Postpartum haemorrhage (PPH)

Dr. V. Sichone
 Outline
• Learning objectives
• Definition
• Blood estimation
• Causes
• Risk factors
• Prevention
• Management
 Learning objectives
1. Define postpartum hemorrhage, differentiate
between primary and secondary PPH.
2. Recall the four Ts as causes of PPH
3. Identify possible risk factors for PPH
4. Describe appropriate prevention (active
management of the third stage of labour) and
treatment of PPH.
5. Describe the implications of PPH on the health
and well-being of the mother and her new baby.
 Definition
• Primary PPH is classically defined as blood loss
from the genital tract, exceeding 500 ml within
24 hours of vaginal delivery and 1000 ml during
a caesarean section.
• PPH can be minor (500–1000 mL) or major
(1000 mL).
• Major PPH is further divided into:
moderate loss btn 1000–2000 mL and
massive loss > 2000mL (30–40% of blood volume)
 Definition
• Secondary PPH is defined as excessive blood loss from the
genital tract after 24 hours following delivery, until 6-12
weeks post-delivery
• For clinical purposes, any blood loss that has the potential
to produce hemodynamic compromise should be
considered a PPH.
• The amount of blood loss required to cause hemodynamic
compromise depends on the pre-existing condition e.g
anemia (e.g. iron deficiency, SCA, thalassemia) or volume
contracted states (e.g. dehydration, Pre-eclampsia)
 Estimating blood loss
• All health care providers have significant difficulty
estimating blood loss (Bose, 2006).
• Underestimation result in lack of recognition of
PPH, and inadequate or inappropriate
management.
• Blood and fluid replacement may be insufficient
resulting in associated complications.
• Smaller volumes < 300 ml are more likely to be
accurately estimated
 Aetiology

It is helpful to think of the causes of PPH in terms of

the four T‘s:
• Tone - uterine atony (70-80%)
• Trauma - uterine, cervical, or vaginal injury (10-
15%)
• Tissue - retained placenta or clots (3-5%)
• Thrombin - pre-existing or acquired coagulopathy
(1-2%)
 Causes of Secondary PPH
• Products of conception – retained placental
tissue and membranes
• Endometritis
• Placental site trophoblastic tumour
(gestational trophoblastic tissue)
• Arterio-venous malformations (e.g. pseudo-
aneurysm of the uterine artery)
 Risk Factors for PPH

Abnormalities of Uterine Contraction (Tone)

• Over-distended uterus e.g Polyhydramnios , Multiple gestation,
Macrosomia
• Uterine muscle exhaustion e.g. Rapid labour ,Prolonged
labour ,High parity
• Intraamniotic infection e.g. Fever, PROM
• Functional or anatomic distortion of the uterus, i.e. distended
bladder, Fibroid uterus, Placenta previa or abruptio , Uterine
anomalies
• Uterine-relaxing medications - Halogenated anesthetics,
nitroglycerin, magnesium sulphate
 Risk factors for PPH
Retained Products of Conception (Tissue)
• Abnormal placentation- retained cotyledon or
succinturiate lobe
• Previous uterine surgery
• High parity
• Atonic uterus –retained blood clots
 Risk factors for PPH
Genital Tract Trauma (Trauma)
• Tears (lacerations) of the cervix, vagina, or perineum -
Ruptured vulval varicosities, precipitous delivery ,
operative delivery , mistimed or inappropriate use of
episiotomy
• Extensions, lacerations at CS- malposition, deep
engagement
• Uterine rupture -previous uterine surgery , high parity
• Uterine inversion -high parity, fundal placenta
 Risk factors for PPH
Abnormalities of Coagulation (Thrombin)
Pre-existing states - hemophilia A , von Willebrand‘s
disease, History of liver disease
Acquired in pregnancy -
• ITP, thrombocytopenia in PE,
• DIC in preeclampsia ,dead fetus in utero, severe
infection/sepsis , placental abruption ,amniotic
fluid embolus
• Therapeutic anticoagulation
 Prevention of PPH
1. Identification and management, if possible, of the risk
factors for PPH
2. AMTSL
• Compared to expectant management, AMTSL is
associated with
– reduced maternal blood loss,
– reduced postpartum hemorrhage,
– reduced postpartum anemia,
– reduced need for blood transfusions and
– a decrease in the incidence of prolonged third stage of labour
 AMTSL
1. Following the delivery of the baby, palpate the abdomen
to R/o another baby. Give Oxytocin 10 IU IM or 5 units
IV bolus or 20-50 units in 1L NS at 60 drops/minute.
2. If oxytocin is not available
– Ergometrine 0.2 mg IM
– Syntometrine IM
– Misoprostol 400–600 µg orally
3. Controlled cord traction (CCT)
4. Uterine massage
5. Placenta examination
Management Algorithm for PPH ‘HEMOSTASIS

• H -Ask for Help and Hands on uterus (uterine

massage)
• E -Ensure ABC (Airway, Breathing & Circulation),
Ensure availability of blood and Ecbolics (drugs
that contract the uterus), Establish aetiology,
• M -Massage uterus, bi-Manual compression,
aortic compression
• O -Oxytocin infusion/prostaglandins IV/IM/per
rectal
 Management Algorithm for PPH
‘HEMOSTASIS
• S -Shift to theatre-aortic pressure or anti- shock garment
if considering transfer
• T -Tamponade balloon/uterine packing after exclusion of
tissue and trauma /Consider Tranexamic acid 1 g i.v.
• A -Apply compression sutures e.g. B-Lynch/modified
• S -Systematic pelvic
devascularization-uterine/ovarian/quadruple/internal iliac
• I -Interventional radiology, if appropriate uterine artery
embolization
• S -Subtotal/total abdominal hysterectomy
 Complications of PPH

• Significant blood loss up to 500 ml in 1 minute can

occur during PPH leading to exsanguination within 10
minutes
• PPH is associated with orthostatic hypotension, anemia,
and fatigue.
• Postpartum anemia is associated with lactation failure
placing the health of the newly born infant at risk.
• Maternal attachment (bonding) to the newborn is
essential for the long-term well-being of the infant. .
 Complications of PPH
• Extreme fatigue resulting from anemia may
make maternal care of the newborn and other
siblings more difficult
• Less commonly myocardial ischemia, DIC, and
death may occur.
• More rarely, damage to the anterior pituitary
gland (Sheehan syndrome) may result in delay
or failure of lactation as well as secondary
infertility.
 Remember
• Blood loss is consistently underestimated.
• Underestimation may result in inadequate
treatment resulting in complications or death.
• Ongoing trickling can lead to significant blood loss.
• Blood loss is generally well tolerated by healthy
women, to a point.
• Anemia and other underlying health conditions
may profoundly affect a woman‘s ability to tolerate
any amount of blood loss.