Postpartum Hemorrhage Dr.Suresh Babu Chaduvula Professor Dept. of Obstetrics & Gynecology College of Medicine, Abha, KKU, Saudi Arabia

POSTPARTUM HEMORRHAGE [ PPH ] Definition: More than 500 ml of blood loss following normal vaginal delivery of the fetus or 1000ml following Cesarean section. Clinically the amount of blood loss from or into the genital tract which will adversely affect the general condition of the patient Hemorrhage leading to fall in hematocrit by 10 %. Incidence – 1 %

TYPES 1] Primary 2] Secondary Primary – bleeding occurs following delivery of the baby up to 24 hours Primary is two types: A] Third Stage hemorrhage B] True Post Partum hemorrhage

Third Stage hemorrhage: Bleeding occurs before the expulsion of placenta Example- Placenta accreta, retained placenta True Postpartum hemorrhage: Occurs after the expulsion of placenta

Secondary or Delayed or Late Postpartum hemorrhage: Bleeding occurs following delivery of the baby after 24 hours up to 6 weeks.

Primary Postpartum Hemorrhage Causes: 1] Atonic 2] Traumaic 3] Mixed 4] Coagulopathy

Atonic PPH Contributes for 80 % of PPH Commonest cause of PPH Cause – Faulty retraction of the uterus Etiology: 1] Grand Multipara 2] Over- distension of uterus – Multiple pregnancy, Hydramnios, big baby 3] Anemia

4] Prolonged Labor 5] Anaesthesia – Halothane. Ether, Cyclopropane 6] Uterine fibroid 7] Precipitate labor 8] Malformations of uterus – septate uterus, bicornuate uterus 9] Ante partum hemorrhage 10] Initiation & augmentation of delivery with oxytocin

Traumatic PPH 1] Cervix – lacerations 2] Vaginal laceration 3] Perineum injury 4] Paraurethral injury 5] Uterine rupture

Combination of Atonic and Traumatic: Blood coagulation Disorders: Abruptio Placenta, Jaundice, Thrombocytopenic purpura, HELLP syndrome

The Four “T” to remember Tone Tissue Trauma Thrombin

PPH Risk Factors

PPH Risk Factors

PPH Risk Factors

PPH Risk Factors

DIAGNOSIS Vaginal bleeding may be revealed or concealed Alteration in pulse, Blood pressure and Pulse pressure Flabby uterus in atonic uterus

PPH

PREVENTION OF PPH UTEROTONIC DRUGS Routine oxytocic administration in the third stage of labour can reduce the risk of PPH by more than 40% The routine prophylaxis with oxytocics results in a reduced need to use these drugs therapeutically Management of the third stage of labour should therefore include the administration of oxytocin after the delivery of the anterior shoulder.

MANAGEMENT OF PPH Early recognition of PPH is a very important factor in management. An established plan of action for the management of PPH is of great value when the preventive measures have failed.

MANAGEMENT OF PPH

MANAGEMENT OF PPH

DRUG THERAPY FOR PPH

MANAGEMENT OF PPH

MANAGEMENT OF PPH

MANAGEMENT OF PPH

Description of technique The B-Lynch Suturing Description of technique

Summary: Remember 4 Ts Tone Tissue Trauma Thrombin

Summary: remember 4 Ts “TONE” Rule out Uterine Atony Palpate fundus. Massage uterus. Oxytocin Methergine

Summary: remember 4 Ts “Tissue” R/O retained placenta Inspect placenta for missing cotyledons. Explore uterus. Treat abnormal implantation.

Summary: remember 4 Ts “TRAUMA” R/O cervical or vaginal lacerations. Obtain good exposure. Inspect cervix and vagina. Worry about slow bleeders. Treat hematomas.

Summary: remember 4 Ts “THROMBIN” Replacement with blood or Fresh frozen plasma or Platelet rich plasma.

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