Postpartum Hemorrhage

• Leading cause of maternal mortality,

accounting for nearly one third of all maternal
deaths worldwide.
– 60% of all maternal deaths in developing countries
• Defined as blood loss in excess of 500 ml in
vaginal deliveries, 1000 ml in cesarean
deliveries, 1.4 L in an elective cesarean
hysterectomy, and 3.0 L in an emergency
cesarean hysterectomy.
 Primary Etiologies of PPH
• Tone – Uterine Atony
• Tissue – Retained Placenta or its secundines
• Trauma - Lower genital tract lacerations,
pelvic/perineal hematomas, and uterine
inversion
• Thrombin - pre-existing or acquired
coagulopathy (DIC)
Correlation of Blood Loss to Blood Pressure
and Clinical Signs and Symptoms
WHO Classification of PPH
 Assessment
• hemodynamic status is rapidly evaluated while
the underlying etiology of the bleeding is
investigated and ascertained.
 Breathing
• patient’s airway has to ensured and
maintained and oxygen supplementation is
administered, in order to increase the oxygen-
carrying capacity of blood.
 Circulation
• intravenous access is maximized by inserting
multiple large-bore intravenous lines with
maintenance of adequate circulating blood
volume, by infusing appropriate amounts of
crystalloids and transfusing the adequate
proportions of blood components.
UTERINE ATONY
• failure of the uterus to contract and retract
following childbirth
• leading cause of postpartum hemorrhage
(PPH)
 Risk Factors
• Overdistended uterus
– multiple gestation, macrosomia, or polyhydramnios
• Uterine muscle fatigue
– secondary to labor induction/augmentation,
Couvelaire uterus
• Uterine distortion
– Uterine tumors
• Uterine-relaxing drugs
– beta-mimetics, anesthetic drugs
 Recommendations
• Is active management of the third stage of
labor better in reducing PPH compared with
expectant management?
– Active management of the third stage of labor is
associated with reduced maternal blood loss,
postpartum anemia, need for blood transfusion
and additional oxytocics.
• Should we routinely administer oxytocin soon
after the baby’s birth to reduce the incidence
of PPH?
– Administration of oxytocin soon after the baby’s
birth is associated with reduced maternal blood
loss and decreased trend for therapeutic oxytocin.
• Does delayed cord clamping reduce the
incidence of PPH better compared with early
cord clamping?
– Delayed cord clamping does not reduce the
incidence of PPH compared with early cord
clamping.
– Delayed cord clamping is more beneficial to the
baby in terms of improvement of iron status and
increase in hemoglobin.
• Should uterine massage be routinely
performed after delivery of the placenta?
– Uterine massage is associated with reduced mean
blood loss at 30 and 60 minutes and a reduced
need for additional oxytocics.
• Should oral misoprostol (600 μg) be given to
prevent PPH instead of oxytocin?
– Oxytocin is better than oral misoprostol in
preventing PPH.
– Oral misoprostol is associated with more adverse
effects compared with oxytocin.
• Should sublingual misoprostol (600 μg) be
given to prevent PPH instead of oxytocin?
– Oxytocin is the preferred uterotonic compared
with sublingual misoprostol in preventing PPH.
• Should rectal misoprostol (600 μg) be
administered to prevent PPH instead of
oxytocin?
– Oxytocin is the preferred uterotonic compared
with rectal misoprostol in preventing PPH.
– Rectal misoprostol is associated with more
adverse effects compared with oxytocin.
• Should hemostatic agents be routinely given in
the management of uterine atony?
– Hemostatics are adjunctive forms of management
for uterine atony.
• What is/are the procedures to be performed if
active management of third stage of labor and
other standard measures to prevent uterine
atony fail to control the bleeding?
– Conservative, non-surgical measures in the
management of uterine atony may be performed
if bleeding persists after standard treatments.
• What is/are the procedures to be performed if
active management of third stage of labor,
other standard measures, and non-surgical
procedures to prevent uterine atony fail to
control the bleeding?
– Brace compression suture procedures may be
performed for uterine atony if bleeding persists
after standard and non-surgical measures.
RETAINED PLACENTA
• MC Definition - Retention of the placenta in-
utero for more than 30 minutes.
• Management is greatly influenced by the
clinical assessment of whether significant
bleeding is occurring
• In the absence of any evidence of placental
detachment, consider the diagnosis of
complete placenta accreta or a variant.
 Recommendations
• What is the role of umbilical vein injection in
the management of retained placenta?
– Umbilical vein injection may reduce the need for
manual removal of a retained placenta.
• What is the definitive management of
retained placenta?
– Manual removal of the placenta is warranted if the
other maneuvers have failed to deliver the
placenta and significant bleeding occurs. This
followed by administration of antibiotics.
UTERINE RUPTURE
• Uterine Rupture
– full-thickness separation of the uterine wall and the
overlying serosa.
• Rare and often catastrophic complication with a
high incidence of fetal and maternal morbidity.
• Uterine rupture during pregnancy is a rare
occurrence that frequently results in life-
threatening maternal and fetal compromise,
whereas uterine scar dehiscence is a more
common event that seldom results in major
maternal or fetal complications.
• The most consistent early indicator of uterine
rupture is the onset of a prolonged, persistent,
and profound fetal bradycardia.
• Other signs and symptoms of uterine rupture,
such as abdominal pain, abnormal progress in
labor, and vaginal bleeding, are less consistent
and less valuable than bradycardia in
establishing the appropriate diagnosis.
• Uterine scar dehiscence
– separation of a preexisting scar that does not
disrupt the overlying visceral peritoneum (uterine
serosa) and that does not significantly bleed from
its edges.
– the fetus, placenta, and umbilical cord must be
contained within the uterine cavity, without a
need for cesarean section (CS) because of fetal
distress.
• Uterine rupture is associated with clinically
significant uterine bleeding; fetal distress;
expulsion or protrusion of the fetus, placenta,
or both into the abdominal cavity; and the
need for prompt CS, uterine repair, or
hysterectomy.
• UR & USD must be clearly distinguished
because their options for clinical management
and outcomes analyses differ
 Recommendations
• What are the risk factors that predispose to
rupture of the unscarred uterus?
– The normal, unscarred uterus is least susceptible
to rupture. Grand multiparity, neglected labor,
malpresentation, breech extraction, uterine
instrumentation and congenital uterine anomalies
are all predisposing factors for uterine rupture. The
increased risk of uterine rupture attributable to the
use of oxytocin in gravidas with unscarred uteri is
uncertain.
• What are the risk factors that predispose to rupture
of the scarred uterus?
– For women with a single previous CS scar (whether
vertical or transverse) at the lower uterine segment, the
risk for uterine rupture during spontaneous labor is
increased compared to those with unscarred uteri.
– The risk for rupture increases with oxytocin induction or
augmentation, cervical ripening with prostaglandins,
shorter inter-delivery interval, one-layer closure of
uterine incision, lower uterine wall thickness of less than
2-3.5 millimeters, fetal macrosomia and increasing
maternal age.
– The risk for uterine rupture is highest with multiple CS
scars, previous classical CS and previous myomectomies.
• What are the signs and symptoms of uterine rupture
during pregnancy?
– The classic signs and symptoms of uterine rupture are as
follows:
• fetal distress (as evidenced most often by pattern of abnormalities in
fetal heart rate),
• diminished baseline uterine pressure,
• loss of uterine contractility or hyperstimulation,
• abnormal labor or failure to progress,
• abdominal pain,
• recession of the presenting fetal part,
• hemorrhage
• shock
– However, modern studies show that some of these signs and
symptoms are rare and that many may not be reliably
distinguished from their occurrences in other, benign obstetric
circumstances.
• What are the fetal and neonatal consequences
of uterine rupture?
– The consequences of uterine rupture to the fetus
or neonate include
• hypoxia or anoxia,
• acidosis,
• depressed APGAR scores,
• admission to the neonatal intensive care unit
• perinatal death.
• What are the maternal consequences of
uterine rupture?
– The consequences of uterine rupture to the
mother include
• bladder injury,
• severe blood loss or transfusion,
• hypovolemic shock,
• need for hysterectomy
• death
• What are the management options for uterine rupture?
– Conservative surgical management involving uterine repair
should be reserved for women who have the following
findings:
• Low transverse uterine rupture
• No extension of the tear to the broad ligament, cervix, or paracolpos
• Easily controllable uterine hemorrhage
• Hemodynamic stability
• Desire for future childbearing
• No clinical or laboratory evidence of an evolving coagulopathy
– Hysterectomy should be considered the treatment of choice
when intractable uterine bleeding occurs or when the uterine
rupture sites are multiple, longitudinal, or low lying.
– Rupture of a previous CS scar often can be managed by
revision of the edges of the prior incision followed by primary
closure.
• What are the preventive strategies for uterine
rupture?
– The most direct prevention strategy for minimizing
the risk of pregnancy-related uterine rupture is to
minimize the number of patients who are at
highest risk.