POSTPARTUM

HEMORRHAGE
 Postpartum Haemorrhage
(PPH)
BY:

DR.AMAL ZAKI AZZAM

Professor of Obstetrics And Gynecology

Alexandria University
 Definitions
An excessive bleeding from the genital tract occurring at
any time from the birth of the child to 12 weeks postnatal.
Any blood loss that has potential to produce or produces
hemodynamic instability
PPH traditionally over 500 mls. (WHO, 1990; 1989) but
may vary between hospitals/countries
10% decline in hematocrit and need for blood transfusion

PRIMARY
most common refers to the 1st 24 hours
commonest and most dangerous(Mousa & Alfiric, 2007)
Incidence approx. 6% of all deliveries

SECONDARY
occurs after 24 hours up to 12 weeks postnatal (Alexander et al,
2002).
Incidence 1-3% of all pregnancies
Definition
The average blood loss is:
>500ml for vaginal
delivery
>1000ml after C/S
>1400ml for Cesarean-
hystrectomy
Blood loss

Minor 500-1000ml

Moderate 1000-2000ml

Severe over 2000ml

(RCOG, 2009)
Estimating blood loss- how
scientific?
Difficult to measure
Unreliable
Underestimation
Unpredictable
Relevant research
Levy & Moore (1985)
Prasertcharoensuk et al (2000)
Buckland & Homer (2007)
Easy to miss
Physicians underestimate blood loss by
50%
Slow steady bleeding can be fatal
Most deaths from hemorrhage seen after
5h
Abdominal or pelvic bleeding can be hidden
Definitions are of limited value it is much
more important to assess the effect of
blood loss on the mother.
 Hemorrhage Classification And
Physiologic Response
H.Class ABL % Physiologic response
LOSS
1 1000cc 15 Dizziness,palpitations,minimal blood
pressure change

2 1500cc 20-25 Tachycardia,tachypnea,sweating,wea

kness,narrowed pulse
pressure,orthostatic hypotension

3 2000cc 30-35 Significant

tachycardia,restlessness,pallor,cool
extremities,hypotension

4 >2500cc 40 Shock,air hunger,oliguria or anuria

 Four Ts causes Approx.
Incidence(%)
Tone Atonic uterus 70

Trauma Lacerations , 20
hematoma, inversion,
rupture
Tissue Retained tissue, 10
invasive placenta
Thrombin coagulopathy 1

Anderson JM. Am Fam Physician 2007;75:876.

July 17,2008
 Uterine Atony
Hemostasis at placental site
At term, 600ml/min of blood flows
through intervillous space
Most important factor for control of
bleeding from placenta site is
contraction and retraction of
myometrium to compress the vessels
severed with placental separation
Incomplete separation will prevent
appropriate contraction
Tone: Think of Uterine
Atony
Uterine atony causes 70% of
hemorrhage
Assess and treat with uterine
massage
Use medication early
Consider prophylactic
medication...
Some evidence supports use of
oxytocin after delivery of
External bimanual
compression
The left hand dips down as far as
possible behind the uterus. The
right hand is pressed flat on the
abdominal wall; the uterus is
compressed and pulled upwards
into the abdomen.
Internal bimanual
compression
Right hand into vagina. Closed to
form a fist, pushed up in direction of
the anterior vaginal fornix. The left
hand dips down behind the uterus,
pulls it forwards and towards the
symphysis. The 2 hands are pressed
firmly together, thus compressing the
uterus and placental site. Continue
pressure until uterus contracts and
remains retracted
Abdominal aortic
compression
short term emergency
measure Fist is placed on the
mothers abdomen, above
the fundus and below the
level of the renal arteries
(Lumbar 1/2) (just above the
umbilicus and to the left)
Other methods to stop
bleeding
Bimanual
compression of uterus

Point of compression is just

above the umbilicus and to the
left
AORTIC
COMPRESSION
Agent Dose Rout Dose S.E C.I
e Freq
Oxytocin 10-80U in IV continuou Nausea Hyper
(Pitocin) 1000cc of IM s Emesis senstivity
crystalloi IU Water
d solution intoxication
Misoprostol 600- PR Single Nausea
(cytotec) 1000g PO dose Emesis
Diarrhea
fever
Methylergonovi 0.2mg IM Every 2- Hypertension Hypertensi
ne (1amp) IU 4h Nausea/emesi on
(Methargine) s/trap Pre-
placenta eclampsia
tetanic
contraction
PGF2 alpha 0.25mg IM Every15- Nausea Active
(Hemabate) IU 90 min(8 Emesis cardiac,pul
(Prostin) doses Diarrhea monary,ren
(Carboprost) max) Flushing al or
bronchospasm hepatic
disease
PGE2 20mg PR Every 2h Nausea hypotensio
Prostaglandin
potentiates the action of
oxytocin
Controls hemorrhage in
86% when used alone, and
95% in combination.
 RETAINED PLACENTA
RETAINED PLACENTA
Retained placenta is found in 2% of
deliveries. The frequency of retained
placenta is markedly increased at
gestation <26 weeks, and at 37 weeks it
remains three times more common than
at term.
At term, 90% of placentae will be
delivered within 15 minutes.Once the
third stage exceeds 30 minutes, there is a
ten-fold increase in the risk of
haemorrhage.
Management
When the placenta is delivered, it should
be inspected for completeness. Manual
exploration of the uterine cavity is required.

If the placenta is retained as a whole the

fingers of one hand, held as a 'spatula' to lift
the placenta.Curettage with a blunt
instrument. Antibiotics should be routinely
administered.
Invasive Placentation
Caused by missing or defective
decidua.
Placenta accreta:
Abnormal attachment of placenta to the uterine lining due to
an absence of decidua basalis and an incomplete
development of the fibrinoid layer.

Placenta increta
Attachment of placenta to the uterine myometrium(Myom.
Invasion)

Placenta percreta
Attachment of placenta through the uterine
myometrium(Penetration to or beyond serosa)
Epidemiology

There is a well-documented association

between placenta praevia and previous
Caesarean section and placenta accreta.
Removal of Abnormal
Placenta
Oxytocin 10U in 20cc of NS
placed in clamped umbilical vein.
If this fails, get OB assistance.
Check Hct, type & cross match,
2-4 u.
Two large bore IVs.
Anesthesia support.
Removal of Abnormal
Placenta
Relax uterus with halothane
general anesthetic(induce ut
atony)
With fingertips, identify cleavage
plane between placenta and
uterus.
Keep placenta intact.
Remove all of the placenta.
Removal of Abnormal
Placenta
If successful, reverse uterine
atony.
If manual removal not
successful, large blunt
curettage.
Consider prophylactic
antibiotics.
Surgical Management

1. Simple excision of the site of

trophoblast invasion with over
sewing of the area to the uterus
2. Internal iliac artery ligation
3. Hysterectomy
 HAEMATOMAS
HAEMATOMAS
Vulval and paravaginal
haematomas
1. Infralevator haematomas include those of
vulva and perineum
paravaginal haematomas.
ischiorectal fossa
2. Supralevator haematomas spread
upwards
beneath the broad ligament or downwards
to bulge into the walls of the upper vagina.
These haematomas can also track
backwards into the retroperitoneal space.
VULVAL &
VULVAL & PARAVAGINAL
PARAVAGINAL
HAEMATOMAS
HAEMATOMAS

(a) Vulval

(b) Para vaginal

haematomas
 VULVAL &
VULVAL & PARAVAGINAL
PARAVAGINAL
HAEMATOMAS
HAEMATOMAS
Incidence and associations
An acceptable definition would be
any haematoma >4cm in
diameter. The incidence of these
is approximately 1:1000
deliveries.
The injury is frequently related
to
episiotomy
 VULVAL &
VULVAL & PARAVAGINAL
PARAVAGINAL
HAEMATOMAS
HAEMATOMAS
Diagnosis
Although a vulval haematoma is usually
obvious, a paravaginal haematoma may be
missed, with no symptoms until shock
develops. In general, the symptoms depend
upon the size and rate of haematoma
formation. Some genital haematomas may
be up to 15cm in diameter.
Management
1. Resuscitative measure
- haematoma is <5cm in diameter
- not expanding
 VULVAL &
VULVAL & PARAVAGINAL
PARAVAGINAL
HAEMATOMAS
HAEMATOMAS
1. Ice packs
2. Pressure dressings
3. Appropriate analgesia
2-Need for surgical interventions
1. Haematomas >5cm in diameter
2. Rapidly expanding
Sutures with a drain or a pack can be
used.
 SUBPERITONEAL
SUBPERITONEAL
HAEMATOMAS
HAEMATOMAS
Incidence and
associations
Broad ligament haematomas are much less
common than genital haematomas: 1 in 20,000
deliveries. May follow Spontaneous vaginal
delivery, Caesarean section or forceps operations.
Patients presenting immediately tend to show
signs of lower abdominal pain and haemorrhage.
Management
A conservative approach is recommended. If It is
not possible to maintain a stable haemodynamic
state, prompt surgical exploration is recommended
and a hysterectomy may be indicated.
 INJURIES TO
INJURIES TO THE
THE CERVIX
CERVIX
After a vaginal delivery, the
majority of women will have
lacerations and/or bruising of the
cervix.
Bleeding despite a well-contracted
uterus is an indication for examining
the cervix.
Managed in theatre under
anaesthesia.
A laceration into the vault could
extend forward to the bladder or
laterally towards the uterine artery at
the base of the broad ligament.
 INJURIES TO
INJURIES TO THE
THE CERVIX
CERVIX
Repair
For repairing a cervical tear, good
visibility using right-angle retractors
is essential. Using two pairs of ring
forceps applied to the cervix at any
one time, it is possible to inspect the
whole circumference accurately.
Identification of the apex of the tear is
essential before commencing repair.
Uterine Rupture

Rare: 0.04% of deliveries.

Risk factors include:
Prior C/S.
Prior uterine surgery.
Hyperstimulation with oxytocin.
Trauma.
Parity > 4.
Uterine Rupture

Epidural.
Placental abruption.
Forceps delivery.
Breech version or extraction.
Uterine Rupture

Sometimes found incidentally

during routine exam of uterus.
Small dehiscence, less than 2cm
not bleeding,not painful can be
followed expectantly.
Uterine Rupture after
delivery
Hypotension more than expected
with apparent blood loss.
Increased abdominal girth.
 UTERINE RUPTURE
UTERINE RUPTURE
Immediate laparotomy
Repair the uterus.
Frequently the only safe way forward
is hysterectomy.
UTERINE INVERSION
UTERINE INVERSION
Uterine Inversion

Rare: ~1/2500 deliveries.

Causes include:
Fundal placentation
Excessive traction on cord.
Fundal pressure.
Uterine atony.
Invasive placentation
Uterine Inversion
Complete uterine inversion:
The internal lining of the fundus crosses
through the cervical os forming a
rounded mass in the vagina with no
palpable fundus abdominally
Incomplete uterine inversion:
no passage through the os
Uterine Inversion
Blue-gray mass protruding from vagina.
Dimpling of the uterine fundus on
abdominal examination.
Bleeding.
Hypotension out of all proportion to
visible blood loss. worsened by vaso-
vagal reaction. Consider atropine 0.5mg
IV if bradycardia is severe.
High morbidity and some mortality seen:
get help and act rapidly.
Uterine Inversion
Need to replace the uterus
before cervical contraction ring
develops.
Otherwise, will need to use
MgSO4, tocolytics, anesthesia,
and treatment of massive
hemorrhage.
When completed, treat uterine
atony.
 UTERINE INVERSION
UTERINE INVERSION
Do not remove the placenta if it
is still attached; this will
increase the bleeding.
Immediately replace the uterus
through the cervix by manual
compression.
Thrombin

Coagulopathies are rare.

Suspect if oozing from puncture
sites noted.
Work up with platelets, PT, PTT,
fibrinogen level, fibrin split
products, and possibly
antithrombin III.
PPH CARE PLAN
B Blood loss needs
L Loss estimation
E Etiology
E EBL replacement
D Drug therapy
I Intraoperative management
N Nonobstetric services
G General complication
assessment
THE GOLDEN HOUR
As more time elapses between
the point of severe shock and
the start of resuscitation, the
percentage of surviving patient
decreases
The Golden Hour is the time in
which resuscitation must begin
to achieve maximum survival
UPDATES OF NEW
TECHNOLOGIES TO TREAT
POSTPARTUM
HAEMORRHAGE
Measuring Blood Loss
A key step to EFFECTIVE TREATMENT..

Underestimation leads to delayed

intervention.

Visual estimated amounts of blood loss are

far from accurate
Old methods for estimating blood loss tend
to be complex.
(They include weighing soaked clothes
and pads, collection into pans etc., Acid
haematin techniques, Spectrophometric
techniques and measuring plasma volume
changes)
THE BRASSS-V DRAPE
A low cost calibrated plastic
blood collection drape.
BRASSS-V DRAPE:
Direct measurement of blood loss (PPH)
Advantages of Brasss-V

Simple and practical

Low cost: ( Plastic)
Accurate:
Objective
Provides a hygienic delivery
surface
Stopping the Bleeding:
Balloon Tamponade

A balloon (inflated with saline/water) exerts

pressure to stop bleeding from within the uterus in
5-15 mins.
Is very effective (85%) when uterotonics fail. Can
prevent need for laparotomy and hysterectomy.
(Reported success rates range between 70-100%.)
Easy to use
Safer alternative to uterine packing
 Commercially Available
Balloon Tamponades in Use

Sengstaken
Blakemore Rusch hydrostatic
$220 for two devices $77 (quoted 50)

Bakri BT-CATH
$250 per device $200 per device

These commercially available devices are prohibitively

expensive
The Innovative Condom
Tamponade Unit

Developed in
Bangladesh
by Ashkter and Team

The Condom /Catheters

Unit
THE CONDOM TAMPONADE
UTERUS Water/NS

Inflate Condom with

water till no further syringe
bleeding is occuring
(usually about 300-
500 mls )

Condom Giving set OR

String Foleys Catheter

Clean
Apply clamp to keep water within
water
Condom after inflation
 Maintain In-situ for 6-12 hours if
bleeding controlled and patient is
stable.
Give Broad spectrum antibiotic cover
Continue to monitor patient closely,
resuscitate and/or treat shock
necessary
 When patient is stable ( after 6 hours)
slowly deflate condom by letting out 50
mls of water/saline every hour.

Re-inflate to previous level if bleeding

reoccurs whilst deflating.

CT may be kept in place for up to 24 hours

If Bleeding is not controlled within 15

mins of initial insertion of CT abandon
procedure and seek surgical intervention
immediately.
Contraindications To Use

Arterial bleeding requiring exploration

and ligation or angiographic embolization.
Where uterine rupture is suspected
Cervical cancer.
Disseminated Intravascular Coagulation
(DIC)
Non-Pneumatic Anti-Shock
Garment (NASG)
NASG is a simple device that
counteracts shock and decreases
blood loss by applying direct
counter pressure to the lower
parts of the body.

Developed by NASA 20+ yrs ago

Useful as a first aid tool that

Keeps woman alive during
prolonged transportation to
reach help.
NASG - Non-pneumatic Anti-shock
Garment

Physiology shunts blood

to vital organs (anti-
shock)
During delays, provides up
to 48hrs stability
Neoprene and Velcro
 Advantages
It can very easily and quickly
applied. Application requires
about 2 mins
Can be used by persons with
minimal training
Within 2-5 minutes of
application most patients
with severe shock regain
consciousness and vital signs
begin to stabilize
The Non Pneumatic Garment
is less expensive
It also has less danger of
excessive pressures due to
overinflation
Cell savers
blood lost at operation is centrifuged
and washed then returned to pt as
concentrated RBC so transfused with
own blood not someone elses
What are the advantages of
cell salvage ?
Avoidance of hazards of blood
transfusion
Availability
Cost
However
does not replace platelets or
clotting factors
May become contaminated with
fetal red cells (Rh)
Amniotic fluid embolism
Pharmacy
-Recombinant activated factor VII:
IV bolus of 60-100g/kg
Short half life (2h)
-RiaSTAP(fibrinogen concentrate):
Made from human plasma
Approved by FDA
-Hemostatic agents:
Floseal and Gelfoam
Diffuse low volume bleeding
New Intra-Operative Surgical
Techniques
They either act to produce tamponade by
compressing the uterus and apposing its
anterior and posterior walls or to effectively
reduce blood flow to the uterus.

Uterine Compression sutures :e.g.

B-Lynch Brace Sutures
Cho Sutures
Square sutures
Arterial ligation/pelvic devascularization
Selective Arterial embolization (Uterine Artery)
Use of Topical Haemostatic agents
 The B-Lynch Suture

Step 1: Using Absorbale arge suture. B-Lynch Suture #2

In-out-overIn-out-overIn-out-tie

Courtesy: Lynch BC, Coker A, Laval AH et al. The B_Lynch technique for control of Masive PPH,
An Alternative to Hysterectomy. Five Cases Reported. Br. J. Obstet Gynecol 1997, 104 327-376
B-Lynch Suture

Modifications of this
procedure are also
available:
Example Suture is
fixed by taking bites
through Myometrium at
the fundus
UTERINE COMPRESSION
SUTURES
SQUARE VERTICAL
A Straight needle is passed
anterior to posterior and passed
over fundus and ligated anteriorly.

Multiple square sutures are

Passed intramurally and tied
at
Various points. Cho JH, Jun HS, Lee CN: Haemostatic Suturing Technique For uterine Bleeding during
Cesarean Section delivery. Obstet Gynecol 200 0 96:129-131
The Compression
Sutures
Advantages :
Preserves future fertility and
menstrual function
Simple and quick to perform

Disadvantages
Uterine wall ischaemia /Necrosis
Selective Artery
Embolization
Evolved from other angiograpic
embolization techniques ( Since 30
Years)
Gelatin Sponges are injected into the
bleeding vessel until stasis of flow in
target vessel is achieved. Access is
gained via femorals to internal iliac
and subsequently the uterine arteries
Selective Artery
Embolization
Advantages
Preserves Fertility
Useful in Haemorrhage associated with Placenta
praevia

Disadvantages
Requires 24hr availability of radiological expertise.
Patients must be stable
Complications include: Necrosis of uterine wall,
contrast adverse effects, local haematoma
formation
Success rates of the new Technological measures in the
management of PPH

Method Number of Success 95% CI

Cases Rates (%) (%)
B-Lynch/compression 108 91.7 84.995.5
sutures
Arterial embolization 193 90.7 85.794.0

Arterial ligation/pelvic 501 84.6 81.287.5

devascularization
Uterine balloon tamponade 162 84.0 77.588.8

There was no statistically significant difference between the four groups (P =

0.06).
UPDATED STEPS IN THE MANAGEMENT OF SEVERE PPH

PREVENTION AMTSL

UTERINE MASSAGE / MORE

OXYTOCICS
Establish Cause

TEARS COAGULOPATHY
RETAINED ATONY
PLACENTA
(70%)
BIMANUAL COMPRESSION / AORTIC COMPRESSION / ANTI-SHOCK
GARMENT
HYDROSTATIC CONDOM TAMPONADE

SURGERY
COMPRESSION SUTURING; B-LYNCH
PROCEDURE
LIGATION OF UTERINE &
OVARIAN ARTERIES
Maternal mortality due
to PPH
TOO LITTLE TOO LATE
Too Little (IV fluids, oxytocics,
BLOOD, Clotting factors)
Too Late (PG, resuscitation - blood
replacement, decision for
surgery + to get senior surgeon
& anaesthetist involved)
Giving birth should be
about giving life not
giving up a life.
a/r