Post Partum Hemmerrhage (PPH)

POSTPARTUM HEMORRHAGE




By

Prof. Bilqis Afridi
(F.R.C.O.G)
PPH
nA Major cause of Maternal Mortality in low income countries
nRates of 40 maternal deaths per 100,000 births in SubSaharan Africa compared to 1: 100,000 births in U.K
nIncidence of Primary PPH in developed countries is 4-8%, with massive Hemorrhage >1000ml in 1.3%
nObstetrical haemorrhage contributes to 50% of maternal mortality
The Definition
nRigid volumetric Definitions have their limitations
nCurrently suggested definitions
nBlood loss of > 500ml
nA hemorrhage resulting in a hematocrit drop of 10%
nA Hemorrhage that requires immediate blood transfusion
Causes of PPH
UTERINE ATONY (90%)
nMyometrial Causes
nGrand Multiparity
nProlonged use of Oxytocin
nProlonged Labour
nUterine Overdistension
nChorio amnionitis
nFibroid uterus
nDrugs e.g Halothane
nRetained Placenta
Placental Causes
nRetained Placental Tissue
nPlacental abruption
nPlacenta Previa
nAbnormally adherent Placenta
nThe most common abnormality of placenta associated with life threatening PPH is morbidly adherent placenta (MAP)
Genital Tract Trauma
nPerineal/Vaginal tears

nCervical tears

nUterine Rupture

nInversion of Uterus
COAGULATION DISORDERS

nD.I.C:- with complications of pregnancy e.g missed abortion, IUD, PET - eclampsia etc.

nI.T.P:- systemic diseases

nVon ville Brand,s Disease

nPatient on anticoagulants

PREVENTION OF PPH
nCorrection of anemia
nActive Management of the 3rd Stage in all patients
nEarly Oxytocic therapy
nEarly cord clamping
nPlacental delivery with controlled cord traction following separation
nAssociated with meaningful reduction in Hemorrhage, Anemia & need for transfusions
OXYTOCIN
nEffectiveness is Dose dependent

nSyntometrine (ergometrine+ Oxytocin) is more effective than oxytocin alone

nEarly injection at dlivery of anterior shoulder or soon after delivery of the baby is better
nWHO Collaborative trial-Oxytocin, is choice for routine prophylaxis

MISOPROSTOL
nA Prostaglandin E1 Analogue
nAffordable, Easily stored, Shelf life of years
nMyometrial Stimulation by binding to EP-2/EP-3 prostanoid Receptors
nClinically proven uterotonic agent
nHypotensive effect an advantage over Ergot
n400 micro gms (P/R) well tolerated, effective & has Minimal side effects
Obstetrician,s Role
nAvoid unnecessary Episiotomies
-a restrictive Episiotomy policy
§RETAINED PLACENTA
-Manual removal- invasive procedure
§Umbilical Vein injection with oxytocin+0.9% Saline –Uncontrolled studies – shown to decrease need for manual removal
-Early suckling + Nipple stimulaion – not shown to be effective
Management of PPH
nIntervene early and aggressively
nPotential to save Mother,s Lives with Medical and Surgical intervention is considerable
nEssential Elements
nTreat shock- correct Hypo volemia
nAscertain origin of bleeding
nControl lower genital tract bleeding
nEnsure Uterine contraction
nRemoval of Placenta
Emergency Measures
nOxytocin injection with/without ergotamine, I/v bolus or infusion upto 100mu/min

nStimulation of Uterine contractions by Massage

nTwo IV lines to replace volume with hartman/ Hemaccel infusion till blood is available.
Emergency Measures Conti…
nTransfuse blood/Pack cells / FFP as required

nCompression of Aorta above umbilicus and palpate for femoral pulse.

nBimanual Uterine Compression, hand in vagina elevating uterus to keep uterines on stretch

Prostaglandins
nFALIURE OF CONVENTIONAL METHOD
nIntra uterine administration of two gemeprost pessaries
nRectal admn of PGE2 pessary 3mg repeat 3 hourly up to 12 hours
nRectal administration of a large dose of Misoprostol – 1000 mg good effects.
PG Conti..

nPGF2alpha Carboprost. As a 250 microgms injection, I/m or intra myometrial repeat after 15 – 20 minutes up to 5 doses if required.

nIntramyometrial: Trans abdominally into myometrium of uterine fundus using 20 gauge spinal needle , action starts in 5 mins.
Uterine Packing
nNot favored for bleeding from Upper Segment ,likely to relax uterus, rather than initiating contraction
nReal value- Management of Hge from lower segment
nOnce inserted should be removed within 48 hours
nAntibiotics to prevent sepsis
External Aortic Compression
nApplied by giving pressure above umbilicus in midline and slight to the left.

nCompress aorta against vertebral column.

nLoss of femoral pulse is an indicator of success
Cervical & Uterine Tamponade
nFolley,s catheter balloon into intra cervical canal/ uterine cavity while shifting patient to O.T / waiting for consultant.

nSengstaken Blake more tube into uterine cavity (up to 300 ml inflated)

Surgical Intervention
nSuturing of tears – Hemostatic Sutures
nRemoval of placenta/placental pieces by ovum forceps/ large currette
nManage uterine inversion
nLaparotomy(after correcting coagulopathy).
nLigation of uterine/ ovarian/arteries/ Internal illiac ligation
Surg Cont……
nB – Lynch Brace Sutures
Brace like running suture incorporating full thickness of intact uterus , holds the uterus in contraction
Shown to be effective in various studies
nHysterectomy – usually subtotal
Uncontrolled haemorrhage is the most common indication for emergency hysterectomy whether C/S or VD
Ruptured Uterus
nRepair- in women of low parity

nHysterectomy

nTotal/ Subtotal

nTHE last resort but lifesaving.
Arterial Embolisation
nUterine
novarian
nInternal Illiac

Using absorbable gelatin sponge has proven to be of value in controlling PPH in research centres
So far not available for routine use

nExtensive training of the labour ward staff

nApplication of clinical guidelines has shown to reduce the occurrence of massive post partum haemorrhage
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