1

POST PARTUM
HEMORRHAGE
PRESENTED BY: DR. EBONG CLIFORD
DR. JUNIE METOGO
SUPERVISED BY: PR. DOHBIT SAMA
DEPARTMENT OF GYNECOLOGY-OBSTETRICS
FMBS, UNIVERSITY OF YAOUNDÉ I
2

TARGET: M1 STUDENTS,
GENERAL MEDICINE

FMBS, UNIVERSITY OF YAOUNDÉ I

3 OBJECTIVES

• Define postpartum hemorrhage

• Identify the etiologies of postpartum hemorrhage.

• Describe the presentation of a patient with PPH due to each etiology.

• Outline the management options available for PPH

4 PLAN

• Introduction
• Overview PPH (definitions, importance, reminders)
• Pathophysiology
• Diagnosis
• Management
• Conclusion
5 INTRODUCTION

• 2017: 295 000 maternal deaths, ~ 810/day from preventable causes (despite 38% drop
in MMR from 2000)

• About 94% of all maternal deaths occur in low and lower middle-income countries
(~ 66% in Sub-Saharan Africa, 40%↓)

• Postpartum hemorrhage (PPH):

• The leading cause of maternal mortality in low-income countries, and
• The primary cause of nearly one quarter of all maternal deaths globally
6 INTRODUCTION

• Most deaths resulting from PPH occur during the first 24 hours after birth

• Uterine atony, the primary cause of PPH, accounts for 70% to 80% of all
hemorrhage.

• Skilled care before, during and after childbirth can save the lives of women
and newborns.
7 INTRODUCTION

• The majority of cases of PPH/MD could be avoided:

• Through the use of prophylactic uterotonics during the 3rd stage of labor and
• By timely and appropriate management of PPH

• The Active Management of the Third Stage of Labor (AMTSL)

• Contributes to reduce maternal deaths
• 8 steps, including injection of oxytocin 10 units IM (step 2)
 INTRODUCTION
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• Other contributors to maternal deaths :

• Antepartum hemorrhage
• Infections (usually after childbirth)
• High blood pressure during pregnancy (pre-eclampsia and eclampsia)
• Complications from delivery
• Unsafe abortion
• Indirect contributors:
• Infections (eg malaria, HIV),
• Chronic conditions (eg cardiac diseases, diabetes)
 OVERVIEW
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Definitions

• Postpartum hemorrhage: a blood loss of 500 ml or more from the GT within 24

hours after birth, irrespective of route of delivery (WHO)

• PPH occurring in the first 24 hours after delivery may be called primary or early PPH

• Bleeding occurring from 24 hours to 6 weeks after delivery, > expected, is usually called
secondary, late, or delayed PPH

• NB: bleeding may be concealed or mixed with amniotic fluid

 OVERVIEW
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Definitions

• American College of Obstetrics and Gynecology (2017)

• PPH = cumulative blood loss >1000 ml with signs and symptoms of hypovol. within
24 hrs of the birth process, regardless of the route of delivery

• Blood loss at the time of vaginal delivery greater than 500 mL should be considered
abnormal with the potential need for intervention
 
11 OVERVIEW
Importance

Diagnostic and therapeutic:

Epidemiology:
• Many etiologies, different treatments
• PPH in 3-5% of obstetric cases, 20% with no
risk factor Prognostic:
• 295 000 maternal deaths/year, ~ 810/day; • Delayed/inappropriate treatment leads to
• ¼ due to PPH morbi-mortality
• Risk of relapse
• Cameroon: MMR 406/100,000 LB (EDS 2018)
 OVERVIEW
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• Reminders

• Blood supply to the uterus: uterine, ovarian and round ligament arteries

• Uterine flow: from 50 ml/min to 1L at term. ie. 10% cardiac output, 80% for
intervillous space (≥ 600 mL/min)

• Muscular layer of spiral arteries destroyed by remodeling by trophoblasts, creating a

low-pressure system
• With placental separation, these vessels at the implantation site are avulsed
 OVERVIEW
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• Reminders

• Hemostasis is achieved by:

• Myometrial contraction to strangulate these large open vessels

• Young Laplace formula: F=2T/r

• Followed by clotting to obliterate the vessel lumens

• Clotting also essential for hemostasis in lacerations

 PATHOPHYSIOLOGY
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• Pathogenesis

• Etiologies of PPH (the 4 Ts)

• Tone: Uterine atony

• Tissue: Retained tissue/placenta

• Trauma: GT tears, uterine rupture, uterine inversion

• Thrombus: Coagulopathy
 PATHOPHYSIOLOGY
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• Postpartum bleeding > expected (> ~ 20% blood)  hypovolemia  release of

catecholamines

• Persistent bleeding
•  shock (tachycardia, tachypnea, weak pulse pressure, delayed capillary refill)

•  Anemia
 PATHOPHYSIOLOGY
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• Complications

• Hypovolemic/hemorrhagic shock
•  Ischemic injury to the liver, brain, heart, and kidneys
•  Sheehan syndrome or postpartum hypopituitarism

• Complications related to the management:

• Transfusion-related: acute lung injury, hemolytic reactions
• Infections

• Maternal death
 DIAGNOSIS
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Typical case: PPH due to uterine atony

• Risk factors

• Uterine over-distention (multiple gestation, polyhydramnios, macrosomia)

• Uterine fibroids,

• History of atony in previous delivery

• Muscle fatigue (High parity (4+), prolonged oxytocin use, prolonged labor,
precipitated labor, placenta abruption
 DIAGNOSIS
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Typical case: PPH due to uterine atony

• Risk factors 2

• Primiparity, prolonged 3rd stage labor

• General anesthesia

• Full bladder, Chorioamnionitis

• Others: Past history of macrosomia, delivery < 34 wks, recent malaria (Nkwabong et al)
 DIAGNOSIS
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Typical case: PPH due to uterine atony

• Clinical features

• V bleeding with clots/red blood. Beware: moderate/protracted bleeding, or collection in uterus

• Signs of shock (may appear late). Women with small blood volume (small size, severe PE, CRF)
more vulnerable

• Uterus soft, boggy; Placenta/membranes complete,

• VE with valves: bleeding from endovervix

• Uterine massage/revision  clots, no tissue

 DIAGNOSIS
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Other forms: PPH due to retained tissue

• Risk factors

• Morbid placenta insertion (ultrasound)

• Grand multip

• Advanced maternal age

• Previous uterine surgery

• IUFD

• Succenturiate lobe (US)

 DIAGNOSIS
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Other forms: PPH due to retained tissue/placenta

• Clinical features

• Placenta incomplete/not delivered

• Fundal height ++, uterus usually soft

• Cord may be visible at vulva

• Bleeding may be active or not

• Signs of separation?

• Uterine revision  placenta/tissue/membranes

 DIAGNOSIS
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Other forms: Trauma of the genital tract

• Risk factors

• Instrumental delivery, precipitous labor (cervix, vagina, perineum)

• Grand multiparity, malpresentation/intrauterine manipulation, scar uterus, induction/augmentation,

fundal pressure (uterine rupture)

• Grand multip, fundal placenta insertion, excessive cord traction, short cord (for uterine inversion)

• Malpresentation, engagement of presentation (extension of CS incision)

• Unskilled birth attendant

 DIAGNOSIS
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Other forms: Trauma of the genital tract

• Clinical features

• Persistent bleeding despite a firm, well-contracted uterus

• Examination of the genital tract with valves for tears or hematoma

• Use 2 long ring forceps to explore the cervix

• Supracervical bleeding may require manual exploration of the uterus to exclude a uterine tear

• Signs of hemoperitoneum?
 DIAGNOSIS
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Other forms: Coagulopathy

• Risk factors

• Disseminated intravascular coagulopathy (DIC), preeclampsia, placental

abruption, IUFD, amniotic fluid embolism, severe infection/malaria

• Acquired thrombopenia in pregnancy (idiopathic, preeclampsia)

• Inherited coagulation defect (hemophilia A, Von Willebrand, History of PPH)

• Anticoagulant therapy, massive transfusion, acute fatty liver

 DIAGNOSIS
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Other forms: Coagulopathy

• Clinical features

• Vaginal bleeding without clots

• Bleeding from other sites/oozing

• Bedside clotting test, lab (FBC, PT, PPT)

 DIAGNOSIS
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Other forms: Delayed/secondary PPH

• Risk factors

• Chorio-amnionitis/prolonged PROM
• Endouterine maneuvers
• Cesarean section
• Morbid placenta insertion
• IUFD
• Low socioeconomic status, young maternal age
 DIAGNOSIS
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Other forms: Delayed/secondary PPH

• Clinical features

• Renewed vaginal bleeding

• Uterine subinvolution
• Fever
• Ultrasound  retained tissue?
 DIAGNOSIS
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Other forms: complicated forms

• Acute kidney injury

• Sheehan syndrome (pituitary necrosis)

29 MANAGEMENT

Goal

• Stop bleeding
• Restore normal hemodynamics
 MANAGEMENT
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Options:

• General measures

• Call for help

• IV fluids, preferably crystalloids, 2 large bore IV lines
• Oxygen therapy by mask
• Uterine massage, Empty bladder
• Blood collection for group/rhesus, FBC, clotting
• Bimanual compression of the uterus, compression of the aorta
• Blood and blood products
• Monitoring: blood loss, vital signs, urine output
 MANAGEMENT
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Options: Medical

• Oxytocin: undiluted bolus  serious hypotension or cardiac arrhythmias

• Methylergonovine (Methergine) second-line

• Regimen is 0.2 mg IM/IV. Can be repeated at 2 to 4-hour intervals as needed
• CI , especially IV: preeclampsia, HIV patient on protease inhibitor

• Misoprostol (Cytotec): a synthetic prostaglandin E1 analogue

• ACOG: 600-1000 μg to treat

• Tranexamic acid, 1g iv over 10 min, may be repeated after 30 min. Use within 3 hours of onset of bleeding
 MANAGEMENT
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Options: Surgical

• Hysterectomy (subtotal)

• Ligation of arteries
• Uterine

• Hypogastric ± selective ovarian artery ligation (75 and 93.7%: Nkwabong et al.,
2017)

• B-Lynch

• Other options: Embolization of arteries, IU balloon (tamponade)

 MANAGEMENT - PROCEDURE
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• General measures

• General assessment: bleeding, vitals

• Call for help

• IV fluids (crystalloids), 2 large bore IV lines (2l/2h)

• Oxygen therapy by mask

• Compression of the aorta

• Blood collection for group/rhesus, FBC, clotting

• Blood and blood products

 MANAGEMENT - PROCEDURE
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Specific measures

• Palpate uterus/abdomen

• If atone: massage, compression, empty bladder and give uterotonics

• If no fundus: uterine inversion?  reduction/GA
• Hemoperitoneum?

• Examine blood for clots: no clots => clotting tests: lab/bedside => FFP, PLTs, or fresh blood

• Examine GT with valves: cervix, vagina and perineum

• Uterine revision/exploration if scar uterus. UR diagnostic and therapeutic

• Monitoring: blood loss, vital signs, urine output

 MANAGEMENT - PROCEDURE
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• If bleeding persists after 15-30 min:

• If bleeding still persists after 15-30 min:

• Blood transfusion • Consider surgery/embolization for

atony/placenta increta
• Other measures as appropriate
• Depending on availability, desire for
• More oxytocics
pregnancy
• Aortic/uterine compression
36 MANAGEMENT
37 MANAGEMENT

• Barriers to care: ANC and childbirth • Factors contributing to Maternal death

from PPH (the 3 delays)
• Poverty

• Distance to facilities • Delay in seeking care

• Lack of information • Delay in reaching care
• Inadequate and poor quality services • Delay in receiving adequate and
• Cultural beliefs and practices appropriate care
 MANAGEMENT
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• Prognosis

• PPH a leading cause of maternal and fetal morbidity

• Correct and timely institution of treatment can vastly improve the patient
outcomes (oxytocin IV/IM, etc.)
• Risk of relapse

• Risk of progress to death

39 CONCLUSION

• PPH: serious and common complication of childbirth

• Requires anticipation, prompt recognition, timely and adequate team

management
40 REFERENCES

• Ann EVENSEN, Janice M. ANDERSON, Patricia FONTAINE, Postpartum Hemorrhage: Prevention and
Treatment. http://www. aafp.org/afp, Volume 95, Number 7, April 1, 2017

• William’s obstetrics, 25th edition, 2018

• Elie Nkwabong, Celestine Koumwo Mouafo, Théophile Nana Njamen3

Risk factors for uterine atony in two semi-urban hospitals. Int J Pregn& Chi Birth. 2020;6(2):45‒49

• Elie Nkwabong, Joseph Nelson Fomulu, Calvin Tiyou and Yvette Nkene Mawamba. Hypogastric arteries
ligation for the management of postpartum hemorrhage: a simple method of reducing uterine bleeding during
surgery. J Pregnancy Reprod , Volume 1(3): 1-3, 2017
41

THANK YOU