POSTPARTUM HAEMORRHAGE

(PPH)HAMDU, fahad Nassor.

1. INTRODUCTION

Of all stages of labour, the 3rd stage is the most crucial for the mother. Fatal complications may appear unexpectedly in otherwise normal 1st and 2nd stages.

Postpartum haemorrhage is one among the important complications. Others include:

Retention of placenta

Shock

Obstructed labour

Infections, etc……………….

Postpartum haemorrhage is one of the commonest cause of maternal death in our hospitals. It accounts for large proportion of maternal death in Tanzania.

2. DEFINITION

PPH is a loss of 500 mls or more blood from the genital tract after delivery (WHO).

CLINICALLY it is defined as “any amount of bleeding from or into the genital tract following birth of the baby up to the end of pueperium which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure”

The average blood loss following vaginal delivery and caesarian delivery is 500mls and 1000mls respectively.

Depending upon the amount of blood loss PPH can be:Minor (<1L)

Major (>1L)

Severe (>2L)

Blood loss <500mls can also cause death in: Severely anaemic women

Women with severe pre-eclampsia and eclampsia since they have contracted blood volume.

3. TYPES

1. PRIMARY: if the haemorrhage occurs within 24 hrs. following delivery (in majority of cases it occurs 2 hrs. following delivery).

- primary PPH is further divided into:

Third stage haemorrhage: bleeding occurs before expulsion of placenta.

True postpartum haemorrhage: bleeding occurs subsequent to expulsion of placenta (majority)

2. SECONDARY: Haemorrhage occurs beyond 24 hrs. and within pueperium.

Also known as DELAYED or LATE PUPERAL HAEMORRHAGE

4. CAUSES OF PRIMARY PPH

a) ATONIC UTERUS

b) TRAUMA

c) RETAINED TISSUES

d) BLOOD COAGULOPATHY

THE 4 Ts

TONE

TISSUE

TRAUMA

THROMBIN

a) ATONIC UTERUS

This is the commonest cause of PPH (80%) Accounts for about 60% of maternal death

Commonly seen in association with:

Over-distension of the uterus: (large foetus, multiple pregnancies, polyhaydromnious)

Prolonged labour: poor retraction, infection and dehydration are important factors.

Anaesthesia: depth of anaesthesia and anaesthetic agents (ether, halothane) may cause atonicity.

Malformation of the uterus: e.g. Septate uterus may cause excessive bleeding.

Mismanaged third stage of labour: this includes:

i. Too rapid delivery of the baby preventing the uterine wall to adapt to the diminishing contents.

ii. Premature attempt to deliver the placenta before it is separated.

iii. Pulling the cord.

iv. Manual separation of the placenta (increases blood loss during caesarean delivery)

Grand multipara: inadequate retraction and frequent adherent placenta contribute to it.

Drugs: use of tocolytic drugs e.g. Mg.SO4 ,

nifedipine, etc…

Initiation or augmentation of delivery by oxytocin: post-delivery uterine atonicity is likely unless the oxytocin is continued for at least one hour following delivery.

Full bladder

b) TRAUMATICAccounts 20% of PPH

trauma to the genital tract usually occurs following operative delivery and even after spontaneous delivery.

Trauma usually involves:

Uterus (laceration/ rupture)

Cervix (lacerations)

Vagina (laceration)

Perineum (episiotomy wound and lacerations)

Para-urethral region

C) RETAINED TISSUES

Retained products of conception including bits of placenta and blood clots may cause PPH due to imperfect uterine retraction.

This is mostly associated with:

• Mismanagement of third stage of labour

• Incomplete separation of placenta

• Abnormally adherent placenta ( accreta, Increta, pancreta)

D) BLOOD COAGULOPATHY

Blood coagulation disorders are less common causes of postpartum haemorrhage. They include:

Disseminated intravascular coagulopathy (DIC)

Thrombocytopenia.

Blood coagulation disorders are associated with

Abruptio placenta

Jaundice in pregnancy

Thrombocytopenic purpura

In IUD

Etc………..

5. CAUSES OF SECONDARY PPH

1. RETAINED PRODUCTS OF CONCEPTION

2. INFECTION (esp. over lacerations)

3. ENDOMETRITIS

4. SECONDARY BLEEDING FROM CAESSARIAN SECTION WOUND

5. PUPERAL SEPSIS

6. RUPTURED UTERUS

6. SYMPTOMS AND OBJECTIVE FINDINGS

Vaginal bleeding

Light headness

Weakness

Palpitations

Change in vital signs

Oliguria

hemoglobin and hematocrit

7. DIAGNOSIS OF PRIMARY PPH

In the majority, the vaginal bleeding is visible outside (but rarely the bleeding is totally concealed as vulvo-vaginal or broad ligament haematoma).

Weak pulse, rise in pulse rate.

Raised RR

Low blood pressure

On occasion, blood loss is so rapid and death may occur within few minutes.

In traumatic haemorrhage, the uterus is found well contracted

In atonic haemorrhage, uterus becomes flabby and becomes hard on messaging

Change in vital signs

8. DIAGNOSIS OF SECONDARY PPH

The bleeding is bright red and of varying amount.

There is varying degree of anaemia

Evidence of sepsis is present

Ultrasonography is useful in detecting the bits of placenta inside the uterine cavity.

9. MANAGEMENT OF PRIMARY PPH

The principles of management are:

A. To empty the uterus of its contents and make it contract

B. To replace the blood

C. To ensure effective haemostasis

IMMEDIATE MEASURES

Call for help!!! Involve the senior staff on call

put in 2 large bore (14 gauge) IV cannulas.

Keep patient flat and worm.

Send blood for group, cross matching diagnostic tests and ask for at least 2 units of blood

Infuse rapidly 2 litres of normal saline (crystalloids) to re-expand the vascular bed.

Give oxygen by mask 10 – 15L/min

Insert Foley catheter to empty the bladder and monitor urine output.

Start 20 units of oxytocin in 1L of normal saline IV at the rate of 60 drops/min.

Transfuse blood as soon as possible.

Monitor the following: PULSE

BP

RR

URINE OUTPUT (CONTINUOUS CATHETARIZATION)

TYPE AND AMOUNT OF FLUID THE PATIENT RECEIVED

IF PLACENTA IS ALREADY DELIVERED AND UTERUS ATONIC

Rub the uterus to make it contract, hard and express the blood clot

If contraction is not coming compress the uterus intermittently bimanually. IT MAY BE NECESSARY TO CONTINUE THE COMPRESSION FOR A PROLONGED PERIOD UNTILL THE TONE OF THE UTERUS IS REGAINED

IF THE UTERUS IS STILL NOT CONTRACTING PERFORM UTERINE TAMPONADE METHODS:

TIGHT INTRAUTERINE PACKING

BALOON TEMPONADE

Injection oxytocin drip is started (10 units in 500ml of NS) at the rate of 40-60 drops/min.

If the uterus is contracted, check the cause and site of bleeding.

Explore the uterus to exclude retained products of conception and coexistent bleeding sites AND REPAIR THEM IF FOUND.

EXPLORE THE UTERINE CAVITY FOR RETAINED POC AND EVACUATE THEM IF FOUND.

rarely if bleeding is uncontrollable SURGICAL METHODS are implemented. these include:

ligation of uterine arteries: the ascending branch of the uterine artery is ligated at its lateral border btw upper and lower uterine segment. in atonic haemorrhage it is effective in abt. 75% of cases.

ligation of ovarian & uterine artery anastomoses if bleeding continues, is done just below the ovarian ligament

ligation (uni / bilateral) of anterior division of internal iliac artery: reduces distal blood flow. bilateral ligation can avoid hysterectomy in abt. 50% of cases.

angiographic arterial embolism under fluoroscopy can be done using gel foam. success rate is greater than 90% and it avoid hysterectomy

hysterectomy: if the uterus fails to contract and bleeding continues inspite of the above measures

Keep accurate records

Give Fe and Folic acid for 6 wks.

Check Hb and discharge if Hb is above 8g/dl

See her at follow up postnatal clinic at 2, 4 and 6 wks.

IF PLACENTA IS UNDELIVERED AND BLEEDING

It implies that the placenta is partially or wholly separated but retained in the uterus

Attempt delivery of placenta by controlled cord traction

If this fails maintain uterine contraction by oxytocics and conduct manual removal of placenta on the delivery bed immediately.

After manual removal give 0.5 mg ergometrine IM/IV

Massage the uterus

Give antibiotics of Ampicillin and metronidazole for 5 days

Give Fe and Folic acid for 6 wks.

Check Hb and discharge if Hb is above 8g/dl

See her at follow up postnatal clinic at 2, 4 and 6 wks.

IF PLACENTA IS UNDELIVERED AND NOT BLEEDING

Implies that the placenta is not separated at all and may be abnormally adherent

Perform the immediate measures as described above then council the patient for manual removal of the placenta and get informed consent.

Send the patient to the theatre and conduct manual removal of the placenta.

Get ready for possible hysterectomy in abnormally adherent placenta with uncontrolled bleeding after manual removal and evacuation.

Give antibiotics

Give Fe and Folic acid for 6 wks.

Check Hb and discharge if Hb is above 8g/dl

See her at follow up postnatal clinic at 2, 4 and 6 wks.

IF UTERUS IS WELL CONTRACTED, PLAENTA IS DELIVERD AND BLEEDING CONTINUES

Implies that there are genital tract injuries.

Explore for the possibility of rupture of the uterus, tears of the cervix, lacerations of vagina or perineum.

Place woman in lithotomy position and use good light.

Find bleeding point and clump it to ensure haemostasis.

Suture perineal and vaginal lacerations under local anaesthesia.

If the apex of the cervical tear is high up into the uterus and can not be reached from below or if rupture of the uterus is suspected or diagnosed, a laparotomy is indicated for repair or hysterectomy.

Check general condition.

Give Fe and Folic acid for 6 wks.

Check Hb and discharge if Hb is above 8g/dl

See her at follow up postnatal clinic at 2, 4 and 6 wks.

10. MANAGEMENT OF SECONDARY PPH

PRINCIPLES:

to access the amount of blood loss and replace it

to find out the cause and take appropriate steps to rectify it

SUPPORTIVE THERAPY:

blood transfusion, if necessary

Administer Methergin 0.2mg IM if bleeding is uterine in origin.

Administer antibiotics

CONSERVATIVE:

If bleeding is slight and no apparent cause is detected, a careful watch for a period of 24 hrs.

ACTIVE TREATMENT:

Preferable to explore the uterus urgently under general anaesthesia (as the commonest cause is retained POC)

If present the POC are removed.

Material removed are to be sent for histological examination.

Bleeding from uterine wounds can be controlled by haemostatic sutures, but may rarely require ligation of internal iliac arteries or may end in hysterectomy.

COMPLICATIONS OF PPH

EARLY COMPLICATIONS

Shock

Renal failure

Coagulation disorders

Death

LATE COMLICATIONS

Hepatitis BSyphilisHIV

11. PREVENTON OF PPH

ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR.

CORRECTING PRENATAL ANAEMIA.

ASESSING THE MOTHERS BELIEF AND ACCEPTANCE OF BLOOD TRNSFUSION.

AVOID EPISIOTOMY.

AVOID ASSISTED DELIVERY or CAESARREAN SECTION.

MANAGING AND IDENTIFYING RISK FACTORS.

MEDICINE IS NOT CONGENITAL!! IT IS ACCUIRED

SLOWLY U WILL UNDERSTAND!!

Thank you for listening