerns that over resuscitation leads to pulmonary edema

failure to appreciate the dynamics of fluid shifts in the body.

 Resuscitation
1. O2 by mask

2. Place 2 large bore IV line .. (Central venous line if necessary) .

3. Draw blod : CBC , coagulation , cross matching , createnine level, & urea &
electrolyte .

4. immediate fluid replacement (NS or Ringer`s lactate )

5. Order blood transfusions PRBCs if blood loss is ongoing and thought to be in

excess of 2000 mL or if the patient’s clinical status reflects developing shock
despite aggressive resuscitation

6. FFP (1 IU for each IU of blood ) & if coagulation profile is abnormal

7. Platelet concentrate if platelet count is < 50000 /L & the bleeding continues .
Keep monitoring

Pulse , BP, urine output , blood gases & level of

conciousness .

Regular CBC & coagulation tests .

Management of primary PPH
Management of the
underlying cause of
PPH
Uterine atony

Assess uterine size and tone… by

placing a hand on the uterine fundus
and massaging the uterus, which
serves to express any clots that have
accumulated in the uterus or vagina.
If the uterus is found to be boggy and
not well contracted, commence
vigorous massage and therapeutic
oxytocin.

Oxytocin can be administered

as a 5-U intravenous bolus, as 20 or as 10 U intramyometrially with
U in 1 L of NS intravenously run a spinal needle if no immediate
as fast as possible, intravenous access is available.
 Drug Therapy For PPH
Drug Dose Side Effects Contraindications
10 IU IM/IMM -Usually none -hypersensitivity
Oxytocin 5 IU iv bolus -ctx
10-40 IU/L -N&V
-water intoxication

0.25mg IM -peripheral vasospasm -HTN

Ergot drugs 0.125 mg IV -HTN -peripheral disease
ergometrine (ergonovine) Q5mins X 5 doses -N&V -Raynauld’s
methylergometrine -hypersensitivity
(methergine)
0.25 mg IM/IMM -flushing -hypersensitivity
Hemabate Q15mins X 8 doses -diarrhea/N&V -asthma
(PGF2α) -O2 desats -active cardiac, pulmonary, renal, or
-bronchospasm hepatic disease
-restlessness
400-1000mcg PR/PV/PO -pyrexia/flushing -hypersensitivity
Misoprostol X 1 dose -N&V/diarrhea -pregnancy
(PGE1) -abd pain
-HA

20U/100ml saline -acute HTN -coronary artery disease

Vasopressin Inject 1ml at bleeding -bronchospasm -hypersensitivity
site -N&V/cramps
-HA, vertigo
-angina
-death if iv
Emptying the bladder may aid in ongoing assessment
and facilitate uterine contraction and subsequent
therapeutic maneuvers.

bimanual massage of the uterus ( express vaginal ,

cervical or uterine clots & stimulates uterine
contractions )
Packing of the uterus may be an option until
the operating room is ready or if surgery is
not an immediately available option.

Intrauterine catheters for

tamponade of bleeding
Surgical Therapy
Curettage

Tamponade (Balloon, packing etc…)

B-Lynch sutures

Uterine artery ligation

Ovarian artery ligation

Internal iliac ligation (hypogastric Artery)

Hysterectomy

Selective arterial embolization

Cervical laceration

Visualize the cervix with a ring forceps.

No need for suturing unless they are
actively bleeding.
Using absorbable , interlocking stitch.

Apply pressure or packing over the repair.

Vaginal laceration

An absorbable , continuous ,
interlocking stitch is used.

Approximate the tow ends together

without leaving a dead space.
Lower genital tract
hematoma

Large &
expanding Small & stable
Incision &
drainage
Expectant
Ligation of management
bleeding
arteries
Packing for
24-36 hr
Broad ligament & retroperitoneal
hematomas

Expanding
Stable & not
expanding
Evacuation

Expectant ligation of
management torn
vessels
 laprotomy &
Uncontrolled bilateral
bleeding from hypogastric
vaginal approach artery ligation
Uterine rapture

Rarely it can be
repaired

Subtotal or total
abdominal
hysterectomy
 Uterine inversion
Immediate IV volume expansion with crystalloid.

When stable >> remove the placenta & replace the uterus

If this is unsuccessful >> IV nitroglycerin (100mg) >> try again

Once replaced >> Oxytocin infusion

Surgery :
Laprotomy >> vertical incision in the posteror cervix to incise the
constricted ring >> reduce the uterus >> repair the incision .
 Coagulopathy
Suspected if manual exploration has excluded uterine
rupture or retained placental fragments in a well
contracted uterus

• Risk factors
Confirm the Dx by • Abnormal coagulation test

•Platelet concentrate
•FFP
Management : •Cryoprecipitate
•Packed RBCs
Management of secondary PPH
Intravenous infusion

Blood cross matching

Syntocinon
Combinations of broad spectrum antibiotics:
Amoxicillin , gentamicin & metronidazole
Gentle digital evacuation of the uterus under
general anasthesia + antibiotic cover
Iron supplementation .
Manual removal of placenta is accomplished as the
fingers are swept from side to side and advanced
(A) until the placenta is detached, grasped, and
removed (B).
B-Lynch uterine compression suture
technique