1. Postpartum Hemorrhage
Abdulah Al-Tayyem;MD;JBOG
Consultant Ob&Gyn
Urogynaecology
Zarka Govern. Hospital

2. PPH: excessive blood loss after delivery sufficient to affect the general condition of the mother
(tachycardia and or hypotension).
Types:
-primary within 24h
-secondary after the first 24h up to 42nd day

3. Causes -uterine atony -genital trauma -coagulations disorders
-3rd stage complications:
-mismanagement of the 3rd stage of labour
-acute inversion of the uterus
-abnormal or incomplete placental separation

4. Factors predispose to uterine atony
Overdistended uterus:-polyhydramnios -macrosomia
-multiple pregnancy
Uterine muscle exhaustion: -prolonged labour
-grand multiparity -precipitate labour
Intrauterine infection: -prolonged ROM -chorioamionitis
Functional or anatomic distortion of the uterus:
-fibroid uterus – placenta previa –uterine anomalies
Certain general anesthetics( halothane)
History of previous PPH

5. Factors predispose to genital tract trauma
A precipitate delivery, or an operative or manipulative delivery predispose the genital tract to lacerations :
-cervix vagina -perineum
Malposition ,malpresentations or deep engagement of the fetal head ) CS,instrumental deliveries)
Previous uterine surgery
Abuse of oxytocin

6. Factors predispose to retained product of conception
An incomplete placenta at delivery
Previous uterine surgery
Multiparity
An abnormal placenta on US
Intrauterine infections may lead to adherent placenta

7. Abnormalities of coagulation
Hemophilia A or Von Willebrad’s disease
Idiopathic thrombocytopenic purpura(ITP)
History of liver disease
Use of anticoagulants
Acquired in pregnancy:
-thrombocytopenia with PET(HELLP syndrome)
-DIC caused by: -abruptio placentae
-chorioamionitis
-IUFD

8. Diagnosis History taking Physical examination
tachycardia and hypotension my be present without evidence of excessive blood loss in cases of uterine rupture
Consistency of the uterus( lax,firm)
Asses amount of vaginal bleeding
Look for laceration
Determine whether the placenta has been delivered

9. In women with hypertension or pre-eclampsia,
severe blood loss may cause a misleading normal blood pressure reading and an under diagnosed state of shock

10. Degree of Hemorrhagic Shock
Symptom
Systolic B.P
Volume loss
%of B.V
Grade type
Palpitation
dizziness
normal ml
(10-15%)
Grade 1
compensated
Weakness
sweating
Slight fall ml
(15-25%)
Grade 2
Restlessness, pallor,oliguria
70-80 mmHg ml
(25-35%)
Grade 3
Collapse,anuria
Shortness off breath
50-70 mmHg ml
(35-45%)
Grade 4

11. Investigations : as in APH
After the history and physical examination are completed, the cause of PPH can be determined as follow:

12. Diagnosis off PPH Probable diagnosis
Symptoms and sings sometimes present
Symptoms and sings typically present
Atonic uterus
shock
Primary PPH ,
Uterus soft and not contracted
Tears of cervix,
Vagina or perineum
Complete placenta
Uterus contracted
Primary PPH
Retained placenta
Placenta not delivered with 30 min after delivery
Immediate PPH
Portion of the maternal surface of the placenta missing or torn membranes with vessels

13. Diagnosis off PPH Probable diagnosis
Symptoms and sings sometimes present
Symptoms and sings typically present
Retained placental fragments
Inverted uterus apparent at vulva
Primary PPH
Uterine fundus not felt on abd.palpation
Slight or intense pain
Rupture uterus
Amount of bleeding is not related to the degree of shock
Tender abdomen
Rapid maternal pulse
State of shock
Primary PPH) bleeding intraabdominal a/o vaginal)
Severe abdominal pain(may decrease after ruptrure
Secondary PPH
Bleeding is variable) light to heavy,continuous or irregular) and may be foul-smellig
Anemia Fever
Bleeding occurs more than 24h after delivery
Uterus softer and larger than expected for time since delivery

14. Management Preventive are during the antenatal period.
Preventive care during labour and delivery.
Emergency rules
First aid management
Use of utertonic agents :oxytocin,misoprostol

15. Active Management
Placenta retained: manual removal under adequate anesthesia.
Uterine inversion reposition of the uterus
Placenta delivered:
-uterus soft use oxytocin
-exploration under general anesthesia ,
repair any cervical tears.
-tear extends beyond the vaginal vault
do laparotomy.

18. At Lapatotomy : Surgical compression suture-(Lynch suture)
Balloon tamponade
Surgical repair
Ligation of the uterine ,utero-ovarian or hypogastric arteries
Subtotal hysterectomy

20. Important Considerations
Remember that a postpartum women can lose a large amount of blood in a very short time.
You must act promptly and anticipate complications
Assure adequate team coverage
A laparotomy for PPH is an extremely urgent situation, do not delay while waiting for blood transfusion.
Administer prophylactic antibiotics, Ampicillin 2 gm IV ,before and after the procedure
Do not give oxytocin as an undiluted IV push since the women may collapse

21. Thank you