1. Postpartum Hemorrhage Dr.Ghassan A. Barayan, MBBS
Management of
Postpartum Hemorrhage
Done by Group C2
Presented by :
Dr.Ghassan A. Barayan, MBBS

2. Case Hx
G5 P4 + 0 lady , in active labour pain . Admitted to the hospital and she delivered a 3.8 kg baby. Immediately after the placental delivery she had heavy vaginal bleeding .
DDX
management

4. Maternal mortality Hemorrhage Infection Hypertension Thromboembolism
The single most
Important cause of
Maternal death
Every year, women die because of postpartum hemorrhage – one every 4 minutes

5. Definition Estimated blood loss with vaginal delivery: > 500cc
Estimated blood loss with C/S: > 1000cc
1ry : within 24h after delivery
2ndry : after 24h up to weeks

6. Avoid underestimating significant bleeding
Don’t underestimate EBL
Don’t disregard slow but unrelenting trickle
If signs of shock* without high EBL, must consider hidden bleeding (internal injury, hidden hematoma)
Requires urgent treatment

7. A 60 kg pregnant has 6L of blood volume at 30 weeks

8. Epidemiology
Incidence : 4 % 88 % of deaths are seen in the first 4 hrs Abdominal or pelvic bleeding can be hidden

9. Early postpartum hemorrhage causes
Uterine atony
Genital tract trauma
Retained placental tissue
Low placental implantation due to relative musculature in the LUS so insufficient control of bleeding
Uterine inversion
Coagulation disorders
Abruptio placentae
Amniotic fluid embolism
Retained dead fetus
Inherited coagulopathy

10. Four “Ts”* Tone . . . . . . - Uterine atony
Tissue Retained products
Trauma Tears, abrasions
Thrombin Clotting disruptions

11. Clinical presentation
The patient whether presents with
Vaginal Bleeding OR
Severe hypovolemic shock

12. “Tone: Think of Uterine Atony”
Uterine atony causes 80% of hemorrhage
failure of uterus to contract after placental separation

13. Hx : identify risk factor
Uterine overdistention: -multiple gestation polyhydromnios fetal macrosomia
Prolonged oxytocin administration
Prolonged labor
Precipitous labor (last <3h )
Halogenated anesthesia
Magnesium sulfate ttt of pre-eclampsia
Chorioamnionitis
Uterine fibroids
Grand multiparity

15. Bimanual Uterine Exam
Confirms diagnosis of uterine atony: the fundus is soft “ boggy “ , poorly contracting

16. Initial Assessment (orders)
Remember ABCs
Check the vitals and correct the shock state
Start a large-bore IV
Obtain CBC
Platelet count , PT , PTT
Blood crossmatch (keep 4 units of packed RBCs in hand )
IV infusion of norm.saline or ringer lactate (it’s best to avoid glucose containing fluids)
3ml of crystalloid / ml of EBL

17. Initial Assessment (orders).cont.
Insert urethral catheter to monitor urine output
Blood and blood product transfusion may be required if
blood loss is continuing,
if the blood volume lost is over 30%,
or if the patient’s clinical status reflects developing shock despite aggressive resuscitation

18. Management
Bimanual Uterine massage is often adequate for stimulating uterine involution. medications

19. Oxytocin ( pitocin )
promotes rhythmic contractions of the upper uterine segment
Give IM or IU, no rapid IV infusion (Can cause  BP)
10 – 40 U in 1 L NS at 250cc/h. / IV
Can get Antidiuretic effect in very high doses

20. Methylergonovine Methergine 0.2 mg IM only Max. of 3 doses
contracts both upper and lower uterine segments tetanically
causes vasoconstriction and hypertension
contraindicated in hypertension
side effects: HTN, nausea, vomitting

21. Prostaglandins F2 Hemabate 0.25mg intramyometrial q 15min
Rapid response 3-10 minutes
Max. 8 doses
Avoid in asthmatic patients.
This is 80% to 90% effective in stopping PPH in cases that are refractory to oxytocin and ergometrine

22. misoprostol
Cytotec Recent data indicates that it can be used as 1st line 800 – 1000 mcg rectally

23. Other measures Uterine packing or tamponade
When uterotonic agents fail
Useful in cases of placenta praevia or accreta
Either gauze or Foley, Sangestaikin blakemore tube
Recent reports of large series have confirmed the high success rates of balloon devices
Uterine artery embolization by placing angiocatheter and injecting thrombogenic material

24. Embolization

25. Exploratory laparotomy :
B-lynch technique : effective in uterine atony
Bilateral uterine artery ligation
Hypogastric artery ligation
Suprecervical or TAH is the definitive treatment for intractable PPH

28. Human recombinant factor VIIa
New treatment to control severe , life threatening hemorrhage
It acts on the extrinsic clotting pathway
Cessation of bleeding occurs in minutes

31. 2-Tissue: Retained placenta
Prolong 3rd stage of delivery( > 30 minutes) seen in ~ 6% of deliveries.
Prior retained placenta.
Prior manual removal of placenta
Prior C/S, curettage p-pregnancy, uterine infection, and increased parity.
Prior C/S scar & previa (25%)
Most patients have no risk factors.

32. US evaluation of retained tissue should be performed before uterine instrumentation

33. Brandt-Andrews maneuver
To determine if the placenta has separated Firm traction is applied to the umbilical cord with one hand while the other applies suprapubic counterpressure

34. Abnormal adherent placenta
Caused by missing or defective decidual layer .
Placenta Accreta:
Placenta adherent to myometrium.
Placenta Increta:
myometrial invasion.
Placenta Percreta:
penetration of myometrium to or
beyond serosa.

35. Placenta Accreta: Most common type.
With incidence of % if previous C/S or previa
The incidence increase as the no. of previous C/S increased
Prior uterine surgery and placenta praevia in the current pregnancy r 2 important RF –
US and color doppler
TAH is the definitive treatment

36. Placenta accreta and uterine atony are the 2 commonest causes of postpartum hysterectomy

37. Removal of Abnormal Placenta
Oxytocin 10U in 20cc of NS placed in clamped umbilical vein.
If this fails, get OB assistance.
Check Hct, type & cross 2-4 u.
Two large bore IVs.
Anesthesia support.

38. Removal of Abnormal Placenta
Relax uterus with halothane general anesthetic and subcutaneous terbutaline.
Bleeding will increase dramatically.
With fingertips, identify cleavage plane between placenta and uterus.
Keep placenta intact.
Remove all of the placenta.

41. Removal of Abnormal Placenta
If successful, reverse uterine atony with oxytocin, Methergine, Hemabate.
Consider surgical set-up prior to separation.
If manual removal not successful, large blunt curettage or suction catheter, with high risk of perforation, so to be done on US guidance
Consider prophylactic antibiotics.

43. Trauma (3rd “T”)
(cervical, vaginal and preineal laceration) Suspected if bleeding persists and uterine fundus is contracting. Episiotomy Hematoma Uterine inversion Uterine rupture
In C/S LT laterl extension of the incision can damage ascending branches of the uterine a while inferior extension damages the cervical branches.

44. Genital tract Trauma
Risk factors include: Instrumented deliveries forceps or vaccum. Primiparity. Pre-eclampsia. Multiple gestation, fetal macrosomia. Prolonged second stage, precipitous delivery VBAC Clotting abnormalities.

45. Repair of cervical laceration
At the two lateral angles while dilating the first stage. Repair lacerations quickly. Place initial suture above the apex of laceration to control retracted arteries.

46. Vulvar Hematomas
more likely w/ operative vaginal deliveries and episiotomies
excessive unilateral swelling and pain
Hematomas less than 3cm in diameter can be observed expectantly.
If larger or expanding , incision and evacuation of clot is necessary.
Irrigate and ligate bleeding vessels.
With diffuse oozing, perform layered closure to eliminate dead space.
Broad spectrum antibiotics should be given

47. Limited from spread by fascia lata
Central tendon of the perineum prevents it from crossing the midline

48. Uterine rupture association

49. Retroperitoneal heamtoma
more likely after C/S delivery – symptom may be shock, excess flank pain.

50. Uterine Inversion Rare: ~1/2500 deliveries
Turning inside out of the uterus
C/F:
Acute abdominal pain
Blue-gray mass protruding from vagina.
Suspect if shock disproportionate to blood loss

51. Causes include: Uterine atony.
Excessive traction on cord while exerting fundal pressure before complete placental separation
Manual removal of the placenta
Abnormal placentation
Uterine anomalies

52. Hypotension worsened by vaso-vagal reaction.
Avoid excessive cord traction, and always guard the uterus when applying traction
Hypotension worsened by vaso-vagal reaction.
Consider atropine 0.5mg IV if bradycardia is severe.

54. Uterine Inversion: Replace through Cervix

55. Uterine Inversion: Restitution

56. If replacement is unsuccessful :
Uterine relaxant agents like NG IV ( 100 ug ) , Terbutaline, MgSO4

57. Uterine Rupture Complete separation of the uterine wall
Incidence is 0.5 %
Prior scar in 40 %

58. Risk factors include: Prior C/S Prior uterine surgery, myomectomy
Classical : 4-7 %
Lower transverse < 1 %
Prior uterine surgery, myomectomy
Hyperstimulation with Oxytocin
Trauma.
Breech version and extraction
Abruptio placenta
Uterine manipulation during labor
”Forceps delivery, intra –uterine pressure cath
insertion”
Parity > 4.
spontaneous

59. Uterine Rupture Suspect if: Rx : sudden change in FHR tracing
Fetal parts easily palpated abdominally
Fetal bradycardia in 50 – 70 % of cases
vaginal bleeding
abdominal tenderness
maternal tachycardia
signs of shock are out of proportion to visible blood loss
R/O abruptio placenta
Rx :
ABCs.
IV fluids.
Immediate laparotomy and deliver the infant and repair the scar

61. Thrombosis (4th “T”) Coagulopathies are rare.
Pre-existing conditions (congenital)
ITP, von Willebrands
Obstetric-related
Hypertensive disorders, HELLP
Abruption
Fetal demise
Sepis
Drugs (e.g. aspirin)
Suspect if oozing from puncture sites noted.
Work up with platelets, PT, PTT, fibrinogen level, fibrin split products, and possibly antithrombin III.

62. Maintain: Fibrinogen > 100mg/dl with FFP
Platelets > 50,000 with packed platelets
Hematocrit > 30% with PRBCs

63. AFE 1/20.000 pregnancies Causes 10 % of maternal deaths in US
Mortality rate is 80 %
S & S :
Hypoxia
Hypotension and shock
Altered mental status
DIC
Bronchospasm
Clinical diagnosis
Labs : ABG, electrolytes, CBC and coagulation profile
Definitive diagnosis is demonstrating the fetal squamous cells and lanugo in the pulmonary vascular space

64. Rx :
ABC
Intubation
IV access with volume support, inotropic agents and pressors
PRBC and FFP as coagulopathy risk is 50 % in the first 2 hrs.

65. Management of excessive bleeding once vitally stable
Regardless of the cause, replacing RBC mass is mandatory
2 iron tablets ( each 300 mg )
PPH in subsequent pregnancies occurs in 10 %

66. Wait
We are almost done

67. Late postpartum hemorrhage
It complicates 1 % of pregnancies
Late hemorrhage is more likely due to:
Subinvolution of the uterus.
Endometritis.
Uterine fibroid
Retained placental fragment.
Coagulopathy and blood dyscariasis
VWD is present in % of adults with menorrhagia as pregnancy elevates factor 8 level, and drops postpartumply
Treatment : ( depend on the cause )
Uterotonic agents
Antibiotics
Currettage

68. Complications RF Blood transfusion reaction Sheehan’s syndrome :
Failure of lactation
Amenorrhea
Superinvoluted uterus

69. Prevention Active Management of 3rd stage of labour
Oxytocic is given
Cord is clamped
Placenta delivered by controlled cord traction (CCT) with counter-traction on the fundus
Fundal massage
evidence supports use of oxytocin after delivery of anterior shoulder, or more commonly in the U.S after the delivery of the placenta
Strong research support for use of post partum administration of pitocin

70. Summary: Remember 4 Ts
Tone
Tissue
Trauma
Thrombin

73. Thank You