POST PARTUM HEMORRHAGE

By Dr. Rajabu Nyangara Mtilly

MD (UDSM), MMED-OBGY (IMTU)
18th Dec.2014

Introduction
Outlines
Definitions
Epidemiology
Classification
Etiological risk factors
Pathophysiology
Clinical presentation
Management
Complications
Preventions
Challenges
References

Definitions
Postpartum hemorrhage (PPH) as an OBSTETRIC
EMERGENCY is loss of blood
> 500mls following vaginal delivery
>1000mls following caesarean birth.
Another way 10% drop in hematocrit is PPH
Normally blood loss following vaginal delivery
ranges btn 300-500mls
NB, Clinical estimation of amount of blood loss
following delivery is greatly inacurate.

Defincont..
Hemorrhage following delivery is from
excessive bleeding from placental
implantation site, trauma to genital tract and
adjacent structures or both.
So PPH is a description of an event rather than
a diagnosis, therefore when encountered a
cause must be determined.

Epidemiology
As a major cause of maternal deaths in high
and low income countries respectively
accounts 1:100,000 and 1:1000
A systematic review reported highest rates of
PPH in Africa (27.5%) while Europe and North
America pointing to 13%.
In Tanzania it accounts 18% of maternal death

Classification
1. Primary PPH-when PPH occurs in the first 24
hours post delivery.
2. Secondary PPH occurs after 24hours post
delivery.

Etiology and risk factors

Etiology can be simplified as four Ts and
others
A. Tone-uterine atony accounts 80% of PPH
B. Trauma-trauma to uterus, cervix, vaginal and
perineum
C. Tissue-Retained POC or clots
D. Thrombin-coagulation disorders
E. Others-eg complications of placenta previa

Etiolog.cont..
A. Uterine atony as a major cause results from
the following risks;
Overdistended uterus due to large
fetus,multiple gestation, hydramnios etc
High parity
Hypotonic myometrium
Some general anaethetics eg halogenated
hydrocarbons

Etiolog.cont..
Poorly perfused myometrium
Following prolonged labour
Following excessive oxytocin-augmented
labour
Misuse of tocolytics
Chorioamnionitis

Etiolog.cont..
B. Tissue
Can be due to avulsed cotyledon, retained
placenta
Clots may accumulate in endometium

Etiolog.cont..
C. Trauma
Ruptured uterus
Lacerations of cervix
Large episiotomies including extensions
Laceration of perineum, vaginal etc
Iatrogenic procedures leading to trauma

Etiolog.cont..
D. Coagulation
This intensifies all above and can be
congenital defects eg. von willbrand dse or
acquired defects eg.
Pathologies that ends up with DIC eg Abruptio
placenta and other consumptive coagulopathy
disorders.
Dilusional coagulopathy disorders
Iatrogenic blood thinning agents

Etiolog.cont..
E.Others
abnormally adherent placenta-accreta,
increta and percreta
Placenta previa complications
Uterine myoma esp. submucous and prev
surgeries
Uterine inversion, placenta abruption

Pathophysiology anatomy

Pathophysiolcont..
Myometrium has a peculiar character of
contraction and retraction.
This means when contractions end, their
relaxation will never allow myofibrils to regain
their prior length.
So progressively myofibrils shortens as
contractions continues repetitively.
This retraction behavior enhances their
tourniquet effect to spiral arteries and hence aids
achieving hemostasis post partum.
The same mechanism supports labor progress.

Pathophysiolcont..
When above characters lack the uterine atony
is encountered and hence hemorrhage per
placental implantation site.
Lack of immediate speculation of cause of
continuing bleeding post delivery and
appropriate interventions may end up with
PPH.

Clinical presentations
A post delivery or C/S woman presenting with
profuse bleeding
Hypovolemic shock signs and symptoms
Diziness, blurring of vision, fainting and
lethargy
Pallor, cold with or without sweaty
extremities, tachycardia, thready weak pulses,
hypotension and dyspnea, sometimes with
dry cough.

Clinical presentcont..
Presence of shock in the absence of visible
blood loss should rise concern on;
uterine rupture, broad ligament hematoma,
amniotic fluid embolism, anaphylactic shock
or thromboembolism and other diferrentials.

Mangement
In any Emergency SHOUT call for HELP
NB. Consider ABCs, Use few secs to identify the
cause of bleeding and resurcitate the pt.
As DELAY MEANS DEATH, DONT LEAVE PT ALONE
Quickly Remind; Has the uterus well contracted?
Has placenta been delivered completely?
Is bleeding due to trauma?
Are there known risks of PPH?

Mn..cont

Imediately after call for help.

Ensure airway is patent, patient is breathing and control
any active bleeding if possible.
Insert bilateral wide bore (14G) cannular and runing iv
crystalloids as fast as possible guided with pt vitals.
Crystalloid(normal saline or ringer lactate) are usually given
in ratio of 3:1 ie 3mls in every 1mls of blood loss.
Draw blood sample for grouping and xmatching, Hb,
hematocrit,bed side clotting time, trace 4units of blood.
Also check RBG, BP and oxygen saturation consider ICU
care for close vital monitoring .
Blood transfusion should be considered in any woman with
postpartum hemorrhage in whom abdominal uterine
massage and oxytocic agents fail to control the bleeding.
In extreme emergency blood group 0-ve may be used

Mn..cont

Transfuse as soon as possible.

Insert urethra cather for output monitoring.
Do other investigations, RFT, FBP etc
Consider referral immediately if facility doesnt fit requirements
of management.

1.CONSERVATIVE MANAGEMENT
A.Uterine atony
Before considering it as diagnosis try to rule out genital
tract trauma ie inspect vagina and cervix for
lacerations.
Explore uterine cavity if is empty massage uterus per
abdomen and,
Give oxytocin at least 20IU in IV infusion of crystalloids
dont prefer bolus administration.
Prostaglandings up to 1000mcg rectally and 600mcg
orally can also be used.

Mn..cont

During administration of uterotonic agents

bimanual compression may control
hemorrhage.

Mn..cont

This technique is usually appllied when

bleeding is unresponsive to oxytocics.
Another way is baloon tamponade.(Bakri
baloon)

Mn..cont
This is not effective if uterus has retained
products
Baloon is inflated with 250-500mls of warm
saline, till uterus is firm and minimal blood loss.
Continue oxy. Infusion and commence broad
spectrum antibiotics.
When successful remove baloon after 12-24hrs,
gradually deflate baloon by 100mls per hour.

Mn..cont
Fundal compression suture by B-lynch suture

Mn..cont
B.genital tract lacerations
It usually from spontaneous or precipitatous
delivery, size, presentation and contracted pelves.
It suspected by bright red bleeding where there is
steady trickle of blood and uterus remains firm.
Treated by suturing any bleeders, vaginal pack
and assess bleeding after removal
If too serious consider blood replacement.

Mn..cont
C. Retained tissue
Occurs when there is incomplete separation of
the placenta.
Presents with bogy relaxed uterus and dark-red
bleeding
Treted D &C, oxytocics and prophylactic
antibiotics
Hematoma-presents with deep severe unrelived
evacuate clots.

Mn..cont
D. Coagulation disorders
If bleeding is difficult to control consider
coagulopathy-consumptive or dilusional.
Usually blood transfusion is whole fresh blood
Not available consider bloody products
Fresh frozen plasma, correcting DIC
cryoprecipitate(when fibrinogen<200mg/dl)
platelet concentrates(when less than
50,000/microlitre)

Mn..cont
E. Uterine rupture
Can be complete, incomplete or dehiscence
Risks increases with prev C/S also when there is
previous myomectomy or mult-para in obstructed
labour.
Surgery should not be delayed owing to
hypovolemic shock because it may not be easily
reversible until the hemorrhage is controlled.
At this point, a decision must be made to perform
hysterectomy or to repair the rupture site. In most
cases, hysterectomy should be performed.

Mn..cont
F. retained placenta
When controlled cord traction fails, manual
removal of placenta necessitates

Mn..cont
In some other situation manual removal fails,
and if forced bleeding becomes extreme that
leads to non-conservative mnx, where
hysterectomy is done. For example placenta
percreta,increta etc
uterine artery embolization or ligature of
internal iliac arteries may be applied to control
intractable PPH.
NB. If surgery is of beneficial mnx, decision
should not be delayed.

Mn..cont
Hysterectomy. Final option, it is warranted
earlier if hemodynamic condition of the
patient is unstable and other management
options have failed.
Two types
Subtotal ( may no be effective for lower segment
bleeding)
Total hysterectomy

Complications
Shock which leads to end organ injuries like
Acute kidney injury if pt not resuscitated well
and immediately.
Multiple organ failure from
hemorrhagic/hypovolemic shock ends into
Death

Preventions
The use of AMTSL
Prenatal screening of risk pts eg those with APH, multiple
gestations, multipara etc
Advice them to deliver at capacitated hospital
Correction of anemia early in pregnancy by advising diet
and hematenics plus deworming
Encourage hospital delivery and emphasis on education to
both clients and health workers targeting recognition of
signs and sy with early referral.
Correcting delay model. Home-infrastructure-hospitalhealthprovider.
Educating community about PPH

Challenges
Lack of facilities and human resource
immediately available for serving life.
Disproportion of client to physician ratio
Poor unavailable diagnostic and treatment
material

References
William obstetrics 22ed 2005-obstetric
hemorrhage
Gynecology by ten teachers-postpartum
hemorrhage
Handout notes on PPH by Dr. Rajab, OBGY
specialist
Internet handouts on PPH
Postpartum hemorrhage - Wikipedia, the free
encyclopedia.htm/2014