Post partum haemorrhage

POST PARTUM HAEMORRHAGE

- A Challenge To Safe Motherhood

WEL COME TO

Taj Mahal
Taj Mahal-One of the seven wonders of the world, One
of the Greatest monuments, dedicated to the memory of
“Queen Mumtaz” who died in child birth, by her
husband “Emperor Sahajahan”, is a testimony and a
grim reminder of the tragedy of maternal mortality, that
can befall any women in childbirth.
Mar 5, 2014

PPH- Prof.S.N.panda & Dr.A.Patnaik

2

Obstetric Haemorrhage
--- Ranks as the First cause of maternal mortality
accounting for 25 – 50 % of maternal deaths

POST ARTUM HAEMORRHAGE
though preventable, accounts for the
majority of the cases of obstetric
haemorrhage, the other causes being
– antepartum haemorrhage, abortion,
ectopic pregnancy and ruptured
uterus.
Mar 5, 2014


3

. . . the most common and severe type of
obstetric haemmorrhage, is an enigma
even to the present day obstetrician as it
is sudden, often unpredicted, assessed
subjectively and can be catastrophic.
The clinical picture changes so rapidly
that unless timely action is taken
maternal death occurs within a short
period.
Mar 5, 2014


4

MAGNITUDE OF THE PROBLEM
Direct Causes (%) of Mat.Mort. in selected countries*
Country

+MMR

Haemorrhage Sepsis

Toxaemia Abortion Obstructed
Labour

INDIA

874

18

14

16

14

03

Bangladesh

600

22

03

19

31

09

Ethiopia

566

6

2

6

25

4

Tanzania

678

18

15

03

17

--

Zambia

118

17

15

20

17

--

USA

15

10

08

17

06

03

*World watch paper 102Jacobson JL ed, 1991
Mar 5, 2014

+MMR – Maternal Mortality Rate / 100000 live births


5

Causes of Mat.Mort. In India
Cause

Reg.Gen. India (1992)

FOGSI (1982)

23.7%

22.3%

Toxaemia

15.2

10.7

Puerperal Sepsis

08.1

28.4

Anaemia

19.4

-

Obstructed Labour

07.1

-

Abortion

11.8

-

Others

14.7

-

Haemorrhage

Mar 5, 2014


6

CAUSES OF 110 MATERNAL DEATHS AT
OUR HOSPITAL FROM 1/1996-7/2000
120

NUMBER

100

80

11

OTHERS

4
5
7

MALARIA

12

ANAEMIA

60

17

40

23

RUPTURED UERUS
UNSAFE ABORTION
VIAL HEPATIIS
PIH

20

0

Mar 5, 2014

31

HAEMORRHAGE

CAUSES

7

PPH - A world of difference
Year

Developing
Countries

1930

1:3000 Births

Not Available

1950

1:20,000

Not Available

1980

1:60,000

1:1000

2000

Mar 5, 2014

Developed
Countries

1:100,000

1:5000


8

DEFINITION: -

Blood loss of 500ml or more per vaginum
during the first 24hrs after the delivery of
the baby.
Risk of Maternal Mortality & Morbidity
are 50 times more after PPH

Mar 5, 2014


9

ASSESSMENT OF BLOOD LOSS
AFTER DELIVERY
 Difficult
 Mostly Visual estimation (So, Subjective &
Inaccurate)
 Underestimation is likely
 Clinical picture -Misleading
 Our Mothers-Malnourished, Anaemic,
Small built, Less blood volume
Mar 5, 2014


10

MECHANISM OF HAEMOSTASIS
AFTER DELIVERY

• Uterine contraction & retraction
• Platelet aggregation → clot
formation

Mar 5, 2014


11

Why PPH ?
1. Uterine atony (80%)
2. Retained Placenta
3. Trauma to genital tract
4. Coagulation disorders
5. Uterine inversion
Mar 5, 2014


12

1. UTERINE ATONY
RISK FACTORS

 Over distension of uterus
 Induction of labour
 Prolonged / precipitate labour
 Anaesthesia (halogeneted) & analgesia
 Tocolytics (Tocolytics (also called anti-contraction medications or
labor repressants) are medications used to suppress premature labor )

 APH
 Grand multiparity
 Mismanagement of 3rd stage of Labour
 Full bladder
Mar 5, 2014


13

2. RETAINED PLACENTA
Simple adhesion
Morbid adhesion>Accreta, Increta &
Percreta

3. TRAUMATIC
 Large episiotomy & extensions
 Tears & lacerations of perineum, vagina
or cervix
 Haematoma
 Uterine rupture
Mar 5, 2014


14

Mar 5, 2014


15

4. COAGULATION DISORDERS
Abruptio placentae
Sepsis :IUD,PROM(premature
rupture of membrane)
Massive blood loss
Massive blood transfusion
Severe PET (Pre-eclamptic
Toxemia)/ Eclampsia
Amniotic fluid embolism
Hepatitis
Mar 5, 2014


16

5. UTERINE INVERSION
←Incomplete InversionFundus felt through the Cx
Complete Inversion with
placenta accreta attached to the
fundus→

Mostly iatrogenic due to
mismanagement of 3rd stage - strong
traction on the cord with a relaxed
uterus / adherent placenta.
Mar 5, 2014


17

SYMPTOMS & SIGNS
Blood loss Systolic BP Signs & Symptoms
(% B Vol)

( mm of Hg)

10-15

Normal

postural hypotension

15-30

slight fall

↑PR, thirst, weakness

30-40

60-80

pallor,oliguria,
confusion

40+

40-60

anuria, air hunger,
coma, death

Mar 5, 2014


18

PREVENTION
Regular ANC
Correction of anaemia
Identification of high risk cases
Delivery in hospital with facility for Emergency
Obstetric Care.
 Otherwise transport to the nearest such hospital at
the earliest.





 Keep speedy transport available

 Local / Regional anaesthesia
 ACTIVE MANAGEMENT OF 3RD STAGE OF
LABOUR
 4th Stage of labour - Observation, Oxytocin
Mar 5, 2014


19

ACTIVE MANAGEMENT OF 3RD
STAGE OF LABOUR (WHO-1989)
 Oxytocics - Routine use in third stage → blood loss ↓
by 30-40%
 10 Units Oxytocin IV bolus
 Syntometrine 1 Amp IV
 Ergometrine 1 Amp IV
 Carboprost ( better than Ergometrine) 0.125 – 0.25 Mg IM

 Early cord clamping
 Controlled cord traction
 Inspection of placenta & lower genital tract
Mar 5, 2014


20

MANAGEMENT OF PPH
 TEAM- Obstetrician,
Anesthesiologist, Haematologist and
Blood Bank
 Correction of hypovolaemia
 Ascertain origin of bleeding
 Ensure uterine contraction
 Surgical management
 Management of special situation
Mar 5, 2014


21

MANAGEMENT OF PPH
CORRECTION OF HYPOVOLEMIA
 Large bore IV line (two)
 Crystalloids (RL)-3ml / ml of
blood loss
 Urine output (desired) –30ml / hr
 Whole blood / pack cell

Mar 5, 2014


22

MANAGEMENT OF PPH
ENSURE UTERINE CONTRACTION
 Palpate fundus
 Uterine massage
 Bimanual compression
 Compression of Aorta against
sacral promontory
 Foleys catheters
Mar 5, 2014


23

MANAGEMENT OF PPH
OXYTOCICS
 Oxytocin:
 Bolus of 10 units IV followed by Continuous
Infusion 100 mu / min

 Ergometrine 0.2 - 0.5mg IV
 Prostaglandins Carboprost- 0.25mg start, Rpt.15-30 min,
Maximum 2.0mg, Route-IM / intramyometrial
 Sulprostone- 400-600 micro gm
Mar 5, 2014


24

MANAGEMENT OF PPH
OTHER MODES
 M.A.S.T (Military Anti Shock Treatment)
 UTERINE PACKING
 UTERINE TAMPONADE
• Large bulb Foleys
• Sangstaken blakemole tube

Mar 5, 2014


25

MANAGEMENT OF PPH
SURGICAL TREATMENT
Depends on
 Extent & cause of haemorrhage
 General condition of patient
 Future reproduction
 Experience & skill
Mar 5, 2014


26

MANAGEMENT OF PPH
SURGICAL TREATMENT







Mar 5, 2014

Repair of trauma if any
Uterine Artery ligation
Utero ovarian A. Ligation
Internal Iliac A. Ligation
Brace suturing of Uterus
Hysterectomy
Angiographic embolisation

27

MANAGEMENT OF PPH
RETAINED PLACENTA
 EUA(examination Under
Anaesthesia & Manual Removal
 If Placenta accretaObservation
Cytotoxic drugs- Methotrexate
Hysterectomy

Mar 5, 2014


28

MANAGEMENT OF PPH
ACUTE INVERSION OF UTERUS
 Manual replacementUnder GA / Uterine relaxant

 Hydrostatic method
 Surgical method ( Usually delayed
procedure)
Mar 5, 2014


29

MANAGEMENT OF PPH
MANAGEMENT OF DIC
 Fresh blood transfusion
 Blood products
Cryoprecipitate
Fresh frozen plasma
Platelet concentrate
Mar 5, 2014


30

MORBIDITY & MORTALITY from PPH
 Shock & DIC
 Renal Failure
 Puerperal sepsis
 Lactation failure
 Blood transfusion reaction
 Thromboembolism
 Sheehan’s syndrome
 >25% Maternal deaths are due to PPH
Mar 5, 2014


31

Intelligent anticipation, skilled supervision,
prompt detection and effective institution
of therapy can prevent disastrous
consequences of PPH.

Mar 5, 2014


32

Mar 5, 2014


33

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