Postpartum Hemorrhage(PPH)

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Postpartum Hemorrhage(PPH)

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Major causes of death for pregnancy
women(maternal mortality)

• Postpartum hemorrhage(28)
• heart diseases
• pregnancy-induced hypertension
• (or Amniotic fluid embolism )
• infection

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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

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Major causes

• Uterine atony (90)
• lacerations of the genital tract(6)
• retained placenta(3-4)
• coagulation defects (blood dyscrasia)
• (4T tone, tissue,trauma,thrombin)

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1. Uterine atony

• Local factors
• overdistention of the uterine (hydramnios,
  multiple pregnancy, macrosomia )
• condition that interfere with contraction(leiomyom
  as)
• complications(PIH,anaemia, placenta praevia

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

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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

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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

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• Mechanical stimulation of uterine contraction
• Massage of uterus through the abdomen and
  bimanual compression
• intrauterine packing

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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

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2. Lacerations of the genital tract

• Causes
• Instrumented delivery (forceps)
• manipulative delivery(breech extraction,precipitou
  s labor, macrosomia)
• Types
• perineum laceration
• vaginal laceration
• cervical laceration

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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

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management

• Vaginal examination soon after delivery
• repair
• cervical laceration gt2cm in length and be
  actively bleeding
• laceration of vaginal and perineum

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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

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• 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)

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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

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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

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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

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

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

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• 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,

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• Potential complications of PPH
• Postpartum infection
• Anemia
• Transfusion hepatitis,
• Sheehans syndrome
• Ashermans syndrome
• The best management of PPH is prevention

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Key words

• the definitio n of HHP
• The causes of HHP
• treatment methods of Uterine atony
• the types of retained placenta
• the degrees of the perineal and vaginal
  laceration