1.  Obstetric Emergency  Follow Vaginal or C/S  Best definition - Diagnosed Clinically Excessive Bleeding makes patient symptomatic Other def- EBL > 500 ml -NVD EBL > 1000 ml –C/S

2. Other definitions of PPH 10% loss of Hb Concentration Most likely we underestimate EBL

3.  Uterine atony > 90%( 1/20 deliveries )  Uterine, Cervical or Vaginal lacerations(1/8 deliveries)  Coagulopathy  Other-Uterine inversion, Uterine rupture, poor haemostasis

4. Grand MultiUterine abnormality- Fibroids PhxProlonged Labour Multiple pregnancyPrecipitate Labour PolyhydramniosDysfunctional Labour ChorioamnionitisOperative Delivery PET,HELLP,APH,FDIU,AFEMacrosomia

5.  Fundal massage  IV access- 16 G  Uterotonic drugs- Syntocin 10 to 40 units  Ergometrine- 500mcg( C.I -Asthma, HT )  Misoprostel 1000 mcg( 1 RCT and 1 non RCT )

6.  > 1000 ml best Mx in Theatre  Notify Obstetric and Anaesthetic Consultant  Notify Blood bank, Haematologist and Theatre  PGF2 α (Carboprost) 250mcg every 15 mins max 2 mg  Infuse large amount of IV fluids to prevent Hypotension

7.  T/F Blood products -Pack cells -FFP (All clotting factors) -Cryoprecipitate( Fibrinogen.factor V,VIII, XIII and VWF) -Platelets( 1 unit=50 ml, 6 units increase by 30,000) EUA -Check Vagina, Cervix,Uterus

8. Uterine packs used variable success Foley Catheter- # 24 30 ml balloon to 60ml leave for 12-24 hours Sengstaken- Blackemore tube

9. Involve Gyne Oncologist if possible Best Vertical midline incision Uterine vessel ligation ± Utero Ovarian Hypogastric artery ligation B-Lynch suture (compress the uterus) ( simple to learn,safe, fertility preserves)

10. Recombinant facer VIIa ( Novo seven) ( Obs & Gyne 2003 case report ) -Effective when conventional methods fail -Bypassing inhibitors to factor VIII and IX Dose 60mcg/Kg to 100 mcg/Kg

11. Precautions before closing the abdomen Haemostasis Inspect bladder and Ureters

12. 2°PPH 24 Hours to 6 weeks Incidence 0.5 to 2% Pathogenesis – Uterine atony 2º to retained products or infection But exact cause unknown

13. Treatment No RCT Uterotonics Antibiotics If retained products D&C

14. 132 Consecutive women 75 D&C Tx Successful 90% 57 Med Tx Successful 72% Complication of Surgery Perforation 3% Uterine adhesions US does not distinguish which patient need surgery or medical Tx