POSTPARTUM HEMORRHAGE

Def1: Any blood loss of >500mL (vaginal) and >1000mL (caesarian) following delivery. (Blood loss estimation inaccurate)
Def2: 10% drop of PCV. (Depends on timing of test after onset)
Def3: Any bleeding which result in the signs & sx of hemodynamic instability. (Blood loss response differ from ppl esp
anemia, PET, cardiac diseases, dehydration)
INCIDENCE
HEMOSTATIC MECH
TYPE
RISK FACTORS
The leading
At term, the estimated blood flow to Primary (Early) PPH:
Previous PPH
Laceration
cause of
the uterus 500-800mL/min. 10-15%
Excessive blood loss
Abruptio
Instrumental
maternal
of Cardiac output.
within 24h of delivery Retained
delivery
mortality.
Natural hemostatic mech:
(esp 1st 6h).

LGA
placenta
Occur in 4% of 1) Contraction & retraction of
Secondary (Late)
Failure to
HTN disorders
deliveries.
myometrial fibers
PPH: Excessive blood
progress
Induction &
2) Hypercoagulable state in late
loss between 24hduring 2nd
Augmentation of
pregnancy
6wks postpartum
stage
labor
3) Integrity of the genital tract
(esp 2nd wk)
Placenta
accreta
ETIOLOGY
Bleeding mostly from endometrial spiral arterial arterioles & decidual veins that supplied & drain intervillous spaces of
placenta.
Causes of primary PPH: 1) Tone; 2) Trauma; 3) Tissue; 4) Thrombosis; 5) Uterine Inversion
TONE (ATONY, 75-80%)
TRAUMA
TISSUE
THROMBOSIS
UTERINE INVERSION
Failure of contraction & retraction of
Vascular beds in
- Retention of Preexistent: ITP,
Just after 2nd stage
myometrial muscle fibers.
genital tract are
part of
TTP.
of labor, due to
Predisposing factors:
engorged during
placenta.
Acquired:
uterine atony, cervix
1) Uterus overdistention Multiple
pregnancy.
50% cases of
1- Abruptio (Leak is open & placenta
gestation, LGA, Polyhydroamnios.
1) Laceration in
2ndary PPH.
AF)
attached.
2) Prolonged labor fatigue.
cervix & vagina
2- HELLP (low Plt) Inexperienced doc
3) Drugs Halogen anest, nitrate, NSAID,
spontaneous/
- Incomplete
3- Sepsis DIC
exert fundal
MgSO4, Nifedipine.
instrumental/
separation of
4- Dilutional
pressure while pull
4) Placenta previa - content of
manipulation of
accreta or
coagulaopathy
umbilical cord before
musculature of the wall.
fetus/ LGA/
precreta.
5- Amniotic fluid
complete placental
5) Bacterial toxins chorioamnionitis,
precipitous labor.
embolism
separation.
endometritis & septicemia.
2) Uterine rupture
intravascular
Inversion Traction
6) Fibroid esp intramural.
intraperitoneal
infusion of small
of peritoneal
7) Grand multipara >5
bleeding.
amt of AF.
structure

8) Precipitous labor
9) Abruptio esp concealed coz interstitial
bleeding.
CLINICAL
MANIFESTATION
Heavy vaginal
bleeding
BP
HR
RBC count (Hct)
Swelling & pain in
tissues in the
vaginal & perineal
area.

3) Hematoma
perineal, vaginal or
broad ligament
hematoma.
COMPLICATION

DDx OF CAUSES

Hx: Ask risk factors of uterine atony & coagulopathy.

Exam:
Soft boggy & large uterus with profuse vaginal bleeding?

Atony.

Bright red bleeding b4 separation of placenta? Trauma.

Abdominal / vaginal mass increasing in size? Hematoma.

Bleeding severe, bright red, no clots but uterus contracts

well? Coagulopathy.
Cupping of fundus or non-palpable fundus? Uterine
inversion.
Fever & tenderness? Endomyometritis.
If no cause identified Manual exploration of genital tract.
MANAGEMENT OF PRIMARY POSTPARTUM HEMORRHAGE
Identification of those at risk of PPH. Start prophylactic measures during labor to minimize maternal mortality.
1. CBC Hb & Plt (correct anemia if present). 2. Blood typing & Ab screening (Xmatch 2-6units blood) 3. Insert large bore IV
line.
ROUTES OF MANAGEMENT
RESUSCITATION
EVALUATE
SURGICAL
PROGNOSIS
Oxygen by mask.
Monitor pulse, BP, 1. Laparotomy to drain
Depends on
2 large bore IV lines. Central venous line.
Urine output,
free blood & inspect any
cause of PPH,
Draw blood CBC, coagulation screen, urea, creatinine,
blood gases, level injury & repair.
duration,
electrolyte.
of consciousness. 2. Uterine artery ligation
amount of
Immediate fluid replacement with NS or RL.
Order regular CBS 3. Internal iliac (inferior
blood loss &
Transfuse RBC as available & appropriate.
counts &
hypogastric) artery
effectiveness
FFP if abnormal coagulation test results & sites oozing.
coagulation tests
ligation.
of rx.
Cryoprecipitate if abnormal coagulation tests not
to guide blood
4. Total hysterectomy
Prompt dx &
corrected with FFP.
component
5. Selective arterial
rx.
Plt concentrates if plt count <50x10/L & bleeding
therapy.
embolization
continues.
MANAGEMENT OF UNDERLYING CAUSE

Anemia
Hypotension & hypovolumic shock
Renal failure
Risks of blood transf
Surgery complications & sepsis
Sheehan syndr
Venous thrombosis & embolic effects
(coz of surgery, bed rest &
hypercoagulable state)

Vasovagal response
Vasodilation
Hypovolemic shock.

TONE
Assess uterine size & tone.
Bimanual express clots,
stimulate uterine
contractions.
Empty bladder.
Uterine artery ligation,
selective arterial
embolization or subtotal/
total hysterectomy.
Uterotonic drugs.

TRAUMA
Cervical & vaginal
lacerations absorbable
continuous stitch.
Large lower genital tract,
unstable broad lig &
retroperitoneal hematoma
incision, drain, ligation,
packing.
Uterus rupture sub/TAH.

TISSUE
Removed even if bleeding stopped
with use of uretrotonics.
Diffcult without GA.
Resuscitate adequately. Manual
explore.
Vaginal hand in situ to
discomfort, infxn, trauma.
Adherent? Curettage.

COAGULOPATHY
Confirm by risk factors &
abnormal coagulation
test.
FFP: 1U=1g fibrinogen
Cryoprecipitate:VIII, XiII &
fibrinogen.
Plt concentrate: 1u 2025k plt.
Packed RBC: 1U 1g/dL

SECONDARY POSTPARTUM HEMORRHAGE

ETIOLOGY
RISK FACTORS
Retained products of conception (RPOC)
C-section
most common cause of 2ndary PPH
Prolonged ROM
Infection often 2ndary to RPOC. 1-3% after
Prolonged labor with multiple exams.
spontaneous vaginal delivery. Most common
Manual removal of placenta
cause of postnatal morbidity between day2Mothers age at extremes
10.
Low socioeco status
Maternal anemia
placental site - amt of bleeding. Lacerations includes episiotomy
Trauma

Rupture
of
vulval
hematoma
Internal fetal monitoring
Extent of bleeding less than
Pre-existing uterine disease Fibroids
Severe meconium staining in liquor
primary PPH.
Others (rare) Blood disorders, Carcinoma of
Prolonged surgery
cervix.
ASSESSMENT
INVESTIGATIONS
MANAGEMENT
Dx obtained clinically.
Crossmatch 2-4units of blood if
Mainstays: Bed rest & IV antibiotic
[Hx: Crampy ab pain? Passage of bits of placenta?
marked bleeding.
therapy.
Sx of infxn. Duration of labor. Smooth?
Coagulation profile as indicated. Curettage not performed outinely
Instrumental? Placenta complete? Complication?]
Speculum exam check status
(risk of uterus perforation)
Exam: Check temp, HR, BP.
of cervical os & obtain
No oxytocin.
Assess uterine size. Larger than appropriate?
endocervical swab.
Gentle digital evacuation of uterus
Assess clinical signs of blood loss. Estimate total
US may be used if RPOC
under GA performed with antibiotic
blood loss.
suspected. Blood clots may
coverage.
Establish IV line as indicated.
resemble RPOC.
Iron supplement if Hb low.
Oxygen via face mask as indicated.
CBC
OVERVIEW
Commonly presents as
prolonged or excessive bleeding
once woman has returned home
after 24h-6wks postpartum.
Most commonly at 2nd wk.
2ndary to sloughing of eschar on