1. Postpartum Hemorrhage
Obsterics & Gynecology Hospital of Fudan University
Weirong Gu

2. Postpartum Hemorrhage(PPH)
Blood loss in excess of 500 ml following birth within the first 24 hours of delivery
Serious intrapartum complication
The most significant cause of maternal death worldwide, mortality : per year (1 maternal death every 4 minutes)
Incidence: 4–6% of pregnancies
Actual incidence: more high because of inaccurate, significant underreporting
Blood is mixed with amnion fluid
There is no single, satisfactory definition of postpartum hemorrhage
An estimated blood loss in excess of 500 mL following a vaginal birth or a loss of
greater than 1,000 mL following cesarean birth often has been used for the
diagnosis, but the average volume of blood lost at delivery can approach these amounts

3. Classification Primary PPH Secondary PPH
Occurring within the first 24 hours of delivery
4–6% of pregnancies
Caused by uterine atony in 80% or more of cases
Secondary PPH
Occurring between 24 hours and 6–12 weeks postpartum
1% of pregnancies
Postpartum hemorrhage generally is classified as primary or secondary.
primary hemorrhage occurring within the first 24 hours of delivery in 4–6% of pregnancies, is caused by uterine atony in 80% or more of cases
secondary hemorrhage occur between 24 hours and 6–12 weeks postpartum in approximately 1% of pregnancies

4. Etiology 4 “ T ” Tone: uterine atony Tissue: retained placenta
Trauma: vaginal, cervical, or uterine injury
Thrombin: coagulopathy (pre-existing or
acquired)
——SOGC guideline (number 235, October 2009): Active Management of the Third Stage of Labor: Prevention and Treatment of Postpartum Hemorrhage
In regard to the underlying causes of PPH, SOGC(the society of obstetricians and gynaecologists of canada) suggest it may be helpful to think in terms of the 4 Ts:
There are ……
Interact as both cause and effect

5. 1st “T”——uterine atony The most common and important cause of PPH
The primary protective mechanism for immediate hemostasis after delivery:
Myometrial contraction causing occlusion of uterine blood vessels ——living ligatures of the uterus
Blood flow from the vascular space to the uterine cavity via the myometrium is impeded
The most common and important cause of PPH is uterine atony.
after delivery, The primary protective mechanism for immediate hemostasis is myometrial contraction causing occlusion of uterine blood vessels, the so-called living ligatures of the uterus.
Thus blood flow from the vascular space to the uterine cavity via the myometrium is impeded.

6. Uterine atony Etiologic category and process Clinical risk factors
Overdistension of uterus
Polyhydramnios, Multiple gestation, Macrosomia
Uterine muscle exhaustion
Rapid labor, Prolonged labor,
High parity, Oxytocin use
Intra-amniotic infection
Fever, Prolonged rupture of membranes
Functional/anatomic distortion of uterus
Fibroids, Placenta previa,
Uterine anomalies
Uterine-relaxing medications
Halogenated anesthetics,
Nitroglycerin
Bladder distension
The etiologic category and process of uterine atony involve ……caused by ……
The clinical risk factor of …….including……..
Fever, Prolonged rupture of membranes usually suggest intra-amniotic infection
Fibroids, Placenta previa, uterine anomalies will cause functional/anatomic distortion of uterus, then myometrial contraction is affected.

7. Placenta abruption 胎儿
子宫内膜 胎盘 脐带 宫颈 出血
Placenta previa

8. Twin pregnancy fibroid Uterine anomalies 胎盘 肌壁间肌瘤 脐带 浆膜下肌瘤 内膜下肌瘤 胎儿 带蒂宫颈 脐带 阴道
fibroid
肌壁间肌瘤
浆膜下肌瘤
内膜下肌瘤 带蒂
Uterine anomalies
举例：双胎合并前置胎盘，妊娠合并子宫巨大肌瘤等
A patient was pregnancy with twins and had placenta previa.
At 36w, she waked up with a start to find herself lying in pool of blood.
Emergenct CS was done .
In operation ,uterine atony occurred and wasn’t corrected by utrotonic drugs.
Finally the bleeding was ceased by using uterine tampon.
The next day, the patient bled again when tampon was extracting.
So extraction was stopped and she was undergone embolism.
The tampon was extracted totally 24hours later,and the patient no more bled.

9. 2nd “T”——Tissue retained
Etiologic category and process
Clinical risk factors
Avulsed lobule, Succenturiate lobe
Incomplete placenta at delivery
Abnormally adhered:
Accreta,
Increta,
Percreta
Placenta previa with or without previous uterine surgery,
Prior myomectomy,
Prior cesarean delivery,
Asherman’s syndrome,
Submucous leiomyomata,
Maternal age older than 35 years
If bleeding persists, other etiologies besides atony must be considered.
Even if atony is present, there may be other contributing factors.
when the placenta is delivered，check the completeness of the placenta.
If there is avulsed lobule or succenturiate lobe retained in uterus, bleeding will occur.
Besides that, abnormal attachment of the placenta to the inner uterine wall (placenta accreta) can cause massive hemorrhage.
Infact, accreta and uterine atony are the two most common reasons for postpartum hysterectomy.
Risk factors for placenta accreta include placenta previa with or without previous uterine surgery, prior myomectomy, prior cesarean delivery, Asherman’s syndrome, submucous leiomyomata, and maternal age older than 35 years.
Prior cesarean delivery and the presence of placenta previa in a current pregnancy are particularly important risk factors for placenta accreta.

10. Succenturiate lobe This is a placenta ,cord
The allow refer to a succenturiate lobe
Succenturiate lobe

11. Placenta accreta Accreta Increta
Percreta
Placenta villi attach Placenta villi invade Placenta villi penetrate
to the myometrium into the myometrium through the myometrium
The term placenta accreta is used to describe any implantation in which there is abnormally firm adherence to the uterine wall.
placental villi are attached to the myometrium in placenta accreta
With placenta increta, villi actually invade into the myometrium
Finally, with placenta percreta, villi penetrate through the myometrium

13. 3rd “T”——Trauma of the genital tract
Etioiogic category and process
Clinical risk factors
Lacerations of the cervix, vaginal, or perineum
Precipitous delivery
Operative delivery
Puerperal Hematomas
Nulliparity, episiotomy, and forceps delivery
Precipitous delivery and Operative delivery are the risk factors of lacerations of the cervix, vaginal, or perineum.
With puerperal hematomas, Nulliparity, episiotomy, and forceps delivery are the most commonly associated risk factors
外阴组织弹性差
急产、产力过强、巨大儿
阴道手术助产操作不规范
会阴切开缝合时止血不彻底
Uterine rupture usually occurs in patient with previous uterine surgery.
The most common cause of uterine rupture is separation of a previous cesarean hysterotomy scar.
Complete uterine inversion after delivery of the infant is almost always the consequence of strong traction on an umbilical cord attached to a placenta implanted in the fundus.

14. Lacerations of perineumII I
Laceration of cervix
I- IV Lacerations of perineum
定义：
1度：laceration of perineum skin and introitus vaginae mucosa, few bleeding
会阴部皮肤及阴道入口粘膜，未达肌层，一般出血不多
2度：laceration to muscular layer of perineal body,involving posterior vaginal mucosa,more bleeding
达会阴体肌层，累及阴道后壁粘膜，甚至阴道后壁两侧沟向上撕裂使原解剖结构不易辨认，出血较多
3度：sphincter ani exterus ruptured, few bleeding, but damage of tissue is serious
肛门外括约肌已断裂，甚至直肠阴道隔及部分直肠前壁有裂伤，出血量不一定多，但组织损伤严重
Lacerations of cervix
III
Lacerations of perineum

15. 4th “T”——trauma of Thrombin (coagulopathy)
Etioiogic category and process
Clinical risk factors
Pre-existing states
Primary thrombocytopenia
Aplastic anemia
Acquired in pregnancy
HELLP syndrome
Abruption placenta
Prolonged intrauterine fetal demise
Sepsis
Amniotic fluid embolism
Significant hemorrhage
Elevated blood pressure
Antepartum hemorrhage
Fetal demise
Fever
Sudden collapse
Less commonly, postpartum hemorrhage may be caused by coagulopathy.
Clotting abnormalities should be suspected on the basis of patient or family history or clinical circumstances.
Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, prolonged intrauterine fetal demise, sepsis, and amniotic fluid embolism are associated with clotting abnormalities acquired in pregnancy.
Significant hemorrhage from any cause also can lead to consumption of clotting factors.

16. Clinical manifestation
Vaginal bleeding
Bleeding with characteristic soft, poorly contracted (“boggy”) uterus on bimanual pelvic examination
——uterine atony
Bleeding while the uterus is firmly contracted
—— retained placenta
——genital tract laceration
Bleeding without clot
——coagulopathy
Pelvic or rectal pressure and pain
——genital tract hematomas
Because the single most common cause of hemorrhage is uterine atony, the bladder should be emptied and a bimanual pelvic examination should be performed.
The finding of the characteristic soft, poorly contracted (“boggy”) uterus suggests atony as a causative factor.
Bleeding while the uterus is firmly contracted
Genital tract hematomas should be suspected if a patient feel pelvic or rectal pressure and pain.
specific

17. Clinical manifestation
Hypovolemic shock
Irritable,pallor and clamminess of skin, tachycardia, narrow pulse pressure
——mild degree of shock
产后出血主要表现为阴道流血或伴有失血过多引起的并发症如休克、贫血等
阴道流血：
不同原因的产后出血临床表现不同
休克症状，面色苍白，脉搏细数，血压下降
举例：剖宫产术后，腹腔内出血，烦躁，误诊为神经系统问题，die
the patient was irritable and extracted transfer line herself at 4hours after CS.
the doctor on duty misdiagnosed nervous system disease and asked neurologist’s consultation.
In fact，the patient was at mild degree of shock because of intraperitoneal hemorrhage.
Unfortunately,the patient died of delayed diagnosis.

18. Diagnosis （ estimates of blood loss ）
Weight method：
Blood loss(ml)＝（dressing wet weight after birth－dressing dry weight before birth）/1.05(specific gravity of blood)
Volume method:
Collect blood using a container
Area method：
10cm*10cm gause soak blood = 10ml blood
PPH is easy to be dignosed, but the estimates of blood loss are always underreporting.
Objective estimate methods include ……
减subtract 除以 divide 等于 equal to
产后出血容易诊断，但临床上目测阴道流血量的估计往往偏少
较客观检测出血量的方法有。。。。。。

19. Weight method
会阴垫 perineal pad
秤 scales
刻度ruling

20. Volume method
Container put under patient’s buttocks to collect blood

21. Shock index Shock index =heart rate/systolic pressure（mmHg）
（normal <0.5）
shock index estimate loss of blood（ml） loss of blood volume
0.6~ <500~ <20%
= ~ ~30%
= ~ ~50%
≥ ~ ≥50~70%
Mercury

22. Management of PPH The initial goal
Identifying and treating the cause of blood loss
Instituting resuscitative measures to maintain hemodynamic stability and oxygen perfusion of the tissues
The initial goal of management is to Identify and treat the cause of blood loss while instituting resuscitative measures to maintain hemodynamic stability and oxygen perfusion of the tissues.

23. Initial assessment and treatment for PPH
Call for help
Resuscitation
Assess the “ABC”
Monitor BP, P, R
Empty bladder, monitor urine output
IV line
Crystalloid, isotonic fluid replacement
Oxygen by mask
Laboratory tests
Complete blood count
Coagulation screen
Blood grouping and cross
——SOGC 2009
SOGC propose Initial assessment and treatment for PPH ：
Call for help from midwife, other obstetrians, anaesthetist, and so on.
The “ABCs” should be observed and vital signs, oxygen saturation, and urinary output monitored.
An IV infusion of crystalloid solution should be instituted, using large-bore tubing, along with oxygen supplementation.
Laboratory tests involve ……
A visual assessment of clotting can be done at the bedside while blood is sent for analysis and matching for transfusion.

24. 1st “T”——Uterine atony Uterine massage Uterotonic drugs
Diminish bleeding, expel blood and clots, and allow time for other measures to be implemented
Uterotonic drugs
Ongoing blood loss in the setting of decreased uterine tone requires the administration of additional uterotonics as the first-line treatment for hemorrhage
Compression or massage of the uterine corpus can diminish bleeding, expel blood and clots, and allow time for other measures to be implemented.
Ongoing blood loss in the setting of decreased uterine tone requires the administration of additional uterotonics as the first-line treatment for hemorrhage

25. Uterine massage
Bimanual compression of the uterus between the fist in the anterior fornix and the abdominal hand usually controls hemorrhage from uterine atony. 22

26. IV: 10–40 units in 1 liter normal saline or lactated Ringer’s solution
Uterotonic drugs
Drug
Dose/Route
Frequency
Comment
Oxytocin
IV: 10–40 units in 1 liter normal saline or lactated Ringer’s solution
IM: 10 units
Continuous
Avoid undiluted rapid IV infusion, which causes hypotension
Carbetocin
IV/IM：
100 μg
Ergometrine
IM: 0.2 mg
Every 2–4 h
Avoid if patient is hypertensive
Uterotonic drugs is the first line treatment for hemorrage from anoty.
Intravenous drip 静脉滴注
Intramuscular injection 肌肉注射
Carbetocin is a long-acting oxytocin，given IV is as effective as oxytocin
μg 微克microgram

27. Uterotonic drugs (prostaglandin preparation)
Dose/Route
Frequency
Comment
15-methyl PGF2α
(Hemabate)
IM: 0.25 mg
Every 15–90 min, 8 doses maximum
Avoid in asthmatic patients
Diarrhea, fever, tachycardia can occur
Dinoprostone
(PGE2)
Suppository: vaginal or rectal 20 mg
Every 2 h
Avoid if patient is hypotensive. Fever is common.
Misoprostol
(PGE1)
800–1,000 mcg rectally
前列腺素制剂 prostaglandin preparation

28. If bleeding continues Uterine tamponade Exploratory laparotomy
Uterine artery embolization
If bleeding continues, tamponade of the uterus can be effective in decreasing hemorrhage secondary to uterine atony .
Such approaches can be particularly useful as a temporizing measure, but if a prompt response is not seen, preparations should be made for exploratory laparotomy.

29. Uterine tamponade
Indication：uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after vaginal delivery
Technique
Comment
—Packing
—4-inch gauze; can soak with 5,000 units of thrombin in 5 mL of sterile saline
—Foley catheter
—Insert one or more bulbs; instill 60–80 mL of saline
—Sengstaken–Blakemore tube
—SOS Bakri tamponade balloon
—Insert balloon; instill 300–500 mL of saline
When uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after vaginal delivery, uterine tamponade may be useful.
Usually, we pack the uterine cavity with gause
The sameeffect often can be derived more easily using a Foley catheter, Sengstaken-Blakemore tube, or, more recently, the SOS Bakri tamponade balloon,

30. Packing Bakri Balloon tamponade
Packing with gauze requires careful layering of the material back and forth from one cornu to the other using a sponge stick, and ending with extension of the gauze through the cervical os.
This is the SOS Bakri tamponade balloon, the balloon is inserted into uterine cavity and instilled ml saline, specifically tailored for tamponade within the uterine cavity in cases of postpartum hemorrhage secondary to uterine atony
Removed 24hours later.
Packing Bakri Balloon tamponade

31. Exploratory laparotomy
Indication：When uterotonic agents with or without tamponade measures fail to control bleeding in a patient who has given birth vaginally
Techniques
Compression sutures
Artery ligation
Hysterectomy
When uterotonic agents with or without tamponade measures fail to control bleeding in a patient who has given birth vaginally, exploratory laparotomy is indicated.

32. Compression sutures B-Lynch technique
First reported by B-lynch in 1993
Compress the uterine corpus and decrease bleeding
Rare Complication：uterine ischemic necrosis with peritonitis
a surgical technique for severe postpartum atony in which a pair of vertical brace, #2-chromic sutures were secured around the uterus.
When tightened and tied, they give the appearance of suspenders—or braces—that compress the anterior and posterior walls together
Uterine ischemic necrosis with peritonitis is its rare complication.

33. Modified B-Lynch
e.g. Hemostatic multiple square suturing
For postpartum hemorrhage caused by uterine atony, placenta previa, or placenta accreta
Eliminateing space in the uterine cavity by suturing both anterior and posterior uterine walls
A number of modifications of the B-Lynch technique have been described .
Hemostatic multiple square suturing is another new surgical technique for postpartum hemorrhage caused by uterine atony, placenta previa, or placenta accreta.
The procedure eliminates space in the uterine cavity by suturing both anterior and posterior uterine walls.
One study reported on this technique in 23 women after conservative treatment failed.
All patients were examined after 2 months, and ultrasound findings confirmed normal endometrial linings and uterine cavities.

34. Artery ligation Bilateral uterine arteries ligation
Bilateral internal iliac arteries ligation
Bilateral ovarian arteries ligation
Artery ligation is performed to diminish the blood flow to the uterus,
Bilateral uterine artery ligation and internal iliac arteries ligation accomplishes the same goal, and uterine artery ligation is quicker and easier to perform.
To further diminish blood flow to the uterus, similar sutures can be placed across the vessels within the utero-ovarian ligaments.

35. Uterine arteries ligation
sketch map
Uterine arteries ligation
Internal iliac arteries ligation

36. Artery ligation
Diminish the pulse pressure of blood flowing to the uterus
The timing of this intervention is important: it must be done without delay, before excessive blood loss has occurred
Surgical skill is required to avoid failure and complications such as damage to other vascular structures and the ureters
To perform artery ligation, the timing of this intervention is important: it must be done without delay, before excessive blood loss has occurred.
Surgical skill is required to avoid failure and complications such as damage to other vascular structures and the ureters

37. Hysterectomy
Indication: massive hemorrhage has not responded to previous interventions
Notice: If hysterectomy is performed for uterine atony, there should be documentation of other therapy attempts
When massive hemorrhage has not responded to previous interventions, hysterectomy is inevitable.
Because the patient will lose her fertility, so it must be noticed that If hysterectomy is performed for uterine atony, there should be documentation of other therapy attempts.

38. Hysterectomy subtotal total cavity cavity uterus salpinx endometrium
overy
myometrium
In order to control bleeding quickly, subtotal hysterectomy can gain time.
But if uterine atony caused by placenta previa, total hysterectomy maybe optimal choice.
subtotal
cervix
bladder
total
vagina

39. Arterial embolization
Indication: stable vital signs , persistent bleeding, especially if the rate of loss is not excessive
Used for bleeding that continues after hysterectomy
Used as an alternative to hysterectomy to preserve fertility
Arterial embolization is another choice to treat PPH
A patient with stable vital signs and persistent bleeding, especially if the rate of loss is not excessive, may be a candidate for arterial embolization.
Embolization can be used for bleeding that continues after hysterectomy or can be used as an alternative to hysterectomy to preserve fertility.

40. Radiographic identification of bleeding vessels
Embolization with gelfoam, coils, or glue, or balloon occlusion
Radiographic identification of bleeding vessels allows embolization with Gelfoam, coils, or glue. Balloon occlusion is also a technique used in such circumstances.

41. An algorithm suggested for the management of atonic PPH
H.A.E.M.O.S.T.A.S.I.S.
H: Ask for help
A: Assess (vital parameters, blood loss) and
resuscitate
E: Establish etiology and check medication
supply (oxytosin, ergometrine) and availability
of blood
M: Massage uterus
O: Oxytocin infusion, prostaglandins
(intravenous, rectal, intramuscular, intra-
myometrial)
Now we summarize the treatment of atony PPH.
An algorithm has been suggested by FIGO for the management of atonic PPH. It is called H.A.E.M.O.S.T.A.S.I.S.

42. S: Shift to operating room, exclude retained
products and trauma, bimanual compression
T: Tamponade balloon, uterine packing
A: Apply compression sutures
S: Systematic pelvic devascularization (uterine,
ovarian, internal iliac)
I: Intervention radiologist, uterine artery
embolization if appropriate
S: Subtotal or total abdominal hysterectomy
——ICM/FIGO guideline 2006: Postpartum
hemorrhage today: initiative 2004—2006

43. 2nd “T”——Tissue retained
Diagnosis: detection of an echogenic mass in the uterus by ultrasonography
Directed therapy
Whole placenta in uterus：manual removal
Incomplete separation （avulsed lobule, succenturiate lobe）： gentle curettage
Placenta accreta
curettage
wedge resection
medical management
hysterectomy
The possibility that additional products of conception
remain within the uterine cavity should be considered.
Ultrasonography can help diagnose a retained
placenta. Retained placental tissue is unlikely when
ultrasonography reveals a normal endometrial stripe.
Although ultrasonographic images of retained placental
tissue are inconsistent, detection of an echogenic mass in
the uterus is more conclusive. Ultrasound evaluation for
retained tissue should be performed before uterine
instrumentation is undertaken (9). Spontaneous expulsion
of the placenta, apparent structural integrity on
inspection, and the lack of a history of previous uterine
surgery (suggesting an increased risk of abnormal placentation)
make a diagnosis of retained products of the
placenta less likely, but a curettage may identify a succenturiate
lobe of the placenta or additional placental tissue.
When a retained placenta is identified, a large, blunt
instrument, such as a banjo curette or ring forceps, guided
by ultrasonography, makes removal of the retained
tissue easier and reduces the risk of perforation.
The extent (area, depth) of the abnormal attachment
will determine the response—curettage, wedge resection,
medical management, or hysterectomy. Uterine conserving
options may work in small focal accretas, but abdominal
hysterectomy usually is the most definitive treatment

44. Manual removal of placenta
After grasping the fundus through the abdominal wall with one hand, the other hand is introduced into the vagina and passed into the uterus, along the umbilical cord. As soon as the placenta is reached, its margin is located, and the border of the hand is insinuated between it and the uterine wall (Fig ). Then with the back of the hand in contact with the uterus, the placenta is peeled off its uterine attachment by a motion similar to that used in separating the leaves of a book. After its complete separation, the placenta should be grasped with the entire hand, which is then gradually withdrawn. Membranes are removed at the same time by carefully teasing them from the decidua, using ring forceps to grasp them as necessary.

45. 3rd “T”——Trauma to the Genital Tract
Lacerations of perineum, vagina, or cervix
Genital tract hematomas

46. Lacerations of perineum, vagina, or cervix
Identification and proper repair of lacerations
Transfer to a well-equipped operating room
Proper patient positioning
Adequate operative assistance
Good lighting
Appropriate instrumentation (eg, Simpson or Heaney retractors)
Adequate anesthesia
Lacerations should be ruled
out by careful visual assessment of the lower genital
tract. Proper patient positioning, adequate operative
assistance, good lighting, appropriate instrumentation
(eg, Simpson or Heaney retractors), and adequate anesthesia
are necessary for the identification and proper
repair of lacerations. Satisfactory repair may require
transfer to a well-equipped operating room.

48. Genital tract hematomas
May not be recognized until hours after the delivery
Sometimes occur in the absence of vaginal or perineal lacerations
The main symptoms are pelvic or rectal pressure and pain
Genital tract hematomas also can lead to significant
blood loss. Progressive enlargement of the mass indicates
a need for incision and drainage. Often a single bleeding
source is not identified when a hematoma is incised.
Draining the blood within the hematoma (sometimes
placing a drain in situ), suturing the incision, and if
appropriate, packing the vagina are measures usually
successful in achieving hemostasis. Interventional radiology
is another option for management of a hematoma.
Genital tract hematomas may not be recognized until
hours after the delivery, and they sometimes occur in the
absence of vaginal or perineal lacerations. The main
symptoms are pelvic or rectal pressure and pain.

49. Directed therapy
Draining the blood within the hematoma (sometimes placing a drain in situ)
Suturing the incision
Packing the vagina
Interventional radiology
Genital tract hematomas also can lead to significant
blood loss. Progressive enlargement of the mass indicates
a need for incision and drainage. Often a single bleeding
source is not identified when a hematoma is incised.
Draining the blood within the hematoma (sometimes
placing a drain in situ), suturing the incision, and if
appropriate, packing the vagina are measures usually
successful in achieving hemostasis. Interventional radiology
is another option for management of a hematoma.

50. 4th “T”——Coagulation Defects
Directed therapy
Appropriate testing
Blood products infused as indicated
Simultaneous surgery if the coagulopathy caused or perpetuated by the hemorrhage
When a coagulopathy
is suspected, appropriate testing should be ordered,
with blood products infused as indicated. In some situations,
the coagulopathy may be caused or perpetuated by
the hemorrhage. In such cases, simultaneous surgery and
blood product replacement may be necessary.

51. Response to hemorrhage before laboratory results are known
Baseline studies
Complete blood count with platelets
Prothrombin time
Activated partial thromboplastin time
Fibrinogen
A type and cross order
Be ordered when excessive blood loss is suspected and should be repeated periodically as clinical circumstances warrant
Response to hemorrhage before laboratory results are known
Baseline studies should be ordered when excessive
blood loss is suspected and should be repeated periodically
as clinical circumstances warrant. Clinicians
should remember that the results of some studies may be
misleading because equilibration may not have occurred.
In addition, response to hemorrhage may be required
before laboratory results are known. Baseline studies
include a complete blood count with platelets, a prothrombin
time, an activated partial thromboplastin time,
fibrinogen, and a type and cross order. The blood bank
should be notified that transfusion may be necessary.

52. The clot observation A simple measure of fibrinogen
A volume of 5 mL of the patient’s blood is placed into a clean, red-topped tube and observed frequently. Normally, blood will clot within 8–10 minutes and will remain intact
If the fibrinogen concentration is low, generally less than 150 mg/dL, the blood in the tube will not clot, if it does, it will undergo partial or complete dissolution in 30–60 minutes
The clot observation test provides a simple measure
of fibrinogen (10). A volume of 5 mL of the patient’s
blood is placed into a clean, red-topped tube and
observed frequently. Normally, blood will clot within
8–10 minutes and will remain intact. If the fibrinogen
concentration is low, generally less than 150 mg/dL, the
blood in the tube will not clot, or if it does, it will undergo
partial or complete dissolution in 30–60 minutes.

53. Prevention of PPH
AMTSL (active management of the third stage of labor)
Routine use of uterotonics
Early cord clamping, controlled cord traction
Appropriate uterine massage after delivery of the placenta
Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning.
Active management of the third stage of labor is helpful to prevent PPH.
It involve routine use of uterotonics after delivery of the newborn and before delivery of the placenta, early cord clamping, and controlled cord traction.
The primary goal of these interventions was to assist placental delivery, thereby allowing the uterus to contract and reduce blood flow across the
myometrium.
Then massage uterus appropriately after delivery of the placenta.

54. Etiology of secondary PPH
Subinvolution of placental site
Retained products of conception
Infection
Inherited coagulation defects

55. Secondary postpartum hemorrhage
The extent of bleeding usually is less than that seen with primary postpartum hemorrhage
Ultrasound evaluation can help identify intrauterine tissue or subinvolution of the placental site
Treatment may include uterotonic agents, antibiotics, and curettage
Secondary hemorrhage occurs in approximately 1% of
pregnancies; often the specific etiology is unknown.
Postpartum hemorrhage may be the first indication for
von Willebrand’s disease for many patients and should
be considered. The prevalence of von Willebrand’s disease
is reported to be 10–20% among adult women with
menorrhagia (37). Hence, testing for bleeding disorders
should be considered among pregnant patients with a
history of menorrhagia because the risk of delayed or
secondary postpartum hemorrhage is high among
women with bleeding disorders (38, 39).
Uterine atony (perhaps secondary to retained products
of conception) with or without infection contributes
to secondary hemorrhage. The extent of bleeding
usually is less than that seen with primary postpartum
hemorrhage. Ultrasound evaluation can help identify
intrauterine tissue or subinvolution of the placental site.
Treatment may include uterotonic agents, antibiotics,
and curettage. Often the volume of tissue removed by
curettage is minimal, yet bleeding subsides promptly.
Care must be taken in performing the procedure to avoid
perforation of the uterus. Concurrent ultrasound assessment
at the time of curettage can be helpful in preventing
this complication. Patients should be counseled
about the possibility of hysterectomy before initiating
any operative procedures.

56. Summary of PPH management
Management may vary greatly among patients, depending on etiology and available treatment options, and often a multidisciplinary approach is required
Balancing the use of conservative management techniques with the need to control the bleeding and achieve hemostasis
Uterotonic agents should be the first-line treatment for postpartum hemorrhage due to uterine atony
When uterotonics fail following vaginal delivery, exploratory laparotomy is the next step
When treating postpartum hemorrhage, it is necessary
to balance the use of conservative management techniques
with the need to control the bleeding and achieve
hemostasis. A multidisciplinary approach often is
required. In the decision-making process, less-invasive
methods should be tried initially if possible, but if unsuccessful,
preservation of life may require hysterectomy.
Management of postpartum hemorrhage may vary greatly
among patients, depending on etiology of the bleeding,
available treatment options, and a patient’s desire for
future fertility. At times, immediate surgery is required
because time spent using other treatment methods would
be dangerous for the patient. There are few randomized
controlled studies relevant to the management of postpartum
hemorrhage, so management decisions usually
are made based on clinical judgment.
Uterotonic agents should be the first-line treatment for postpartum hemorrhage due to uterine atony.
Management may vary greatly among patients, depending on etiology and available treatment options, and often a multidisciplinary approach is required.
When uterotonics fail following vaginal delivery, exploratory laparotomy is the next step.
In the presence of conditions known to be associated with placenta accreta, the obstetric care provider must have a high clinical suspicion and take appropriate precautions.

57. Reference Williams Obstetrics, 23rd Edition
ACOG Practice Bulletin No Postpartum hemorrhage
ICM/FIGO guideline 2006: Postpartum hemorrhage today: initiative 2004—2006
SOGC guideline (number 235, October 2009): Active Management of the Third Stage of Labor: Prevention and Treatment of Postpartum Hemorrhage
RCOG Green-top Guideline No. 52 May 2009:Prevention and management of postpartum haemorrhage

58. THANKS!