Postpartum Hemorrhage - Definition - Etiologies - Management

1. by Shanyar Qadir
Shanyar.com

2. 
2 of 26
 Blood loss of:
 > 500 mL during vaginal delivery
 > 1,000 mL following cesarean delivery
 Measurements are subjective and likely inaccurate
 Primary (early): within 24 hrs of delivery
 Secondary (late): from 24 hrs – 12 wks post-
delivery
Definition

3. 
3 of 26
 Defined clinically as excessive bleeding that makes the patient
symptomatic
 10% drop in hematocrit
 Signs/symptoms of blood loss
Objective Criteria

4. 
4 of 26
 One of the most common obstetrical emergencies
 Major cause of maternal morbidity
 One of the top 3 causes of direct maternal death in
both developing and developed countries
 Leading cause of admission to the ICU
 Incidence
 4% after vaginal delivery
 6.5% after C/S delivery
Why is it important?

5. 
5 of 26
Causes of PPH can be remembered as the 4 ‘Ts’
Tone Uterine atony
Trauma Injury to cervix, vagina, perineum
Tissue Retained placenta &/or membranes
Thrombin Clotting disorders
Etiology

6. 
6 of 26
 Call for help, ABCs
 O2 by mask initially
 2 x 14-gauge IV lines
 FBC & clotting studies
 Test for renal function & liver function tests
 Cross-match at least 6 units of blood
 IV fluid resuscitation
 Notify blood bank & consult hematologist
 Foley catheter into the bladder & fluid balance chart
 Blood transfusion asap, O- if not available
 Central venous pressure & arterial lines
 May need FFP, platelets & cryoprecipitate (consult hematologist)
 Eliminate the cause
Initial Management

7. 
7 of 26
 Most common cause of excessive PPH
 Risk Factors:
 Overworked: Rapid or prolonged labor (most common)
 Infected: Chorioamnionitis
 Relaxed: MgSO4, β-agonists, halothane
 Overdistended: Multiple pregnancies, macrosomia,
polyhydramnios
Uterine Atony (80%)

8. 
8 of 26
 Clinical Findings:
 A soft uterus (feels like dough) palpable above the
umbilicus.
 Management:
 Uterine massage
 Uterotonics (oxytocin, ergonovine, misoprostol, carboprost)
 Surgical: Uterine packing or compression balloon,
B-Lynch suture, sequential arterial ligation, selective arterial
embolization, hysterectomy
Uterine Atony (80%)

9. 9 of 26
Bimanual Uterine Massage

10. 10 of 26
Compression
Balloons

11. 11 of 26B-Lynch Suture

12. 
12 of 26
 Risk Factors:
 Difficult delivery (shoulder dystocia, macrosomia)
 Instrumental delivery (forceps, vacuum extractor)
 Clinical Findings:
 Identifiable lacerations (cervix, vagina, perineum) in
the presence of a contracted uterus.
 Management:
 Surgical repair.
Genital Lacerations (15%)

13. 13 of 26
Cervical Laceration Repair

14. 
14 of 26
 Risk Factors:
 Accessory placental lobe (most common)
 Abnormal trophoblastic uterine invasion
 Clinical Findings:
 Missing placental cotyledons in the presence of a
contracted uterus.
 Management:
 Manual removal or uterine curettage under US guidance.
Retained Placenta (5%)

15. 15 of 26
Placenta
Fetal side

16. 16 of 26
Placenta
Maternal side

17. 17 of 26
Succenturiate Placental Lobe

18. 
18 of 26
Manual removal of placenta

19. 
19 of 26
Uterine curettage

20. 
20 of 26
 Risk Factors:
 Abruptio placenta (most common)
 Severe preeclampsia
 Amniotic fluid embolism
 Prolonged retention of a dead fetus
 Clinical Findings:
 Generalized oozing
 Bleeding from IV sites or lacerations in the presence of a
contracted uterus.
 Management:
 Removal of pregnancy tissues from the uterus
 Intensive care unit (ICU) support
 Selective blood-product replacement.
DIC (Rare)

21. 
21 of 26
 Risk Factors:
 Fundal placentation
 Excessive cord traction
 Previous uterine inversion.
 Clinical Findings:
 Beefy-appearing bleeding mass in the vagina and failure to
palpate the uterus abdominally.
 Management:
 Elevating the vaginal fornices and lifting the uterus back into
its normal anatomic position
 IV oxytocin.
Inverted Uterus (rare)

22. 
22 of 26
Progressive degrees of inversion

23. 
23 of 26
Manual replacement of uterine inversion

24. 
24 of 26
Clinical Diagnosis Management
Uterus not palpable Inversion (rare) ↑ fornices, IV oxytocin
Uterus like dough Atony (80%) Uterine massage,
oxytocin, ergot, PG
F2α
Tears in vagina, cervix Laceration (15%) Suture & repair
Placenta incomplete Retained placenta (5%) Manual removal or
curettage
Diffuse oozing DIC (rare) Remove POC, ICU
care, blood products
Summary

25. 
25 of 26
Thank You!

26. 
26 of 26
1. Obstetrics by Ten Teachers, 19e - 2011
2. Williams Obstetrics, 24e - 2014
3. A Comprehensive Textbook of Postpartum
Hemorrhage, 2e - 2012
4. Step Up to Obstetrics & Gynecology – 2014
5. Obstetrics & Gynecology Lecture Notes – 2013
6. Postpartum hemorrhage on Wikipedia
(http://en.wikipedia.org/wiki/Postpartum_hemorrhage)
Sources