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Postpartum Hemorrhage

The first clinical college of three


gorges university, Wang Xiaojin
 Definition
 Incidence

 Etiology

 Diagnosis and clinical effect

 Prognosis

 Prevention

 Management
Definition
Postpartum hemorrhage (PPH) involves loss
of over 500mL (vaginal delivery ) or 1000mL
(cesarean section) of blood in the first 24
hours postpartum. In the majority,Hemorrhage
occurs within two hours following delivery.

Hemorrhage may occur before,during,or


after delivery of placenta.
Actual measured blood loss during
uncomplicated vaginal deliveries has
been shown to average 700ml , and
blood loss may often be underestimated.
nevertheless, the criterion of 500mL is
acceptabal on historical grounds.
The clinical definition which is
more practical states
Any amount of bleeding from or into the
genital tract following birth of the baby
upto the end of the puerperium which
adversely affects the general condition of
the patient evidenced by rise in pulse rate
and falling blood pressure is called PPH
Incidence
The incidence of excessive blood
loss following vaginal delivery is 2-3%
in china. Postpartum hemorrhage is the
first leading cause of maternal mortality
in china and is the third in the U.S.
Etiology
Causes of postpartum hemorrhage
1. uterine atony
2. retained placental tissue,
3. genital laceration
4. coagulation defects
UTERINE ATONY

Postpartum bleeding is physiologically


controlled by constriction of interlacing
myometrial fibers that surround the blood
vessels supplying the placenta implantation
site. Uterine atony exists when the
myometrium cannot contract.
Atony is the most common cause of
postpartum hemorrhage.

Risk factors include


•rapid or protracted labor(most common);
•infected uterus;
•overdistended uterus
(macrosomia,twins,polyhydramnios)
RETAINED PIACENTAL TISSUE

retained placental tissue and membranes


cause 5-10% of postpartum hemorrhage.
Risk factors include
•noncontracted uterus(most common)
•accessory placenta lobe
•placenta accreta or placenta increta
Accessory plancenta
GENITAL LACERATION
Lacerations can involve the uterus,
cervix, vagina, or vulva.
Risk factors include
• uncontrolled vaginal delivery
(most common)
• large-sized infant
• use of forceps or vacuum extraction
COAGULATION DEFECTS
Risk factors include
•abruptio placenta (most common)
•severe preeclampsia
•amniotic fluid embolism
•fetal demise
These may present as disseminated
intravascular coagulation (DIC)
Autoimmune thrombocytopenia
and leukemia may also occur in
pregnant women
DIAGNOSIS AND CLINICAL EFFECTS

• In the majority, the vaginal bleeding is visible


outside, as a slow trickle. Rarely, the bleeding
is totally concealed either as vulvo-vaginal or
broad ligament haematoma.
• Alteration of pulse, blood pressure and pulse
pressure appears only after 20-25% loss of
blood volume.
• On occasion, blood loss is so rapid and brisk
that death may occur within a few minutes.
The effect of blood loss depends on-
(a)Pre-delivery haemoglobin level,
(b)degree of pregnancy induced hypervolaemia
(c)speed at which blood loss occurs.
State of uterus, as felt per abdomen, gives a
reliable clue as regards the cause of bleeding.
• In traumatic haemorrhage, the uterus is
found well contracted.
• In atonic haemorrhage, the uterus is found
flabby and becomes hard on massaging.
• Both the atonic and traumatic cause may co-
exist. Even following massive blood loss
from the injured area, a state of low general
condition can make the uterus atonic.
•retained placental tissue,
Missing cotyledon on the maternal
placental surface or extension of the vessels
out to the membranes beyond the placental
disk on the fetal surface(accessory placenta).
Failure of the placenta to separate
•coagulation defects Generalized bleeding or
oozing in the presence of a contracted uterus.
PROGNOSIS
• PPH is one of the life threatening emergencies.
It is responsible for maternal deaths in about
10%, specially in the third world countries.
Prevalence of malnutrition and anaemia,
inadequate antenatal and intranatal care and
lack of blood transfusion facilities are some of
the important contributing factors.
• There is also increased morbidity. These
include shock,transfusion reaction, puerperal
sepsis, failing lactation,pulmonary embolism.
• Late sequelae includes Sheehan’s syndrome
(selective hypopituitarism) or rarely diabetes
insipidus.
Sheehan’s syndrome
Postpartum hypotension may lead to partial
or total necrosis of the anterior pituitary gland
and cause postpartum panhypopituitarism, or
Sheehan’s syndrome, which is characterized
by failure to lactate, amenorrhea, decreased
breast size, loss of pubic and axillary hair,
hypothyroidism, and adrenal insurriciency.
The condition is rare.
PREVENTION
Prevention of hemorrhage is preferable
to even the best treatment. PPH cannot
always be prevented. however, the
incidence and specially its magnitude
can be reduced substantially, if the
following guidelines are followed.
PREVENTION

• Antenatal Prevention

• Intranatal Prevention
Antenatal Prevention
• Improve the health status

• Screen the high risk patient

• Blood grouping
Antenatal Prevention (Ⅰ)
Improvement of the health status of the
patient and to keep the haemoglobin
level normal so that the patient can
withstand some amount of the blood
loss.
Antenatal Prevention (Ⅱ)
High risk patients who are likely to
develop PPH(such as twins, hydramnios,
grand multipara,history of previous third stage
complications,severe anaemia) are to be
screened and delivered in a well equipped
hospital.
Antenatal Prevention(Ⅲ)
Blood grouping should be done for
all women so that no time is wasted
during emergency.
Intranatal Prevention
Intranatal Prevention (Ⅰ)
• Slow delivery of the baby is done.Baby
should be pushed out by the retracted
uterus and not to be pulled out.
• During caesarean section spontaneous
separation and delivery of the placenta
reduces blood loss.
Intranatal Prevention(Ⅱ)
• Active management of the third stage,
specially of the “at risk” patients,should
be a routine.
• Temptation of fiddling or pulling the cord
should be avoided, so also the excessive
expression.
Intranatal Prevention(Ⅲ)
• Examination of the placenta and
membranes should be a routine so as to
detect at the earliest any missing part.
• In all cases of the induced or accelerated
labour by oxytocin, the infusion should
be continued for at least one hour after

the delivery
Intranatal Prevention(Ⅳ)
• Exploration of the uterovaginal canal
for evidence of trauma following
difficult labour or instrumental delivery.
• To observe the patient for about two
hours after the delivery and if the uterus
remains hard and contracted only then
she should be sent to the ward.
MANAGEMENT
General principle
• Control bleeding
• Prevention of shock
• Prevention of infection
• Treatment of anemia
Managment of uterine atony
haemostasis
Oxytocin (20u IV in 1000ml saline)
Uterine massage and bimanual compression
Uterine packing
Surgical methods
(a) Ligation of uterine arteries
(b) Ligation of anterior division of internal iliac artery
(c) Radiographic embolization of pelvic vessels
(d) Hysterectomy
The massage is
to be done by
placing four
fingers behind
the uterus and
thumb in front.
bimanual compression
Procedures:
(a) The whole hand is introduced into
the vagina in cone shaped fashion after
separating the labia with the fingers of
the other hand
(b) The vaginal hand is
clenched into a fist with the
back of the hand directed
posteriorly and the knuckles
in the anterior fornix
(c) The other hand is placed
over the abdomen behind
the uterus to make it
anteverted
(d) The uterus is firmly
squeezed between the two
hands.
Uterine packing
Procedure:
A 5 metres long strip of gauze, 8 cm
wide folded twice is required. The
gauze should be soaked in antiseptic
cream before introduction.
The gauze is placed
high up and packed
into the fundal area
while the uterus is
steadied by the
external hand.
Gradually, the rest
of the cavity is
packed. so that no
empty space is left
behind. A separate
pack is used to fill
the vagina.
Intrauterine plugging acts not only by
stimulating uterine contraction but exerts
direct haemostatic pressure (tamponade
effect) to the open uterine sinuses.
Antibiotic should be given and the plug
should be removed after 24 hours.
surgical methods
(a)Ligation of uterine arteries-
During pregnancy, 90% of the blood flow to
the uterus is supplied by the uterine arteries.
Direct ligation of these easily accessible
vessels can successfully control hemorrhage
in 75-90% of cases, particularly when the
bleeding is uterine in origin. Recanalization
can occur, and subsequent pregnancies have
been reported.
the ascending
branch of the
uterine artery is
ligated at the lateral
border between upper
and lower uterine
segment. The suture
is passed into the
myometrium 2 cm
medial to the artery.
(b) Ligation of anterior division of internal
iliac artery (unilateral or bilateral)-reduces the
distal blood flow. It helps stable clot formation
by reducing the pulse pressure up to 85%. Due to
extensive collateral circulation, there is no
pelvic tissue necrosis. Bilateral ligation (not
division) can avoid hysterectomy in about 50%
of the cases. Fertility is preserved, and
subsequent pregnancies are not compromised.
(d) Radiographic embolization of pelvic vessels-
Embolization of pelvic and uterine vessels by
angiographic techniques is increasingly common.
This techniques has the advantage of being
effective even when the cause of hemorrhage is
extrauterine and in the presence or absence of
uterine atony. Success rate is more than 90% and
it avoids hysterectomy.
Hysterectomy -rarely uterus fails to contract
and bleeding continues in spite of the above
measures. Hysterectomy has to be considered in
such a situation. It is the definitive method of
controlling PPH. The procedure is undoubtedly
lifesaving.
Decision of hysterectomy should be taken
earlier in a parous woman. Depending on the
case it may be subtotal or total.
Management of
retained placental tissue
• Placenta separated, expression of the
placenta is to be done either by fundal
pressure or controlled cord traction
method.
•Placenta unseparated, manual removal of
placenta under general anaesthesia is to be
done. However, if the patient is in shock,she
is resuscitated first before undertaking
manual removal. If the patient is delivered
under general anaesthesia, quick manual
removal of the placenta solves the problem.
•retained placental products
dilatation and curettage may be performed.
• placenta increta, which may cause difficulty in
getting to the plane of cleavage of placental
separation. hysterectomy is indicated in parous
women, while in patients desiring to have a child,
conservative attitude may be taken. This consists
of cutting the umbilical cord as close to its base as
possible and leaving behind the placenta which is
expected to be autolysed in due course of time.
Appropriate antibiotics should be given.
Methotrexate has been used by some.
STEPS OF MANUAL REMOVAL
OF PLACENTA
Step-1
• the operation is done under general anaesthesia.
In extreme urgency where anaesthetist is not
available, the operation may have to be done
deep sedation with 10 mg diazepam given
intravenously. The patient is placed in lithotomy
position. With all aseptic measures the bladder
is catheterized.
Step-2
• one hand is introduced into the uterus after
smearing with antiseptic solution in cone
shaped manner following the cord, which
is made taut by the other hand. While
introducing the hand, the labia are
separated by the fingers of the other hand.
The fingers of the uterine hand should
locate the margin of the placenta.
Step-3
• counter pressure on the uterine fundus is
applied by the other hand placed over the
abdomen. The abdominal hand should
steady the fundus and guide the movements
of the fingers inside the uterine cavity till
the placenta is completely separated.
Step-4
• As soon as the placental margin is reached,
the fingers are insinuated between the
placenta and the uterine wall with the back
of the hand in contact with the uterine wall.
The placenta is gradually separated with a
side ways slicing movement of the fingers,
until whole of the placenta is separated.
Step-5
• When the placenta is completely separated,
it is extracted by traction of the cord by the
other hand. The uterine hand is still inside
the uterus for exploration of the cavity to
be sure that nothing is left behind.
Step-6
• Intravenous oxytocin is given and the
uterine hand is gradually removed while
massaging by uterus by the external hand
to make it hard.
• After the completion of manual removal,
inspection of the cervicovaginal canal is to
be made to exclude any injury.
Step-7
• The placenta and membranes are to be
inspected for completeness and be
sure that the uterus remains hard and
contracted.
Manual exploration of the uterus
The uterus should be explored immediately
in women with PPH. Ensure that all placental
parts have been delivered and that the uterus
is intact. This should be done even in the case
of a well-contracted uterus.
Manual exploration of the uterus does not
increase febrile morbidity or blood loss.
Technique-
Place a fresh glove over the
glove on the exploring hand
Form the hand into a cone
and gently introduce it by
firm pressure through the
cervix while the fundus is
stabilized with the other
hand. Sweep the back of the
first and second fingers
across the entire surface of
the uterus, beginning at the
fundus.
• In the lower uterine segment, palpate the walls
with the palmar surface of one finger.Uterine
lacerations will be felt as an obvious anatomic
defect.
• All exploration should be gentle, since the
postpartum uterus is easily perforate.
Clinical Aspect of
Postpartum Hemorrhage
UTERINE ATONY
Clinical findings
• soft uterus (i.e.,like dough) that is palpable
above the umbilicus
Management
•Oxytocine (20u IV in 1000ml saline)
•Uterine massage and bimanual compression
•Uterine packing and surgical methods
Retained placenta
clinical findings:
• Missing cotyledon on the maternal placental
surface or extension of the vessels out to the
membranes beyond the placental disk on the
fetal surface(accessory placenta).
• Failure of the placenta to separate
Management :
• Manual uterine exploration
• manual removal of the placenta
Genital laceration
Clinical findings:
• Contracted uterus
• Visible vaginal, cervical,or vulvar
lacerations
Management
• Thorough examination followed by
prompt suturing under adequate anesthesia
and repair the laceration.
Disseminated intravascular
coagulation (DIC)[rare]
Clinical findings:
• Generalized bleeding or oozing in the presence
of a contracted uterus.
Management:
• Removal from the uterus of all contents
• Intensive care support
• Selected blood product replacement [red blood
cells (RBCs), platelets, fresh frozen plasma]
Two types of PPH:
Third stage Hemorrhage: Bleeding
occurs before expulsion of placenta.
True PPH: Bleeding occurs subsequent
to expulsion of placenta (majority).
MANAGEMENT OF
THIRD STAGE BLEEDING
The principles in the management are:
• To empty the uterus of its contents and to
make it contract.
• To replace the blood. On occasion, patient
may be in shock. in that cases patient is
managed for shock first.
• To ensure effective haemostasis in traumatic
bleeding
The following procedures are to be followed:
1. To palpate the fundus and massage the
uterus to make it hard. However, if bleeding
continues even after the uterus becomes
hard, suggests, the presence of genital tract
injury.
2.Ergometrine 0.25㎎ is given intravenously.
3.To start a dextrose saline drip and arrange
for blood transfusion, if necessary.
4.To catheterise the bladder, if it is found to
be full.
5.Sedation may be given with morphine 15
㎎ intramuscularly.
6.Placenta separated, express the placenta
out either by fundal pressure or controlled
cord traction method.
7.Placenta unseparated, manual removal of
placenta is to be done.
8.Traumatic hemorrhage should be tackled
by sutures.
Scheme of management of third stage hemorrhage
(A)

Placenta separated Not separated

Express the placenta out Manual removal


by controlled cord traction under G.A

Traumatic hemorrhage should be tackled by sutures


(A)
• Control the fundus, massage and make it
hard
•Oxytocin
•To start normal saline drip and blood
transfusion
• Catheterise the bladder
MANAGEMENT OF TRUE
POSTPARTUM HAEMORRHAGE
PRINCIPLES
• To diagnose the cause of bleeding:
atonic or traumatic
• To take prompt and effective measures
to control bleeding
• To correct hypovolemia
MANAGEMENT (Ⅰ)
Immediate Measures:The following immediate
measures are to be taken by the attending House
Officer, when the amount of blood loss is more
than a litre .
• Call for extra help –involve the obstetric registrar
(Senior Staff) on call.
• Put in two large bore intravenous cannula.
MANAGEMENT (Ⅱ)

• Send blood for group (if not done before ) and


cross matching and ask for 2 units (at least ) of
blood.
• Infuse rapidly 2 litres of normal saline(crystalloids)
or plasma substitutes (colloids) to re-expand the
vascular bed.
MANAGEMENT (Ⅲ)
• One Midwife/Rotating Houseman should be
assigned to monitor the following –
1. Pulse
2. Blood pressure
3. Type and amount of fluids the patient has
received
4. Urine output
5. Drugs-type, dose and time
6. Central venous pressure (when sited ).
ACTUAL MANAGEMENT
·Atonic ·Traumatic

The first step is to control the fundus and


to note the feel of the uterus.
If the uterus is flabby, the bleeding is
likely to be from the atonic uterus.
If the uterus is firm and contracted, the
bleeding is likely of traumatic origin.
Atonic uterus
Step - Ⅰ
(a) Massage the uterus to make it hard and express the
blood clot.
(b) Morphine 15 mg may be given intramuscularly.
(c) Inj oxytocin drip is started (10 units in 500 ml of
normal saline) at the rate of 30-40 drops per minute.
Step - Ⅰ
(d) To empty the bladder, if it is found full
(e) To examine the expelled placenta and
membranes, if available, for evidence of
missing cotyledon or piece of membranes.
If the uterus fails to contract, proceed to the
next step.
Step-Ⅱ
Manual exploration of the uterus- Ensure
that all placental parts have been delivered
and that the uterus is intact.
In refractory cases:
PGE 1000ug per rectum is effective
Step-Ⅲ
•Uterine massage and bimanual compression
•Uterine packing
•Surgical methods
(a) Ligation of uterine arteries
(b) Ligation of anterior division of internal iliac artery
(c) Radiographic embolization of pelvic vessels
(d) Hysterectomy
SCHEME OF MANAGEMENT OF TRUE P.P.H
A
To feel the uterus by abdominal palpation

Uterus atonic uterus hard and contracted


B
Uterus remain atonic exploration
C
Uterus atonic haemostatic sutures
D on the tear sites
Uterine tamponade
E (any method)
Uterus atonic F Surgical methods G Hysterectomy (rarely)
A. immediate measuers
• Call for extra help
• Commence I.V.line with a wide bore cannula
• Send blood for cross matching and ask for 2
units (at least) of blood
• Rapidly infuse normal saline/haemaccel 2
litres till blood is available
B.
Massage the uterus to make it hard
To add oxytocin 10 units in 500ml of
N.saline, at the rate of 40 drops per minute.
To examine the expelled placenta.
To catheterise the bladder.
C.
 Exploration ofthe uterus
 Blood transfusion
 To continue oxytocin drip
D
PGE1 1000ug per rectum
E.
Bimanal compression

Tight intrauterine packing under


anaesthesia
G.
stepwise uterine devascularisation procedure
 Ligation of uterine artery
Ligation of anterior division of internal iliac
artery (unilateral or bilateral)
 Radiographic embolization of pelvic vessels
with gelatin sponge
All said and done, it is the intelligent
anticipation, skilled supervision, prompt
detection and effective institution of
therapy that can prevent an otherwise
normal case from undergoing a
disastrous consequences.
Thank You