1. POSTPARTUM HAEMORRHAGE MOHD HANAFI BIN RAMLEE MBBS IIIB 1

2. PPH: DEFINITION PPH is generally defined as blood loss greater than or equal to 500 ml within 24 hours after birth, while severe PPH is blood loss greater than or equal to 1000 ml within 24 Hours. -WHO- ANTEPARTUM HAEMORRHAGE 24 hours 6 weeks PRIMARY SECONDARY Conception 22 weeks Foetal viability POSTPARTUM HAEMORRHAGE 2/15

3. PRIMARY PPH: AETIOLOGY 3/15

4. SECONDARY PPH: AETIOLOGY Retained products of conception Infection Breakdown of uterine wound Chronic sub-involution of uterus Thophoblastic disease (rare) Endometrial cancer (rare) 4/15

6. Retained product of conception

7. Prolonged labour

8. Oxytocin augmentation of labour

9. Grandmultiparity

10. Antepartumhaemorrhage

11. Uterine fibroid

12. General anesthetic drugs (halothane)

13. Precipitate delivery

14. Chorioamnionitis

15. Magnesium sulphate treatment of PIH

16. Anemia5/15

17. PPH: RETAINED PLACENTA Defined as failure of the placenta to be expelled within 30 minutes after delivery of the fetus. 2% of deliveries  continues bleeding Causes: Placenta separated but undelivered Placenta partly or wholly attached Placenta accreta 6/15

18. PPH: GENITAL TRACT TRAUMA Commonly follow an assisted delivery (forceps, ventouse) Episiotomy can sometimes extends upwards and cause bleeding. Uterine rupture at previous caesarean section previous myomectomy 7/15

19. PPH: UTERINE INVERTION Uterus pushed “inside out”, fundus at the introitus A rare complication. Commonly occur due to mismanagement of third stage of labour(controlled cord traction is applied when the uterus is not contract, or excessive fundalpressure) Uterine atony and uterine anomalies. First Degree- (Incomplete)-inverted fundus reached the external os. Second Degree- (Complete)-whole body of the uterus is inverted and protudes into the vagina Third Degree- prolapse of inverted uterus, cervix and vagina outside the vulva Consequences Severe shock - anuria and renal failure Sepsis Chronic inversion Uterus strangulate and slough off 8/15

20. MANAGEMENT: POSTPARTUM HAEMORRHAGE MOHD HANAFI BIN RAMLEE MBBS IIIB 9

21. At ANE: INITIAL ASSESSMENT AND START BASIC TREATMENT 10/15

22. ANE to OT: TEMPORIZING AND TRANSFER INTERVENTION ANE to OT: DRUGS OF CHOICE If not available or bleeding still continue from previous drugs ANE to OT: TORRENTIAL BLEEDING 11/15

23. OT: FINDING THE CAUSES 12/15

24. OT: SURGICAL TECHNIQUES FOR PPH 13/15

25. OT: B-LYNCH SUTURE 14/15

26. SUMMARY Hemorrhage is one of the four leading causes of maternal mortality. The average blood loss from an uncomplicated vaginal delivery is 500 mL, and for cesarean delivery it averages 1,000 mL. Although there is no universally accepted definition for postpartum hemorrhage, it would seem reasonable to define postpartum hemorrhage as blood loss that produces signs and symptoms of hemodynamic instability. Postpartum hemorrhage may be due to uterine atony (the most common cause), genital tract lacerations, retained products of conception, or defection coagulation. Medical management pertains primarily to the treatment of uterine atony and/or associated coagulopathy. Blood volume replacement should begin with crystalloid followed by packed red blood cells to maintain a urine output of 25 to 30 mL or more per hour and the hematocrit at or near 30% ( Uterine packing should be used primarily as a temporizing method to allow time for adequate volume replacement prior to laparotomy. Surgical techniques for the management of postpartum hemorrhage include uterine compression sutures, uterine artery ligation, internal iliac artery ligation, and hysterectomy THANK YOU!!! 15/15