Management Of Postpartum Haemorrhage
BY DR AKPAN, UDORIMA
INTRODUCTION
DEFINITIONS
PHYSIOLOGY OF THIRD STAGE OF LABOUR
ASSESSMENT OF BLOOD LOSS AT DELIVERY
CAUSES OF PRIMARY & SECONDARY PPH
CLINICAL FEATURES
TREATMENT
COMPLICATIONS
PREVENTIVE MEASURES
REFERENCES
CONCLUSION
INTRODUCTION
Obstetric Haemorrhage ranks as the leading cause of maternal mortality accounting for approx. 25% of maternal deaths.
POSTPARTUM HAEMORRHAGE though preventable, accounts for the majority of the cases of obstetric haemorrhage 20-50%.
PPH is the most common and severe type of obstetric haemorrhage.
It is an enigma(difficult to understand) even to the present day Obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic.
Risk of Maternal Mortality & Morbidity are 50 times more after PPH
Accounts for approximately 25% of all maternal deaths.
110000 maternal deaths per year are due to PPH
Nigeria accounts for about 23% of global maternal morbidity burden
DEFINITIONS & TYPES
Defined as bleeding from the genital tract in excess of 500mls after vaginal delivery (WHO 2012) or 1000mls after Caesarean delivery, a decrease of 10% or more in haematocrit (ACOG) between admission and postpartum period or any blood loss enough to cause cardiovascular instability
>1500ml caesarean hysterectomy.
Essentially 2 types of PPH.
- PRIMARY PPH: Occurs within the first 24 hours of delivery : Most common
- SECONDARY PPH Occurs after 24 hours to the end of 6 weeks after delivery
ASSESSMENT OF BLOOD LOSS AFTER DELIVERY
Difficult
Mostly by Visual estimation (Subjective & Inaccurate)
Under-estimation very much likely
Clinical picture – Often manifest late & can be misleading
Our Mothers – Malnourished, Anaemic, Small built, Less blood volume.
MECHANISM OF HAEMOSTASIS AFTER DELIVERY
Uterine contraction & retraction 
Occlusion of the sinuses
Platelet aggregation Clots formation
- Shortest stage, but carries great risk.
- During pregnancy, myometrial fibres are stretched to accommodate fetus.
- After delivery, uterus undergoes contraction and retraction.
- Contraction is a temporary reduction in length of the fibers, which attain their full-length during relaxation. In contrast, retraction results in permanent shortening of the fibers once and for all.
- This culminates in reduction of the surface area of the uterus favoring separation of placenta and effective hemostasis after the separation of the placenta (PHYSIOLOGICAL SUTURE OR LIVING LIGATURE).
PHYSIOLOGY OF THIRD STAGE
LIVING LIGATURE
CAUSES OF PRIMARY PPH
4 Ts plus uterine inversion
- Tone: (Atonic uterus)
Most common cause, up to 80% Polyhydramnios; AF>1500-2000ml or AFI 24-35cm or SDP >/=8-16cm, Fetal macrosomia, Multiple gestation, Co-existing Uterine mass, Previous history of uterine atony, Grandmultiparity, Prolonged/Precipitate labour, oxytocin driven labour, Halogenated Anaesthetic agents,, Tocolytics use, History of APH, Full bladder etc
- Tissue: (Retained products of conception)
- Accounts for about 10%
- Simple adhesion
- Morbid adhesion – Accreta, Increta & Percreta
- Trauma: Genital tract trauma
Forms about 20% Genital lacerations/tears, Large episiotomy & extensions, Haematoma
- Thrombin: Coagulopathy, e.g. DIC Less than 1% – Consumptive coagulopathy (Abruptio placentae, Sepsis from IUFD & PPROM, Massive blood loss, Massive blood transfusion, Preeclampsia with Severe features/Eclampsia, Amniotic fluid embolism, Hepatitis
COMMON CAUSES OF SECONDARY PPH
- Retention of placenta tissue
- Endometritis
- Delayed placental bed involution
Other less common etiologies:
- Congenital coagulopathies
- Submucous fibroids,
- Adherent Placenta
- Ceaesarean scar dehiscence
- Ruptured uterine pseudoaneurysm
CLINICAL FINDING IN PPH: DEGREE OF SHOCK
MANAGEMENT
- It is a dire obstetric emergency and needs to be managed as such.
- Rapid, Aggressive, Timely, collaborative and Skilled interventions are critical for survival.
- “Golden hour”
- Call for help
- Multidiciplinary
- Obstetrician
- Anaesthetist
- Haematologist/Lab scientists
- Midwives/nurses
- **Interventional radiologists
- Other support staff
Ensure ABC of resuscitation for pts in shock.
Establish two IV access (wide bore cannula)
Obtain investigations (FBC, PCV, Electrolytes, Grouping and cross matching, Clotting profile)
IV fluids, preferably, warm crystalloids
Catheterize patient
Rub for contraction
Quickly Inspect placenta/ Genital Exploration
Uterotonic agents
- Oxytocin
- Ergometrine( NOT TO BE USED IN PTS WITH HYPERTENSION)
- Misoprostol
- Syntometrine
- Carbetocin
- Carboprost (Prostaglandin F2 alpha)
Tranexamic acid
Blood and blood products
- Fresh whole blood(Oneg)
- Fresh frozen plasma
- Cryoprecipitate
- Platelet concentrate
MANAGEMENT OF ATONY
- Ensure bladder is empty;
- Massage uterus for contraction;
- Administer oxytocin 10 IU bolus/other uterotonics and relevant medication
- Commence oxytocin infusion
- Do manual compression of the uterus if not well contracted;
- External aortic compression
EXTERNAL AORTIC COMPRESSION
TAMPONADE
Tamponade with specialized catheters
- Bakri
- Rusch
- Sengstaken blake more
- Improvised condom/foleys catheter (resource poor settings)
Commercially Available Balloon Tamponades in Use
THE CONDOM /FOLEY’S CATHETER TAMPONADE
SURGICAL APPROACH
Uterine compression sutures; B- Lynch
Ligation of vessels : Systematic Pelvic Devascularization; (Uterine artery ligation, Ovarian artery ligation, Internal iliac artery ligation)
Arterial embolization
Hysterectomy
- Early recourse to hysterectomy
MANAGEMENT OF TISSUE
- Deliver the placenta and membranes by controlled cord traction or manual removal if retained;
- If membranes are retained do manual vacuum aspiration.
- If it’s morbidly adherent placenta either: administer methotrexate or hysterectomy.
- Give broad spectrum antibiotics.
- Transfuse as appropriate
MANAGEMENT OF TRAUMA
- Episiotomy repair
- Perineal/vaginal tear repair
- Cervical laceration repair
- Uterine repair/Hysterectomy
MANAGEMENT OF THROMBIN
- Multidisciplinary
- Haematologist
- Anaesthetist/Intensivist
- Treat underlying cause
- Give appropriate blood products
NON PNEUMATIC ANTI-SHOCK GARMENT
TREATMENT OF PPH UTERINE INVERSION
Manual replacement –
– Under GA/Uterine relaxant – Tocolytics (terbutaline, nitroglycerin, MgSO4)
– Oxytocin infusion post-replacement
Placenta adherent, LEAVE IN SITU, attempt to deliver may cause MASSIVE HAEMORRHAGE and/or shock.
Prompt manually replace the inverted uterus to its normal position.
A hand inside the vagina and pushing the fundus along the long axis of the vagina toward the umbilicus (Johnson’s Maneuvers).
- Hydrostatic method
- Surgical method (delayed procedure) Huntington & Haultain procedures
MANAGEMENT OF SECONDARY PPH
FEATURES
- Bleeding PV
- Fever
- Feeling of unwell
- Uterine subinvolution
- Abdominal tenderness
- Offensive vaginal discharge
EVALUATION
- Clinical history
- Examination
- Investigation
- FBC
- HVS MCS
- Sepsis screening
- Imaging studies
TREATMENT (underlying cause)
- Resuscitation
- Uterotonics /Antifibrinolytic may be beneficial
- Antibiotic cover
- Evacuation of retained products (requires expertise due to risk of Asherman’s and perforation) – May be done under USS guidance
- Blood transfusion/Blood products/clotting factor concentrates
- Chemotherapy
- Arterial embolization
- Hysterectomy
COMPLICATIONS OF PPH
Early:
- Anemia
- Fatigue
- Hypovolemic shock
- Blood Transfusion Reaction
- Acute kidney injury
- Myocardial Ischemia
- DIC
- Death
- Hysterectomy:
Urinary/ G.I tract injury, Pelvic hematoma, abscess.
Late:
- Uterine synechae
- Sheehan’s syndrome
- Secondary Amennorhea
- Post Partum depression
- Secondary Infertility
PPH PREVENTIVE MEASURES
Regular ANC: Identification of high risk cases
Skilled Birth Attendants
Antepartum correction of anaemia
Delivery in hospital with facility for Emergency Obstetric Care.
Availability of functional Ambulances to transfer high risk cases to higher level of care facility
Local/Regional anaesthesia in place of halogenated GA, as appropriate
Active management of 3rd stage of labour
4th Stage of labour – Observation, Oxytocin infusion postpartum (as indicated)
RECOMMENDATION
- Female Education and Empowerment
- Doctors should be drilled periodically on management of PPH
- Labour ward nurses should also be trained on the importance of holistic care of immediate post partum patient
- Primary health centres should be rejuvenated by the government at several levels.
CONCLUSION
Everywoman will experience bleeding after delivery but not all have PPH.
Prevention, early recognition, prompt and appropriate intervention are key to minimize the ugly trend of PPH
REFRENCES
1.Slide on Management of Post Partum Haemorrhage by Dr Archiving consultant obstetrician )
2.Update slide on Trend on Management of post partum haemorrhage by Prof John Mulbah, Dr Kingsley Onaji
3.Ben- Charlotte video on thmangeagement of post partum haemorrhage
4.Comprehensive Obstetrics In The Tropics Textbook (second edition)
5.Basic Steps in Obstetrics & Gynaecological Procedures Textbook by O.L. Lavant et. al; 2017
6.OBGYN STEP BY STEP; A Concise guide to cases and procedures in Obstetrics And Gynaecology by O.U.j Umeora et. al.
7.https://www.who.int/news/item/09-05-2023-lifesaving-solution-dramatically-reduces-severe-bleeding-after-childbirth
Causes of PPH
