Postpartum hemorrhage

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Presented by:

Dr. Sonu

Introduction

• Considered as a major obstetric emergency
• Leading cause of maternal mortality and morbidity.
• Normal blood loss during vaginal delivery :300-500ml
• Most crucial stage of labor: third stage
• Postpartum hemorrhage (PPH) is responsible for around 25% of maternal mortality worldwide (WHO, 2007),
• Mumtaz, the queen of Shah Jahan, may have died from postpartum hemorrhage while giving birth to her 14th child. The Taj Mahal was built in her memory.

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Definition

• Quantitative:

blood loss >500 ml following birth of baby

• Clinical:
• any amount of bleeding from or into genital tract following the birth of the baby and up to the end of puerperium
• Adversely affects the general condition of the patient
• Evidenced by rise in pulse and falling B.P.
• A decrease in hematocrit by 10%
• Requirement of B.T. in first 24 hours

Amount of blood loss

• vaginal delivery: 500 ml
• C.S. : 1000 ml
• Cesarean hysterectomy: 1500 ml

Types

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1. Primary – bleeding occurs within 24 hrs

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1)Third stage- Bleeding before expulsion of placenta

2)True PPH -Bleeding Subsequent to expulsion of placenta

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B) Secondary-Beyond 24 hrs to 6 weeks

Causes of Primary PPH

• 4 Ts:

1) tone

2) trauma

3) tissue

4) thrombin�

Uterine Atony

**The myometrium fails to contract and

the uterus fills with blood because of

the lack of pressure on the open

vessels of the placental site

The myometrium fails to contract and

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the uterus fills with blood because of

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the lack of pressure on the open blood

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vessels of the placental site.

Atonic uterus

Imperfect contraction and retraction

• Grand multiparity
• Over distension of uterus
• Malnutrition & Anemia
• APH
• Prolonged labor/ Precipitate labor
• Anesthesia and analgesia
• Augmentation of delivery by oxytocin
• Malformation of uterus
• Uterine fibroid
• Mismanaged third stage of labor
• Placenta
• Full bladder
• Chorioamnionitis
• Drugs tocolytics

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Uterine Atony

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Signs

and

Symptoms

Excessive

or

Bright Red

Bleeding

Abnormal

Clots

A boggy uterus that does not

respond to massage

Unusual pelvic discomfort or backache

Traumatic

• Large episiotomy and extensions
• Tears and lacerations of perineum, vagina, cervix. Paraurethral region
• Pelvic hematomas and uterine inversion
• Rupture uterus rare

Tissue

• Bits of placenta
• Blood clots
• Invasive placenta

Thrombin

• Abnormal coagulation pathway
• Conditions are:
• Jaundice in pregnancy
• HELLP syndrome
• Thrombocytopenic perpura
• IUD
• Abruptio placentae

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Diagnosis

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Based on:

• Bleeding
• Hemodynamic stability of patient
• State of uterus P/A

Prevention

ANTENATAL-

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• Improvement of health status –e.g. Hb level
• High risk patients (causes of PPH) are to be delivered in equipped hospital.
• Placental localization must be done in women with previous caesarean delivery.
• Women with morbid adherent placenta are to be delivered by senior obstetrician.
• Blood grouping should be done in all women.

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Intranatal

• Active management of third stage of labor , as it reduces PPH by 60%.
• Cases with induced labor by oxytocin , infusion should be continued for at least 1 hour after delivery.
• Examination of placenta & membranes
• Women delivered by cesarean section Oxytocin 5 IU slow IV is to be given to reduce blood loss.
• Exploration of utero vaginal canal for trauma.
• Observation for about 2 hours
• During C.S. spontaneous separation of placenta

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Management of third stage bleeding

• Control the fundus ,massage & make it hard.
• Inj. Methergin 0.2 mg IV/Inj Oxytocin 10 units I.M.
• Start Normal saline drip with Oxytocin 10 units at 60 drops per min.
• Catheterize the bladder.
• To give antibiotics

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• If placenta separated –
• Express placenta out by CCT

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• If placenta not separated-

Manual removal under GA is done ,if 2 attempts of CCT fail.

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Manual removal of placenta

• G.A./ Diazepam for sedation
• Lithotomy position
• Slicing movements of fingers
• Exploration of uterus

True PPH principles

• Communication
• Resuscitation- maintain A+B+C
• Monitoring
• Arrest of bleeding

True PPH management

Immediate measures

Send blood for cross matching

Ask blood for 2 units

Infuse NS/Haemaccel 2 liters

To feel the uterus by abdominal palpation

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Uterus Atonic Traumatic

Massage the uterus

Oxytocin 10-20 units in 500 ml

N.S 40-60 drops/ min

Inj. methergin 0.2 mg IV

Catheterize the bladder

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contd…

UTERUS ATONIC

Exploration of uterus

Blood transfusion

To cont. Oxytocin drip

UTERUS ATONIC

inj Carboprost 250 μg

Misoprostol 1000μg

UTERUS ATONIC

Bimanual compression

Uterine tamponade

Contd…..

• Tight intrauterine packing under anesthesia
• Balloon tamponade

UTERUS ATONIC

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Surgical methods

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• Ligation of uterine arteries

• Ligation of ovarian & uterine artery anastomosis just below ovarian ligament.

Surgical methods

Contd…..

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• Ligation of anterior division of internal iliac artery (unilateral or bilateral)

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• B-Lynch compression suture and multiple square sutures.

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• Angiographic arterial embolisation

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Hysterectomy

Hysterectomy

Medical options

Oxytocin

• Mode of action:
• Through receptors
• By voltage mediated calcium channels
• Stimulates PG production

Methergin

• Mode of action:
• Acts directly on myometrium
• Excites frequent uterine contractions
• Highly effective in hemostasis

PGs

• Mode of action:
• Change in myometrial cell membrane permeability
• Alteration of membrane bound Ca2+

Carbetocin

• Each ampoule contains 100 μg of carbetocin(I.V./I.M.)
• Slowly over 1 min
• Onset of action – within 2 min
• Lasts for 1 hr
• A single inj of carbetocin is equivalent to 8 hours of oxytocin infusion.

Recombinant factor 7(Novoseven)

• Acts by activating factor X on the activated platelets
• Thrombin burst
• Fibrin clot formation
• Initial dose would be 90μg/kg
• In addition use tranexamic acid(antifibrinolytics)
• Injection 500mg/5ml or tab 500mg
• Dose: 1gm by slow i.v.

vasopressin

• When no other medical methods seems to work
• 1ml of ADH+ 19 ml of NS
• Injected subendometrially
• Immediate action and last for 2-8 hours.
• Side effects are headache, hyponatremia, seizures

Bimanual compression

Uterine tamponade

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Tight intrauterine packing Balloon tamponade

Intrauterine packing

• under G.A.
• Long strip of gauze soaked in P.I. solution/antiseptic cream
• Removed 24 hours later
• Acts by direct hemostatic pressure
• Stimulating uterine contractions
• Risk of concealed hemorrhage and infection

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Balloon tamponade

• Using Foley catheter, Sengstaken-Blakemore tube, Rusch urological balloon, SOS Bakri balloon
• Bakri balloon mde up of silicon& especially used in PPH
• Inflated with 200-500ml of NS
• Average time period:8 -48 hours
• Graduated deflation at 6 hrly interval
• Bleeding control within 15 min

Uterine tamponade

NASG

• Non-pneumatic Anti Shock Garment
• It is a light weight neoprene garment that is made up of 5 segments.
• Temporary first aid device to stabilise a woman who is in shock until blood and surgery can be provided.
• Applies pressure to the lower body and abdomen
• Stabilising vital signs and resolving hypovolemic shock
• Forces blood to essential organs.

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Surgical options

Ligation of uterine arteries

• At the lateral border between the upper and lower uterine segment
• Using No.1 chromic passed into the myometrium 2 cm medial to the artery
• 75% success
• If bleeding continues: Ligation of utero-ovarian anastomosis
• Cannot be used in case of placenta previa or rupture of uterus.

ligation of internal iliac artery

• Indications :
• Traumatic injury without involving the uterus
• Failure of uterine artery ligation
• Hematoma formation after uterine artery ligation
• Procedure:
• Use Mixter’s artery forceps
• Double ligated non absorbable suture1-0 silk
• Immediate drop in pulse pressure of uterine artery to 15-20mm of Hg and forming clot formation

B-Lynch compression suture

• Pair of vertical brace
• No.2 chromic or No. 0 plain or chromic sutures/monocryl suture secured around the uterus
• When tightened and tied ;give the appearance of suspendors or braces that compress the ant and post walls together.
• 80% success rate specially in placenta accreta
• Can avoid hysterectomy
• Complications: uterine ischemic necrosis with peritonitis.

Modified B-Lynch Square sutures by Cho

• Involves multiple full thickness square sutures
• Selected areas of heavy bleeding are square sutured and not the entire uterine cavity
• Drawbacks:
• Development of pyometra
• Asherman’s syndrome

The Hayman technique

• Does not require opening of the uterine cavity
• Quicker to perform
• Complications are:
• Hematometra
• Pyometra
• Asherman’s syndrome

The Pereira technique

• Series of longitudinal and transverse sutures around the uterus
• None of the sutures penetrated the endometrial cavity

The Ouahba’s technique

• 95% success rate
• Involves the placement of 4 sutures
• Two transverse and two near the horns

Uterine artery embolisation

• Embolizing agent: gelatin foam or PVC
• Success rate: 95%
• Most patients resume normal menses following procedure
• Drawbacks:
• 2 amenorrhoea
• Int iliac artery perforation

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Management of Postpartum Hemorrhage

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Determine the Cause

Suture lacerations

Drain expanding hematoma

Replace inverted uterus

Inspect placenta

Explore uterus

Manual removal of placenta

Curettage

Observe clotting

Check coags

Replace factors

Fresh frozen plasma

Oxytocin:* 20 IU/L, infuse

500 ml in 10 minutes then 250 ml/hr

Carboprost:

0.25 mg IM or into the myometrium

Misoprostol:* 800 mg SL, PO, or PR

Methylergonovine: 0.2 mg IM

Ergometrine: 0.5 mg IM

THE FOUR T’s

TONE

Soft “boggy” Uterus

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TRAUMA

Laceration

Inversion

TISSUE

Retained placenta

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THROMBIN

Blood not clotting

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70 percent

20 percent

10 percent

1 percent

* See text for dosing options

Secondary PPH

• Usually occurs in between 8-14 th day of delivery
• Also called delayed or late PPH

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1. Retained products of conception

2. Uterine infection

3. Endometritis and subinvolution

4.Sec. haemorrhage from cesarean wound

5. Withdrawl bleeding

6. Rare : chorion epithelioma, ca of cervix, placental polyp, infected polyp, puerperal inversion of uterus

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causes

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• Bleeding is bright red in colour & varying in amount.
• Evidence of anemia.

INTERNAL EXAMN –

-Reveals sepsis

-patulous cervical os

- subinvolution of uterus

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USG –Helps to detect bits of placenta.

Diagnosis

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Management

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1.Resuscitate

2.Replace the blood and fluid volume

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3.Investigate the status and cause of bleeding.

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4.Arrest the blood loss.

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5. Antibiotics

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6. laparotomy