Postpartum Hemorrhage(PPH)

Definition of PPH
• be defined as a blood loss exceeding 500ml after delivery of the infant

• PPH: occurs in 24 hour of delivery
• the late PPH: occurs after 24 hour of delivery to 6 weeks




Major causes
• Uterine atony (90%)
• lacerations of the genital tract(6%)
• retained placenta(3%-4%)
• coagulation defects (blood dyscrasia)

• (4T: tone, tissue,trauma,thrombin)



1. Uterine atony
Local factors
• overdistention of the uterine (hydramnios, multiple pregnancy, macrosomia )
• condition that interfere with contraction(leiomyomas)
• complications(PIH,anaemia, placenta praevia



Systemic factors:
• nervous
• drugs(magnesium sulfate,sedative)
• abnormal labor(prolonged,precipitous)
• History of previous PPH
• Preeclampsia, abnormal placentation,




pathology
• Contraction constricting the spiral arteries
• preventing the excessive bleeding from the placenta implantation site
• the uterine atony give rise to PPH when no contraction occur



Prevention and therapeutic of uterine atony
• Administration of medicine:
• promotes contraction of the uterine corpus
• decreases the likelihood of uterine atony

• Oxytocin agents
• Methegine
• prostaglandin

• Mechanical stimulation of uterine contraction:

• Massage of uterus through the abdomen and bimanual compression

• intrauterine packing







Surgical methods
• If massage and agents are unsuccessful:
• Ligation of the uterine arteries
• ligation of the hypogastric arteries
• selective arterial embolization
• hysterectomy
taking into account the degree of hemorrhage,the overall status of patient,her future childbearing desires





2. Lacerations of the genital tract
Causes:
• Instrumented delivery (forceps)
• manipulative delivery(breech extraction,precipitous labor, macrosomia)
Types:
• perineum laceration
• vaginal laceration
• cervical laceration


perineum and vaginal laceration

• The first degree tear:
involves only skin and a minor part of the perineal body
• the second degree tear:
involves the perineal body and vagina
• the third degree tear:
involves the anal sphincter and anal canal





management
• Vaginal examination soon after delivery

repair:
• cervical laceration >2cm in length and be actively bleeding
• laceration of vaginal and perineum



3. Retained placenta
• Separation and explosion of placenta is caused by strong uterine contraction

• Placenta tissue remaining in the uterus
prevent adequate contraction and predispose to excessive bleeding


causes:
• adherence of placenta (previous cesarean delivery,prior uterine curettage)

• succenturiate placenta

• placenta accreta (into the decidua)
• placenta increta(into the myometrium)
• placenta pericreta(through the myometrium to the peritoneal)





Prevention and treatment
• The placenta should be examined to see that it is complete or not
• part of placenta is missing, removed digitally
• not separated, manual removal of placenta is done
• hysterectomy is required for placenta increta(percreta,accreta)
• uterine contraction drugs



4. Coagulation defects
Acquired abnormality in blood clotting:
• abruptio placenta,
• amniotic fluid embolism
• severe preclampsia
congenital abnormality in blood clotting:
• thrombocytopenia
• severe hepatic diseases
• leukemia




disseminated intravascular coagulopathy(DIC)
• if bleeding persists in spite of all other treatment described, DIC should be suspected
• the blood passing from the genital tract is not clotting
• shock: reduction of effective circulation
inadequate perfusion of all tissues
oxygen depletion
depression of functions


Record:
• pulse
• blood pressure
• maternal heart rate
• central venous pressure
• urine output
•


Lab tests:
• Hb,
• BT(bleeding time), CT( clotting time),
• platelets count
• fibrinogen
• prothrombin time and patial thromboplastin time
• FDP
• women’s group and cross-matching


Treatment:
• the key is correcting the coagulation defect
• resuscitation must be started as soon as possible
• infusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusion
• blood transfusion is essential
• infusion of platelets, fresh frozen plasma, FDP , clotting factors,

• Potential complications of PPH:
• Postpartum infection
• Anemia
• Transfusion hepatitis,
• Sheehan’s syndrome
• Asherman’s syndrome


• The best management of PPH is prevention