Topic : POST PARTUM HAEMORRHAGE Presenter: Dr. Mutabazi K. Sharif Date: 29th September 2011.

PRESENTATION OUTLINE
Definition Classification

Aetiology
Clinical Presentation Management

Prevention

DEFINITION
Bleeding from the female genital tract of >500mls

after vaginal delivery or >1000mls after caesarian section or any amount of blood that results in hemodynamic instability. NB. Its usually difficult to estimate the amount of blood loss so your clinical acumen suffices.

CLASSIFICATION
Primary/Immediate PPH.

This occurs with in the first 24 hours after the first 24 hours. Secondary /Delayed PPH. This occurs 24 hours after delivery up to six weeks postpartum.

The situation in Uganda

birth(UDHS 2006). Only 41% of deliveries are attended by a skilled birth attendant. Emergency obstetric care (Emoc) coverage is only at 23.9%(MoH Emoc Needs Assessment Survey 2004) Comprehensive obstetric care only at 8.1%. According to UNDP , Uganda's progress towards achieving MDG no.5 (reduce maternal mortality by three quarters by 2015)is uncertain. About 80% maternal death are due to PPH

AETIOLOGY/CAUSES(4-Ts)
Tone .

Causes of Uterine atony. Retained products(placental cotelydons,clots) Polyhydromnios Grand multiparity Multiple pregnancy Macrosomia /big baby Poor management of 3rd stage of labour.

PPH CAUSES contd

Episiotomy
Ruptured uterus Cervical tears

CAUSES contd
Tissue
Retained placental tissue

Thrombin
Disseminated intravascular

and clots

coagulopathy Congenital bleeding disorders Thrombocytopenia(low platelets)

RISK FACTORS
Antepartum
Antepartum haemorrhage IUFD Preclampsia-Eclampsia Chorioamnionitis Grand multiparity Multiple pregnancy Previous h/o PPH Coagulation defects Anaemia

Intra/Post Partum
Prolonged labour

Augmentation of labour
Poor mgt 3rd stage. Vacuum extraction

Internal podalic version

e.g. halothane

CLINICAL FEATURES
Is this PPH?

Consider risk factors Estimate the amount of blood loss(soaked gauze/cotton, blood collected in Kidney dish or Buckets). This is often misleading, use your clinical judgment. General Examination(? Pallor, Cold extremities) CVS, B/P(Syst<90,Diast <60) , PR>110BPM, Shock index(HR/Syst BP, Normal 0.5-0.7, if >0.9 urgent resuscitation required).

CLINICAL FEATURES
Depends on the cause. Atonic uterus.

The uterus is soft and not contracted. Tears . The placenta is complete and uterus is well contracted. Tissue/ Retained placenta/placental products. Placenta not delivered with in 30 min or placenta is incomplete.

CLINICAL FEATURES
Inverted Uterus

Uterine fundus not felt on abdominal palpation It may be apparent on vaginal examination. Ruptured uterus Bleeding could be vaginal or abdominal(abd distention ,shifting dullness, tenderness+/- fluid thrill). Delayed PPH. Bleeding is variable, uterine subinvolution.

CLINICAL FEATURES
P/A IS the uterus well contracted? V/E. ? Pereneal tears, Cervical tears

EUA.
CNS, is she confused? , do GCS. In case you are in doubt call a colleague.

Work up/ investigations

- Look for thrombocytopenia Coagulation studies e.g. PT, aPTT LFTs(remember HELLP syndrome) Imaging Abdominal U/scan

Management of PPH.
CALL FOR HELP, it is never managed alone, minutes lost in delays may result in death Do a primary survey(ABC)

Perform the A irway assessment evaluating it for patency. Assess B reathing adequacy and provide supplementation with 100% oxygen as needed. Assess the C irculatory status (including peripheral pulses, heart rate, blood pressure, and a perineal examination). Support circulation to vital organs by putting the patient into the Trendelenburg position, placing at least 2 largebore IVs, starting a rapid crystalloid infusions(normal saline/RL) through both IVs, and establishing continuous vital sign monitoring to guide continued management. Never give dextrose. Laboratory studies: Obtain samples for laboratory testing. Consider HB, Grouping and cross match & blood cultures if the patient is febrile or the vaginal blood/discharge is malodorous, as endometritis may be a complicating factor.

Management contd.
Secondary survey.

Perform a focused physical exam. Examine the CVS, ABDOMINEN, Perineal exam r/o tears, RS , Skin and CNS. Midwives should be able to examine the cervix for cervical tears

Management contd
Interventions.

Address the 4Ts plus 1. Start with Tone since it is the most common cause of PPH. NB. WHO recommends empirical treatment of uterine atony in early PPH. Uterine massage and expulsion of any retained products. Pass a urethral catheter. Administer uterotonics.

Management
Drug Oxytocin Ergometrine 15-methyl Prostaglandin F2a 0.25mg Dose and Route IV 20 IU/1L NS/RL 60 drops/min IV 20 IU/1LNSorRL 40 Drops/min IM (IV SLOWLY) 0.2Mg

Continuing dose

Repeat 0.2mg after 15 minutes

0.25mg every 15 minutes

Maximum dose

Not more than 3L containing oxytocin

5 doses(1mg)

8 doses(2mg)

Management contd
Oxytocin is preferred to ergometrine or prostaglandin. If

oxytocin is not available use ergometrine as second line. Ergometrine is contraindicated in pregnancy. Misoprostol may be used as third line in case the above are not available as 800mcg per rectum Trauma. Repair lacerations (perineal or cervical). Tissue . If retained placental is suspected manual removal should be done.

Management contd.
Traction(uterine inversion).

Manual replacement should be attempted Thrombosis . Review the patients CBC and clotting studies. Transfuse with fresh blood if FFP or Platellets are not available.

Management contd
Patient continues to bleed despite the above, Think

about placenta accreta,increta or percreta or ruptured uterus. Do bimanual compression/aortic compression/condom tamponade as you prepare for theatre/Referral. Packing the uterus is not recommended by WHO but can be done if expertise for condom tamponade is not available as definitive measures are being worked on. In theatre you can do uterine artery ligation or Blynch suture or Hysterectomy.

Summary of Management.
Remember HAEMOSTASIS H ask for help A assess vital parameters , blood loss and resuscitate. E establish aetiology plus Ensure availability of blood M massage the uterus O oxytocin infusion S shift to theatre and exclude Trauma(cervical tears and ruptured uterus),Tissue(adherrent placenta) T tamponade, balloon/condom or uterine packing NB the latter is not recommended by WHO but can be used when expertise for condom tamponade is not available.

Summary of Management
A apply uterine compression suture e.g. B-Lynch

S systematic pelvic devasicularisation (e.g. Uterine

artery ligation). I interventional radiology. Uterine artery embolisation. S subtotal/Total hysterectomy

Prevention of PPH

Active management of 3rd stage of labour Skilled birth attendant. Encourage ANC Anemia must always be corrected during pregnancy. Mothers with a previous h/o of PPH,multiparous women, those with multiple pregnancy should deliver at hospitals. Monitor of 4th stage and pueperium. Perform a quick intervention as soon as PPH is diagnosed. Prevent infection with use of prophylactic ABCs Ensure timely referral/consultations.