POSTPARTUM

HAEMORRHAGE
DR. G . G A N I TH A
PRO FE SSO R
O BGYN
 SLOs
Definition
Classification
Risk factors for PPH
Causes of PPH
Diagnosis & Clinical effects
Management
Complications
Prevention
 INCIDENCE OF PPH

• Incidence – 2 to 4% after vaginal delivery

6% after cesarean section
• Accounts for 25% of maternal deaths world
wide

• 38% of maternal mortality in India

 Definition

• Loss of 500ml or more during vaginal delivery,More than

1000ml during caesarean section (WHO)
• Excessive per vaginal bleeding that cause haematocrit
drop more than 10%.( ACOG )

Blood loss significant enough to cause hemodynamic

instability
 CLASSIFICATION

Primary postpartum haemorrhage -Bleeding which

occurs during first 24 hours after delivery of foetus.
Causes: Atonic uterus, Trauma ,Haemorrhagic blood diseases.
Secondary postpartum haemorrhage - Bleeding which
occurs after the first 24 hours of delivery and up to the
end of puerperium( 6 weeks postpartum)
Causes: Infection – endometritis, Retained products of conception,
Placental polyp, Placental site trophoblastic disease
 Categories of PPH

• Minor PPH – blood loss of 500ml to 1000ml.

• Moderate PPH – blood loss of 1000ml to 2000ml
• Severe PPH – blood loss more than 2000ml
• Life threatening - >2500 ml
 PHYSIOLOGY
• Haemodilution, expansion of blood volume
• Thrombogenic state
• Living ligature

12/08/2024 SAMPLE FOOTER TEXT 7

 Causes of PPH
T FEATURES RATE(
%)

TONE
uterine overdistension – polyhydramnios, multiple pregnancy, 70%
fibroids.
Uterine exhaustion – prolonged labor, chorioamnionitis,
multiparity, APH, anesthetic agents

TRAUMA
Laceration of cervix and vagina, Rupture uterus, broad ligament 19%
haematoma.
Surgical – angle extension in C- section, episiotomy

TISSUE
Retained placenta and membranes, or products of conception 10%

THROMBI
Congenital or acquired coagulopathies – placental abruption, pre 1%
eclampsia, septicaemia

N
 Causes of atonic PPH
Maternal factors
• Multiparity Labour complications
• Previous history of PPH • Prolonged labour
• Fibroids complicating • Induction of labour
pregnancy
• Precipitate labour
• Maternal anemia
Effect of drugs –
Pregnancy complications
Anesthetic drugs,Magnesium
• Antepartum hemorrhage
sulphate,Nifedipine
• Overdistension of the uterus
- multiple pregnancy,
hydramnios or macrosomia
 Prevention of PPH

• Assess risk factors for PPH on admission

• Use of real time partograph to avoid prolonged labour
• Practising AMTSL – reduce the rate of severe PPH by 70%
• Practising restrictive episiotomy
• Routine inspection of perineum, vagina and cervix for
lacerations
• Routine inspection of placenta and membranes for
completeness
 AMTSL ( Active Management of Third Stage of Labor)
WHO recommendation (2012)

• Oxytocin 10 IU IM or misoprostol 600 µg rectal (if oxytocin not

available or not possible) immediately after delivery
(Recommended)
• Delayed (1-3 min after birth) cord clamping(Recommended).
• Regular and frequent assessment of uterine tone by palpation
of the uterine fundus after delivery of placenta
(Recommended).
• Controlled cord traction for delivery of placenta (Optional)
Visual estimation of blood loss
 Estimation of blood loss – Clinical findings
LOSS OF BLOOD SYSTOLIC BLOOD SYMPTOMS & SIGNS DEGREE OF SHOCK
VOLUME/ % BLOOD PRESSURE
VOLUME
I - 500ml to 1000ml Normal Usually nil compensated
15%

II -1000 to 1500ml SBP = 80 to 100 mm Weakness, Mild

20 to 25 % Hg tachycardia,
sweating,
hypotension
III - 1500ml to SBP = 70 to 80 mm Hg Restlessness, overt Moderate
2000ml hypotension,marked
25 to 35 % tachycardia, pallor,
oliguria,cold,clammy
extremities
IV - >2000ml SBP = 50 to 70 mm Hg Collapse, air hunger, severe
>40% anuria
 DIAGNOSIS OF PPH- history ,abdominal
examination, speculum and vaginal examination, and
examination of the placenta

12/08/2024 14
1.Resuscitation
2. Differential diagnosis of underlying cause
3. Initial management targeted to most
common cause of PPH.

15
 RESUSCITATION
• Two large-bore intravenous cannulae (16 – 18 G)
• Blood for cross-matching and the estimation of hemoglobin, PCV,
coagulation profile,urea and electrolytes.
• Fluid replacement - Crystalloid solutions such as 0.9% saline infused
at the 500 mL in 15 minutes.
• The bladder catheterised, strict input-output record.
• Pulse, BP, respiration and other vitals monitoring
• The woman should be kept warm.
• Oxygen should be administered by a face mask at the rate of 8-10
litres/minute.
MEDICAL METHODS
 UTEROTONICS
• OXYTOCIN - 20 U in 500ml RL/NS @ 60 dpm 10U in
500ml RL/NS @20 dpm
• Methylergometrine - 0.2 mg IM/IV (upto 4 doses)
• Inj.PGF2α – 0.25 mg IM (upto 8 doses)
• 600 – 800 μg misoprostol

• Tranexamic acid – 1g IV
 Bimanual uterine
compression
Aortic compression
Management for unresponsive hemorrhage due
to atonic PPH
Tamponade techniques - gauze, balloons, condom, gloves
Conservative surgical techniques
• Vessel ligation-uterine, ovarian, internal iliac
• Uterine vertical full-thickness sutures - B-Lynch
Compression suture,Modified B-Lynch (Hayman)
• Uterine horizontal full-thickness sutures - Square
suture,Figure-of-eight stitch,Combination of sutures
• Uterine artery embolization

Hysterectomy 21
Intrauterine tamponade – condom
catheter
Intrauterine tamponade

Bakri
balloon

Ebb balloon
SR cannula
NASG suite
Compression sutures –B - Lynch
Compression sutures – Haymanns & CHO sutures
Stepwise pelvic devascularisation
Internal iliac artery ligation
Uterine artery embolisation
 Management Algorithm - HEMOSTASIS
H Call for Help
E Establish aetiology, Ensure ABC, Ensure availability of blood
M Massage the uterus
O Oxytocin infusion / prostaglandins IM or per rectal
S Shift to theatre – aortic pressure or anti shock garment
T Tamponade / consider Tranexamic acid 1gm iv
A Apply compression sutures – B Lynch
S Systematic pelvic devascularisation
I Interventional Radiology – uterine artery embolisation
S Surgery – subtotal or total hysterectomy
 Complications of PPH
• Hypovolemic shock and renal failure,Multiorgan failure
• Infections
• Venous thromboembolism
• Occult myocardial ischemia
• Transfusion-related problems
• Dilutional coagulopathy
• Anemia, fatigue, orthostatic hypotension
• Postpartum anemia, which increases the risk ofpostpartum
depression
• Postpartum pituitary necrosis (Sheehan's syndrome)
32
• Maternal death
 TRAUMATIC PPH
Vaginal haematomas –
• lacerations,episiotomy extensions
• Exploration,hemostasis,packing
Cervical lacerations –
• Walking around cervix
• Suturing
Colporrhexis
laparotomy,hysterectomy,vaginal repair
Uterine rupture 33
 PPH –COAGULATION FAILURE
Causes:
• Von Willebrand disease,ITP
• DIC,HELLP syndrome,severe PIH,AFE,Abruptio placenta,IUD
• Dilutional coagulopathy – rapid infusion of fluids
• Massive transfusion – inadequate component replacement

• PRBC,FFP(1:1) after 4-6 units,cryoprecipitate(fibrinogen

deficiency)

34
A 32-year-old para 3 had a spontaneous vaginal delivery at a
nearby PHC 30 minutes ago. Following the delivery of the
placenta, she had profuse vaginal bleeding. On admission to
the hospital, she looks pale, her pulse is 110 bpm and BP is
100/70 mmHg.

a) What is the possible cause of bleeding?

b) What measures should be taken?
c) If the woman continues to bleed despite these measures,
how would you manage her?
d) If the bleeding continues due to an atonic uterus and there is
PPH -MCQs
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The definition of PPH is

blood loss more than
after vaginal delivery:

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The most common cause

of secondary PPH is:

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The following is not

included in the active
management of the third
stage of labour:

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The most common cause

of primary PPH is:

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The dose of injection

prostaglandin PGF, for
the management of PPH
is:

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. B-Lynch suture is
applied on the uterus
for the treatment of:

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All are uterine

compression
or brace sutures,
except:

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Uterine artery is a
branch of:

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Suture materials used

for brace sutures are all,
except:

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All are done in massive

PPH, except:

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The treatment of uterine

inversion does not
include:

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treatment of total
placenta percreta
include all of the
following EXCEPT:

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ideal treatment for

placenta accreta is:

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The abnormal placental

adherence in which the villi
penetrate through the
myometrium is known as

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The oxytocic drug

contraindicated in the
management of atonic PPH in
a hypertensive patient is

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