Shahida Khaliq
Faisalabad, Pakistan
Obstetrics
Postpartum Hemorrhage
O bstetric hemorrhage is the
world`s leading cause of
maternal mortality, causing 24% of, or
an estimated 127,000 maternal death
annually PPH is the most common type
of obstetric hemorrhage and accounts
for the majority of 14 million causes of
obstetric hemorrhage that occur each
year.PPH accounts for one quarter of
all maternal deaths world wide. l
In developing countries, PPH
accounts for over one third of all
maternal deaths. 2
Definition
There is no single, satisfactory
definition of PPH. PPH is defined as
blood loss more than 500ml following
vaginal delivery or more than 1000ml
following Cesarean delivery.3
The Scottish confidential audit of
severe maternal morbidity defines as
major hemorrhage as estimated blood
loss >2500ml or the transfusion of 5
or more units of blood or treatment for
Coagulopathy (Fresh Frozen Plasma,
4
Cryoprecipitate, Platelets).
Another definition is any blood loss
that causes hemodynamic instability
e.g. a fall in blood pressure as the risk
of dying from PPH depends not only on
the amount and rate of blood loss but
5
also on the health of the woman.
TYPES OF PPH.
PPH is classified as primary or
secondary. Primary PPH occurs within
the first 24hrs after delivery and
secondary occurs between 24hr and
184 April to June 2010
IR-021
12 weeks post partum.6
Aetiology and Risk Factors
PPH is commonly due to abnormalities
of one or a combination of four basic
processes referred to in the 4 T's
mnemonic.
Tone-Poor uterine contraction after
delivery.
Ti s s u e - Re t a i n e d Pr o d u c t s o f
Conception or Blood Clots.
Trauma- To Genital Tract.
Thrombin- Coagulation
Abnormalities.
Common risk factors for PPH are
multiple Pregnancy, Poly-hydramnios,
F e t a l m a c r o s o m i a , o b e s i t y,
Coagulation disorder, primigravidity,
chorioamnionites, prolonged rupture
of membranes, fibroid uterus,
previous caesarean birth, antpartum
hemorrhage, pre eclampsia,
induction of labour, prolonged labour,
instrumental delivery and prior PPH,7
halo-genated anesthetic agents,
nitrates, non steroidal, and
inflammatory drugs, magnesium
sulfate, beta sympathomimetics,
nifedipine and hypothermia due to
massive rescuscitatation or prolonged
uterus exteriorization.
In UK, there is an overall trend towards
later child bearing, increased
maternal age at childbirth with
associated. Increased incidence of
caesarean and instrumental deliveries
as well as placenta previa.8, 9, 10
Pathophysiology:-
The blood vessels that supply the
INDEPENDENT REVIEWS
placental bed pass through an inter-
lacing network of muscle fibres
(myometrium). The spiral arteriolar
arrangements in the uterus might lower
the arterial pressure with which the
blood enters the uterus. Myometiral
contraction is the main driving force for
placental separation and constriction
for the blood vessels. This haemostatic
mechanism is known as physiological
sutures or living ligatures. When the
placenta separates, bleeding occurs
from the placental bed. Uterine atony
results in a failure of the living ligatures
to stop the bleeding. The active
management of the third stage of
labour is associated with a reduction of
the risk of PPH and less need for blood
transfusion by enhancing this
11
physiological process.
Prevention
The prediction of PPH using antenatal
Clinical findings in obstetric hemorrhage.
Blood Pressure
Blood Volume Loss
(Systolic)
500-1000(10-15%) Normal
Slight Fall
1500-2000ml(25-35%)
(80-100mmhg)
Moderate Fall
1500-2000ml(25-35%)
(70-80mmhg)
Marked
2000-3000ml(35-50%)
(50-70mmhg)
risk assessment is poor only 40% of
women who develop PPH have an
identified risk factor. However, PPH if
often a predictable event, women with
identified risk factors should be
transferred to centers with transfusion
facilities and an intensive care unit for
delivery if these are not available
locally. Prevention of PPH should
April to June 2010 INDEPENDENT
include antenatal risk assessment and
management that assures that anemia
or other health problems are treated
and women are sufficiently healthy to
with stand PPH, as well as appropriate
management of labour and delivery.
Components of active
management third stage of labor
The usual components include
1. Administration of uterotonic
agents with in 1 min of birth
2. Controlled Cord traction and
uterine message after delivery
of placenta as appropriate.
This approach reduces the risk
of PPH and postpartum
anemia, transfusion require-
ments, prolonged third stage
of labour and use of thera-
peutic drugs of PPH.11
Degree of Shock
Symptoms + Signs
Palpitations, Tachycardia
Compensated
Dizziness
Pale, Cool Skin, Weakness,
Mild
Sweating, Tachycardia
Blood Flow to vital organs
(liver, Gut, Kidenys), Restlessness
Moderate
Pallor, Oliguria, Mottling of the skin
in the extremties especially the legs.
Restlessness, Agitation collapse,
Severe
Air hanger, Anuria
Use of Oxytocics:
Injectable oxytocin is used mostly. It is
first line agent because it is effective 2-
3 mins after injection and has minimal
secondary effects, it can be used in all
women. Other uterotonics can be used
e.g. ergometrine 500ug 1M with 5 1U
/ ml.12
REVIEWS 185
 Misoprostol, it can be used by oral,
sublingual and rectal routes. The
misuse of misoprostol can lead to
significant maternal morbidity and
even death. A recent Cochrane review
on the use of prostaglandins nor
misoprostal is preferable to
conventional Injectable uterotonics as
part of the management of the third
stage of labour especially for low risk
13
women.
Carbetocin, a long acting oxytocin
agonist has been used for prevention of
PPH. Nevertheless, Carbetocin is
associated with reduced need for
additional uterotonics agents and
uterine message and there are no
significant differences in adverse effects
between carbetocin and oxytocin. 14
The WHO recommends that:
1. Active management of the third
stage of labour include admi-
nistration of a uterotonic soon
after birth of the baby, delay
cord clamping and delivery of
the placenta by controlled cord
traction followed by uterine
message.
2. Active management of the third
stage of labour should be
offered by skilled attendants as
potential risks such as uterine
inversion may result from
inappropriate cord traction.
3. Oxytocin should be offered for
prevention of PPH in
preference to oral, sublingual
or rectal misoprostol.
4. In the absence of active
management of the third stage
of labour, a uterotonic drug
(oxytocin or misoprostol)
should be offered.
186 April to June 2010
Treatment
A systematic and step wise
management of PPH can be achieved
with the use of the following measures.
General Medical Management
Ask for Help
Massive PPH should be managed with
multi disciplinary input. Senior
obstetricians, anesthetist and theatre
staff, hematologist and the blood bank
and hospital porters and intensive care
unit should be alerted.
Assess
Vital parameters, monitoring the
patient's vital signs, Level of
Consciousness, blood pressure, pulse,
Oxygen, saturation, estimation of
blood loss.
Different methods of estimation have
been evaluated and guidelines to
improve accuracy of the visual
estimation of blood loss have been
suggested.15
Resuscitation
Two large bore cannula pass. Send
blood for full blood count, group and
cross match. Coagulation Screen.
Renal and Liver Profile,
I. Raising the legs,
ii. Administer oxygen at 10-
151/m.
iii. A loss of 1 liter of blood
requires replacement with 4-5
liters of crystalloid (0.9%
normal saline and lactated
ringers solution) or colloids
until cross matched blood is
available as most infused fluid
shifts from the intravascular to
16
the interstitial space.
INDEPENDENT REVIEWS
 Management of Postpartum Hemorrhage

Abdominal pain Oozing from Massive Bleeding

and shock without venipuncture sites(rare)
vaginal bleeding (rare)

Consultation for consider coagulopathy call for help

possible retroperitoneal or (coagulation studies) Evaluate ABCs
paravaginal hematoma Administer Fluids
Administer oxygen
Consider transfusion

Placenta Delivered?

Yes No
Vigorous fundal message Manual Exploration
Oxytocin 10-30 unit rapidly in 1 litre of uterus
of intravenous fluid

Firm fundus, uterus contracted Indistinct Distinct

still bleeding bleeding stop claeavage plane cleavage plane

Explore for cervical,

vaginal, or vulvar lesions consider placenta Manual extraction
accereta of placenta

Vaginal, or vulvar Vaginal, or cervical No lesion

hematoma leceration consultation for probable
urgent hystrectomy
Manual exploration
of uterus.
Repair
up to 4cm 4cm or later
and stable and expanding bi manual compression
of uterus while awaiting help
Retained uterine uterine uterine
Placenta Repture inversion atony
ice packs incise, or clots
and observe drain+pack

Remove Resuscitation Resuscitation Resuscitation

+ urgent lapororomy Correction of inversion apply uterotonics
Apply tamponade
Uterine artery embolization
Laporotomy with compression
suture

Hystrectomy

April to June 2010 INDEPENDENT REVIEWS 187

 The Golden Hour
The golden hour is the time at which
resuscitation must be commenced to
ensure the best chance of survival. The
probability of survival decreases
sharply after the first hour if the patient
is not effectively resuscitated.17
A rule of 30 has been used for acute
management of shock. If the patient's
systolic blood pressure fall by
30mmHg, heart rate (HR) rises by 30
beats/min, RR increases to > 30
beats/min and hemoglobin (Hb) or
haematocrit (HCT) drop by 30% and
urinary output is < 30ml/hr, then the
patient is most likely to have lost at least
30% of her blood volume and is the
moderate shock leading to severe
shock. Shock index may also be used in
the monitoring of the woman with PPH.
It refers to heart rate divided by the
systolic blood pressure (SBP). The
normal value is 0.5 - 0.7 with
significant hemorrhage, it increases to
0.9 - 1.1.18
Establish aetiology, ecbolic, ensure
availability of blood.
Establish Aetiology
Identify the cause of bleeding by using
mnemonic 4T's. Through assessment of
the uterine size and tone should be
followed by vigorous uterine message
and administration of therapeutic
uterotonic agents.
Manually exploration of the uterine
cavity under anesthesia to exclude
RPOC's and to look for extended tears
in the cervix and high in the vaginal
wall excluded Coagulopathy.
Treatment of Coagulopathy
Group specific or group O, Rh-
188 April to June 2010
Negative blood should be transfused
until cross-matched blood become
available. 1 liter of fresh frozen plasma
should be administrated with every 6
units of blood transfused.
Platelet Concentration should be kept
9
at more than 50* 10 / liter or more
9
than 80-100* 10 /liter if surgical
intervention is likely.
Cryoprecipitate and other clothing
factor (VI11, XIII, Von Willebrand
Factor) may be required if there is DIC
or if the fibrinogen levels is less than
10g/l. Recombinant factor VII may be
used in hemophilic patient's.
The incidence of thrombotic
complication occur in 1-2% with use of
recombinant factor VII.
Treatment of Atony
In case of uterine atony, following
measures should be taken to control
postpartum hemorrhage.
Message the uterus, either manually
(hand on the fundus) or bimanually
(vaginal hand in the anterior fornix,
abdominal hand on the posterior
aspect of the fundus) is a simple and
effective first line measure and reduces
bleeding.
Oxytocin infusion, prostagtandins: I/V
bolus 10 units of oxytocin adminis-
tered. 40 units in 500ml of 0.9%
normal saline, infused at a rate of
125ml/hr.
If the uterus remains atonic after initial
oxytocic therapy, syntometrine or
ergometrine should be repeated.
Carboprost is a prostaglandin F2α
analogue which is administered
INDEPENDENT REVIEWS
intramuscularly and intramyometrially
0.25mg repeated every 15min to a
maximum dose of 2mg. This is 80-90%
effective in stopping PPH. It has bronc-
hoconstrictive properties, therefore
contra-indicated in asthma. Side
effects include diarrhea, vomiting,
fever, headache and flushing.
Dinoprostone is a prostaglandin E2
analogue which may be used vaginally
or rectally. It has effect on hypothalamic
thermoregulation and can cause
temperature elevation.
Misoprostol is a synthetic prosta-
glandin E1 analogue misoprostol use
was associated with a significant
increase of maternal pyrexia and
shivering.19 A recent Cochrane review
concluded that there is insufficient
evidence to show that the addition of
misoprostol is superior to the
combination of oxytocin and
ergometrine for the treatment of
primary PPH20. A combination of these
two agents could provide a sustained
uterotonic effect.
Surgical
When medical treatment fail then
surgical treatment applied.
S- Shift to operating theatre (anti-shock
garment, especially if transfer is
required and bimanual compression).
From low resource settings transfer to a
centre with facilities is indicated.
Antishock garment can reverse the
effect of shock on the body's blood
distribution by applying external
counter pressure to the legs and
abdomen and returning blood to the
vital organs, thus stablizing women
April to June 2010 INDEPENDENT
until a hospital can be reached. A pilot
study showed that compared with
women in a control group, bleeding
decreased by 50% in women
experiencing various forms of obstetric
haemorrhage in whom the NASG was
used. 21
T- Tissue and trauma to be
excluded and to proceed to
tamponade with balloon or
uterine packing.
Previously, uterine packing was
considered that
I. It was a potentially traumatic
and time consuming proce-
dure.
ii. Might conceal on-going
hemorrhage.
iii. Might predispose to the
develop-ment of infection.
iv. Non physiological approach.
But now, Maier concluded that unterine
packing is a safe, quick and effective
procedure for controlling PPH. 22
Uterine balloon tamponade
Number of devices, including the
foley's catheter, a condom, the
sengstaken-blackmore oesophageal
catheter (SBOC), the rush urological
hydrostatic balloon and the bakri
ballon has been used. The SBOC has
been the most frequently reported
device. Overall, the reported success
23
rates vary between 70-100%, Use of
balloon tamponade in the successful
management of PPH secondary to
extensive vaginal lacerations has been
24
recently been reported.
Balloon is inserted and uterine fundus
is palpated abdominally and mark.
Then oxytocin infusion administered to
REVIEWS 189
 keep the uterus contracted and monitor
vitals every 30mins. Antibiotic cover
should be given.
After 6-8 hrs, the uterine fundus
remains at the same level and there is
no active bleeding then catheter
removed, keep the patient fasting for
2hrs after removing balloon.
Apply Compression Sutures
If the patient is stable and bimanual
compression sutures may be used. B-
25
Lynch suture techniques is used. The
ease of application of such sutures is a
β-lynch suture major advantage and fertility is
conserved. The disadvantage are the
need for laparotomy and hysterectomy.
Complications include erosion through
the uterine wall, pyometra and uterine
necrosis.
Systemic Pelvic devascularisation
Systemic Pelvic devascularisation done
where facilities available to control
bleeding.
Pelvic devascularisation requires
laparotomy and progressive, step wise
devascularisation.
26
Whereby the uterine ovarian and finally
internal iliac arteries are ligated.
Vaginal ligation of the uterine arteries
has also been described. Prerequisite
include a haemodynamically stable
patient substantial surgical expertise
and a desire to preserve fertility. The
reported success rates are between 90-
100%.
Interventional radiology with
uterine artery embolisation.
Interventional radiology with uterine
190 April to June 2010
artery embolisation done where facili-
ties available to control bleeding.
Arterial embolisation under fluoros-
copic guidance is also used. The
success rates may be as high as 70-
100% and the procedure has the
potential to preserve fertility.
Prophylatic embolisation may have a
role in a planned caesarean section
when the placenta is thought to be
morbidly adherent.27
Complications include, hematoma
formation, infection, contrast related.
Side effects and ischemia resulting in
uterus and bladder necrosis. The need
for specialized equipment and an
interventional radiologist with a high
degree of expertise are limitations of
this procedure.
Subtotal or total abdominal
hysterectomy
Subtotal or total abdominal hyste-
rectomy as usually the final option in
the management of PPH and should
not be delayed if the conservative
measures have failed. Hysterectomy is
associated with numerous post-
operative complications, including
urinary tract injury, fistula formation,
bowel injury, vascular injury, pelvic
haematoma and sepsis. The loss of
child bearing potential and the
psychological consequences should
also be considered.
All these surgical techniques (Uterine
tamponade, devascularisation,
compression sutures and hyste-
rectomy) requires the ready availability
of specific instruments and equipment.
For this purpose, an obstetric
hemorrhage equipment tray in the
INDEPENDENT REVIEWS
labour ward will facilitate prompt
surgical management of severe
obstetric hemorrhage and may reduce
the need of blood transfusion and
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Shahida Khaliq MBBS, FCPS
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Independent Medical
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INDEPENDENT REVIEWS