PPH

ALGORITHM
 INCIDENCE OF PPH
• Incidence – 2 to 4% after vaginal delivery
6% after caesarean section
• Accounts for 35% of maternal deaths world wide

• 38% of maternal mortality in India (July,2022 )

Discuss under the following headings
Definition of PPH
Classification of PPH
Types of PPH
Risk factors for PPH
Causes of PPH
Diagnosis & Clinical effects
Management
Complications
Prevention
Recent advances
Definition

Loss of blood > 500ml from the genital tract post delivery of a baby.
(WHO)
Excessive per vaginal bleeding that cause haematocrit drop more
than 10% that require immediate transfusion.( ACOG )
Postpartum haemorrhage is
Loss of 500ml or more during vaginal delivery
More than 1000ml during caesarean section
Blood loss significant enough to cause hemodynamic instability
Primary postpartum haemorrhage
Bleeding which occurs during first 24 hours after delivery of
foetus.
Causes:
 Atonic uterus.
 Trauma "laceration or hematoma".
 Haemorrhagic blood diseases.
Secondary postpartum haemorrhage
Bleeding which occurs after the first 24 hours of delivery
and up to the end of puerperium( 6 weeks postpartum)
Causes :
 Infection - endometritis
 Retained products of conception such as : Placental
fragments, Retained piece of membranes, Accessory lobe.
 Placental polyp.
 Placental site trophoblastic disease
 AV malformation – pseudo aneurysm of the uterine artery
Categories of PPH
Minor PPH – blood loss of 500ml to 1000ml.
Major PPH – blood loss of more than 1000ml.
Major PPH is divided into
Moderate PPH – blood loss of 1000ml to 2000ml
Massive PPH – blood loss more than 2000ml ( loss of 30 t0 40% of
blood volume) with haemodynamic instability
 Causes of PPH
T FEATURES RATE(%)

TONE Atony or uterine inertia, uterine inversion, placenta praevia, 70%

uterine overdistension – polyhydramnios, multiple pregnancy,
fibroids.

TRAUMA Laceration of cervix and vagina, Rupture uterus, broad 19%

ligament haematoma.
Surgical – angle extension in C- section, episiotomy

TISSUE Retained placenta and membranes, or products of conception 10%

THROMBIN Congenital or acquired coagulopathies – placental abruption, 1%

pre eclampsia, septicaemia
 Causes of PPH

S.NO PRE EXISTING CONDITION UTERINE OVERDISTENSION,ATONY & DISORDERS OF PLACENTA, UTERINE
DIC & GENITAL TRACT TRAUMA
1 Thrombocytopenic purpura Polyhydramnios Acute uterine inversion
2 Hypertensive disease Multiple gestation LSCS
3 Uterine myoma Macrosomia Operative vaginal delivery
4 Anticoagulant therapy Induced labour Precipitate delivery
5 Coagulation factor deficiency Prolonged labour > 12hrs Previous uterine surgeries
6 Consumptive coagulopathy Chorioamnionitis Breech extraction
7 Mullerian anomalies Tocolytic agents Internal podalic version
8 Anaemia Halogenated anaesthetic agents Obstructed labour
9 Age > 40 years High parity Malpresentation
10 BMI > 35 Abruption /couvellaire uterus Subinvolution

11 Asian ethnicity Placenta previa RPOC

12 Pyrexia in labour Placenta accreta, increta, percreta Rupture uterus
Diagnosis of PPH - symptoms

• Vaginal bleeding either as a slow trickle or a

copious flow
• Enlarged uterus as it fills with blood or
blood clot - feels boggy on palpation
Diagnosis of PPH - Signs
 Shock index
• Shock index = heart rate/systolic BP
• Normal = < 0.5
SHOCK INDEX ESTIMATED BLOOD LOSS ESTIMATED BLOOD LOSS
IN ML IN %

0.6 to 0.9 500 to 750 < 20%

=1 1000 to 1500 20 to 30%
= 1.5 1500 to 2500 30 to 50%
>/=2 2500 to 3500 > / =50 to 70%
 Estimation of blood loss – Clinical findings
LOSS OF BLOOD SYSTOLIC BLOOD SYMPTOMS & SIGNS OBSTETRIC DEGREE OF SHOCK
VOLUME/ % BLOOD PRESSURE SHOCK
VOLUME INDEX

500ml to 1000ml Normal Palpitation, mild <1 compensated

10 to 15% tachycardia, dizziness

1000 to 1500ml SBP = 80 to 100 mm Hg Weakness, marked >1 Mild

15 to 30% Rise in diastolic BP leading tachycardia, sweating
to increased pulse pressure

1500ml to 2000ml SBP = 70 to 80 mm Hg Restlessness, marked >1.5 Moderate

30 to 40% tachycardia, pallor,
oliguria

>2000ml SBP = 50 to 70 mm Hg Collapse, air hunger, >2 severe

>40% anuria
 Rule of 30
30% loss of blood volume = moderate shock
SBP falls by 30 mm Hg
Heart rate rise by 30 beats per minute
Respiratory rate rises by 30 breaths per minute
Urine output falls to < 30 ml / hour
Haematocrit drops by 30%
Visual estimation of blood loss
Estimation of blood loss using V - Drape
Estimation of blood loss using Kelly pad
with measuring cup
Management Algorithm - HEMOSTASIS
H Call for Help & Hands on uterus ( uterine massage )

E Establish aetiology, Ensure ABC, Ensure availability of blood and Ecbolics that contract the uterus

M Massage the uterus

O Oxytocin infusion / prostaglandins i.m or per rectal

S Shift to theatre – aortic pressure or anti shock garment if considering transfer

T Tamponade / consider Tranexamic acid 1gm iv

A Apply compression sutures – B Lynch

S Systematic pelvic devascularisation

I Interventional Radiology – uterine artery embolisation

S Surgery – subtotal or total hysterectomy

• PPH management kit

• Code blue should be declared

• Lowering head end of bed to improve venous return and cerebral

circulation

• Avoid hypothermia by using warmed air blankets and by using

prewarmed resuscitation fluids
 oxytocin
Oxytocin reduces PPH by 60%
• Stimulates the fundal myometrium to contract rhythmically, which
constricts the spiral arteries and decreases the blood flow through the
uterus
• Onset of action
im – 3 to 7 minutes and lasts for 30 to 60 minutes
Iv – instantaneous
• Maximum concentration: 40 units to 1000 mL
• Cold chain to be maintained (2 to 8 degrees)
 Ergometrine
Dose – 0.2mg i.m /slow iv
Causes generalised tetanic
smooth muscle contraction in
both upper and lower segment
of uterus
Contraindicated in
hypertension, heart disease
 Prostaglandins
PGE1
Very effective in the
management of PPH
Recommended dose – 800mcg
per rectal
Can also be given sublingually
and orally
Side effects – nausea, vomiting,
diarrhoea
 Prostaglandins
PGF2alpha
• Dose – 0.25mg i.m every 15
minutes . Can be repeated 8
times
• Arrests bleeding in 87% of
patients
• Contraindicated in bronchial
asthma
 Tranexamic acid
Antifibrinolytic agent – inhibits breakdown
of fibrinogen and fibrin in plasma
Dose – 1gm iv
In continued, hemorrhage after 30 min, the
medication can be re-dosed until surgical or
procedural control is achieved
WOMAN trial – woman given TXA within 3
hours of birth/ haemorrhage had
significantly reduced mortality from
bleeding when compared to controls
 Blood transfusion in PPH
• Lost blood to be replaced with blood
• Exsanguinating haemorrhage results in lethal triad – acidosis, hypothermia and
coagulopathy
• FFP to packed cell transfusion ratio – 1:1
• Packed red cells are preferred than whole blood to avoid fluid overload
• Valid consent should be obtained
• If not feasible, information on blood transfusion should be provided
retrospectively.
• Documentation in the patient’s case notes.
• Volume – 350ml/bag
• Rh D negative blood can be transfused in emergency situation
Fresh frozen plasma
• A ratio of FFP : Platelets: RBC – 1:1:1 is associated with significant reduction in
mortality
• Dose - 12–15 ml/kg for every 6 units of red cells during major obstetric
haemorrhage.
• Subsequent FFP transfusion should be guided by the results of clotting test,
aiming to maintain prothrombin time (PT) and activated partial thromboplastin
time (APTT) ratios at less than 1.5 x normal.
• Thaw between 30 °C and 37 °C in a water bath under continuous agitation
• Complications
 Transfusion-related acute lung injury (TRALI)
 Non-cardiogenic pulmonary oedema developing within 4–6 hours ( TACO )
Cryoprecipitate
• Cryoprecipitate at a standard dose of two 5-unit pools
• Should be administered early in major obstetric haemorrhage.
• Subsequent cryoprecipitate transfusion should be guided by
fibrinogen results, aiming to keep levels above 1.5 g/l.
• 1 unit will increase fibrinogen by about 100 mg/dL
• Volume – 15ml/bag
The FFP and cryoprecipitate should ideally be of the same group as the
recipient
Platelet
• Transfuse when platelet count falls below 50,000/cu.mm
• The platelets should ideally be group compatible.
• RhD-negative women should receive RhD negative platelets.
• A dose of 250 IU of anti-D immunoglobulin is sufficient to cover five
adult therapeutic doses of platelets given within a 6-week period.
• Random donor platelet (RDP) include platelet rich plasma-platelet
concentrate (PRP-PC), Buffy coat- platelet concentrate (BC–PC)
• Single donor platelet (SDP- Aphaeresis-PC) collected from voluntary
thrombocyte apheresis donors with the help of an automated cell
separator
• A single donor platelet concentrate is expected to raise platelet count by
30,000- 60,000/µl
• Random donor platelets increase the platelet count by 5,000- 10,000/µl
• “Standard” platelet dose is to give one platelet concentrate / 10 kg of
body weight and this should increase the platelet count by
approximately 40,000/µl
• Platelets are stored at room temperature with constant agitation, which
is necessary for the maintenance of platelet viability
• Platelet concentrates (PCs) have until recently been stored for a
maximum of five days due to the risk of bacterial growth.
• Volume – 50ml
 Prothrombin complex concentrate
• PCCs contain vitamin K dependent clotting factors (Factors II, VII, IX,
and X) as well as Protein C and Protein S.
• When it comes to PCC, there are 3 and 4 factor coagulants.
• The three factor coagulants contain factors II, IX, X as well as Protein C
and S.
• The 4 factor PCCs contain factors II, VI, IX, and X.
• The PCCs are further characterized as activated and inactivated.
• Activated PCCs are coagulant products that contain factor VII in its
active form of Factor VIIa and these factors can be used in cases such
as Hemophilia A, acquired Hemophilia, and other forms of severe
bleeding.
• Inactivated PCCs are used in individuals with Vitamin K deficiency or
in the urgent reversal of Vitamin K antagonist
Other resuscitative measures during blood transfusion

• patients can experience hyperkalemia from RBC overload,

hypocalcemia from citrate in blood products, and hypomagnesemia
• serial electrolytes should be drawn and repleted accordingly
• In both treatment of hypocalcemia and severe hyperkalemia, 1–2 g of
calcium chloride or gluconate (10 mL of a 10% solution) should be
used
• In the setting of hyperkalemia other measures such as insulin and
glucose, and sodium bicarbonate, and renal replacement therapy will
need to be considered
 End point for transfusion

Haemoglobin - > 8gms/dl

Platelet count -> 75,000/cu.mm

Fibrinogen - > 100gms/l

Prothrombin time - < 1.5 mean control

APTT - < 1.5 mean control

 No role of vasopressors in the
management of hypovolemic shock
Bimanual uterine compression
Intrauterine tamponade
Bakri balloon tamponade
Aortic compression
NASG suite
SR cannula
Compression sutures –B - Lynch
Compression sutures – Haymanns & CHO sutures
Stepwise pelvic devascularisation
Internal iliac artery ligation
• Safe, rapid & effective method of controlling bleeding from the genital
tract.
• Rapid alternative to hysterectomy in women willing to preserve their
fertility
• Only answer in massive broad ligament haematoma, in torn vessels
retracted within the broad ligament and in postoperative
haemorrhage even after hysterectomy where no bleeding point is
detectable
• Excellent collateral circulation – no vascular compromise even after
bilateral ligation
• Pulse pressure reduces by 85%

• MAP reduces by 25 to 50%

• Reduces blood flow by 50%

• Ligation abolishes the trip hammer effect of arterial pulsation

• This promotes clot formation

• Converts arterial system into venous system promoting stable clot

formation
Uterine artery embolisation
 Complications of PPH
 Anaemia

 Dilutional coagulopathy

 Myocardial ischaemia

 Renal failure from prolonged hyptension

 Blood transfusion related complications – immediate & late

 Postpartum depression

 Sheehan syndrome - failure of lactation, amenorrhoea, atrophy of breast, loss of pubic

and axillary hair, super involution of uterus, hypothyroidism, adrenal cortical insufficiency.
 Prevention of PPH
Antenatal care – Identifying high risk patients
Doing USG / MRI for placental localisation
Prevention, diagnosis and treatment of anaemia
Promoting institutional delivery
Promotion of skilled attendance at birth
Community awareness – BCC/IEC
Birth preparedness and complication readiness - PPH management kit
 Promoting Family planning and birth spacing
Prevention of PPH
Assess risk factors for PPH on admission
Use of partograph to avoid prolonged labour
Practising restrictive episiotomy
Practising AMTSL
Routine inspection of placenta and membranes for completeness
Routine inspection of perineum, vagina and cervix for lacerations
During caesarean section allowing spontaneous separation of placenta
Routine immediate postpartum monitoring using MEOWS chart
Obstetric drills to be conducted and debriefing on pitfalls to be done
periodically
Active management of third stage of labour
Recent advances

Recombinant factor VIIa

TEG

ROTEM
Recombinant Factor VIIa
Indications
• In cases of intractable PPH with no other obvious indications for
hysterectomy
• When no blood is available
• In patients with acquired Haemophilia
• Jehovah witness – do not accept blood or blood component
transfusion
-Nigerian medical Journal
Mechanism of action
• Tissue factor (TF)/FVIIa, or TF/rFVIIa interaction, is necessary to
initiate hemostasis.
• At pharmacological concentrations, rFVIIa directly activates FX on the
surface of locally activated platelets.
• This activation will initiate the ‘thrombin burst’ independently of FVIII
and FIX. This step is independent of TF.
• The thrombin burst leads to the formation of a stable clot
Prerequisite for administration

• Hb >7gms/dl
• INR <1.5
• Platelet count is >50x109/l
• Fibrinogen >1 gm/l
• pH>7.2
• Temperature >340C.
Dose
• The recommended initial dose of rFVIIa for treatment of severe
postpartum hemorrhage is ~40–60 µg/kg administered intravenously.
• If bleeding still continuous beyond 15–30 min, following the first dose of
rFVIIa, an additional dose of ~40–60 µg/kg should be considered.
• Repeat 3–4 times at 15–30-min intervals if clinical signs of bleeding are
still present (based on visual evidence).
• If the response remains inadequate following a total dose of >200 µg/kg,
the preconditions for rFVIIa administration should be re-checked, and
corrected as necessary before another dose is considered.
• Only after these corrective measures have been applied should the next
dose of rFVIIa ~100 µg/kg be administered.
Side effects
• most common being pain at the infusion site, fever, headache,
vomiting, changes in the blood pressure and skin-related
hypersensitivity reactions.
• Thrombo- embolic events
Topical application of recombinant activated factor VII during cesarean
delivery for placenta previa
in patients with placenta previa, topical
recombinant activated factor VII may diminish bleeding from the
placenta site without initiation of systemic coagulation.
- AJOG , June , 2017
Thrombo elastography ( TEG )
provides a qualitative assessment of hemostasis in
a patient’s whole blood by testing both platelet
function and coagulation by assaying several
parameters of clot formation within whole blood.
The test is rapid and can be done at the bedside.
help guide the resuscitator in which factor
products are most needed to avoid DIC.
Helps in goal – directed transfusion approaches
rather than in fixed ratios.
Rotational Thrombo elastometry ( ROTEM )
provides the same results as
TEG
 however the mechanism at
which it arrives at those
results differs slightly
 In TEG, a pin rotates within a
cup, however in ROTEM, the
cup rotates around a
stationary pin.