Post Partum Hemmorrhage

Question 1

Post Partum Hemorrhage is simply Excessive bleeding after childbirth. True or false?

Answer 1

True

Blood flow to the placenta at term averages 700-800ml per minute. Considering that an adult has a blood volume of about 5.0 litres, heavy bleeding after delivery, termed postpartum haemorrhage (PPH), can theoretically ex-sanguinate a woman within 8 minutes. In the absence of resuscitation with intravenous fluids and administration of uterotonics, severe PPH can kill a healthy woman within two hours.

Question 2

Classification

Answer 2

CLASSIFICATION
PPH is usually classified as

Primary (also called Early) or

Secondary (Late),

depending on the time of onset or occurrence. It is also classified as
Mild or
Severe
depending on the amount of blood loss.

Question 3

PRIMARY POSTPARTUM HAEMORRHAGE

Answer 3

PRIMARY POSTPARTUM HAEMORRHAGE
It is blood loss of 500ml or more in the first 24hours after vaginal delivery, or 1000ml or more after Caesarean section, or any amount likely to compromise the patient’s haemodynamic status. It is also defined as a 10% drop in haematocrit between the antenatal and postpartum periods.

Question 4

Causes of Primary PPH

Answer 4

Aetiology (the 4 T’s)
 Tone -Uterine atony
 Tissue -Retained placental tissue/clots
 Trauma -Laceration of genital tract, ruptured uterus, inversion of uterus
 Thrombopathy -Coagulopathy

Atonic uterus is responsible for about 90% of Primary PPH.

Question 5

Uterine atony

Answer 5

Uterine atony

Uterine atony is the failure of the uterus to contract adequately following delivery.

Contraction of the uterine muscles during labor compresses the blood vessels and slows flow, which helps prevent hemorrhage and facilitates coagulation.

Causes of uterine Atony
• Uterine over-distention from
— multiple pregnancy,
— polyhydramnios,
— big baby etc

• Prolonged labour

• Oxytocin augmentation/ induction of
labour

• Mismanagement of 3rd stage of labour

• Magnesium sulphate treatment

• Chorioamnionitis

• Halogenated anaesthetic agents

• Uterine leiomyomata

Treatment:
— Uterine massage,
— Oxytocin,
— uterotonics,
— tamponade or packing,
— surgical intervention

Prevention:
Risk stratification and identification,
active management of third stage of labor

Symptoms:
— Uncontrolled postpartum bleeding,
— decreased heart rate,
—pain,
— soft non-contracted uterus

Complications:
—postpartum hemorrhage,
—DIC,
—hypovolemic shock,
—renal failure,
— hepatic failure, and
— death

Diagnostic method:
—Physical exam and
—observed blood loss

Frequency: 80% of postpartum bleeding

Risk factors:
—Obesity,
—uterine distention,
— placental disorders,
— multiple gestation,
— prior PPH,
— coagulopathies

Question 6

PREDISPOSING FACTORS TO PRIMARY PPH

Answer 6

PREDISPOSING FACTORS TO PRIMARY PPH
1. Antepartum Factors
• Previous PPH
• Placental abruption, especially if concealed
• Intrauterine fetal demise
• Placenta praevia
• Gestational hypertension
• Over distended uterus
• Pre-existing maternal bleeding disorder

2. Intrapartum
   • Operative delivery: caesarean section or assisted vaginal delivery
   • Prolonged labour
   • Rapid/Precipitate labour
   • Induction or augmentation of labour
   • Mismanagement of 3rd stage
   • Chorioamnionitis
   • Acquired coagulopathy
3. Postpartum causes
   • Lacerations or episiotomy ( An episiotomy is a cut, or incision, in your perineum. Your perineum is the tissue between the vagina and anus. )

• Retained placenta

• Uterine rupture

• Acute uterine inversion ( Uterine inversion is a rare but serious complication during childbirth where your uterus turns partially or entirely inside out.)

• Acquired coagulopathy ( Acquired coagulopathy(AC) is defined as impairment of the coagulation system and can be recognized as a manifestation of many underlying conditions.)

Question 7

Management of Primary PPH

Answer 7

MANAGEMENT OF PPH
• Immediate management is life-saving. Call for help to mobilize senior staff from obstetrics, midwifery, anaesthesia and haematology.
• Rub the uterus abdominally to stimulate contractions since atony is the leading cause of PPH.
• Secure IV access. A large bore canula of at least 16 gauge should be used.
• Take blood for grouping and cross-matching against 2-4 units of blood. Full blood count and platelet count, blood clotting profile are all obtained.
• Give 10-20 units oxytocin IV
• Continue with IV crystalloid products and give blood as necessary
• Empty the bladder
• If placenta is not delivered, perform Controlled Cord Traction. If unsuccessful perform manual removal of placenta
• If placenta has been delivered check for completeness of the lobes and membranes and continue to rub up contractions.
Prostaglandin F2α may be used as a second line oxytocic. It may be injected systemically or into the myometrium through the anterior abdominal wall. Misoprostol (Cytotec) may be given rectally or orally. Bimanual compression of the uterus is performed, if uterus is still atonic.
If all conservative measures fail to control bleeding the woman is prepared for examination of the genital tract including exploration of the uterine cavity under anaesthesia. Any lacerations are sutured. If there are no lacerations an emergency laparotomy is performed. At laparotomy the uterus is examined for rupture and repaired if possible or a subtotal or total hysterectomy is performed if the rupture is extensive. If there is no uterine rupture but the uterus still contracts and relaxes, a hypogastric artery ligation or a B-Lynch bracing procedure is performed.

NEW DEVELOPMENTS
• Packing the uterine cavity
• Use of balloon / condom tamponade

• Embolisation of the pelvic vasculature with absorbable gelatin sponge or polyvinyl particles by interventional radiologist has also been reported
• Non-pneumatic Anti-Shock Garment (NASG)

Answer 8

PREVENTION OF PPH
Standard protocols should be followed to prevent 1o PPH. Mismanagement of the first and second stages of labour can cause PPH but more often, mismanagement of the third stage. PPH can be prevented if there is
• Proper management antenatally. i.e identification of high-risk patients.
• Proper management of second and third stages of labour.
• Effective use of AMTSL (Active Management of Third Stage of Labour).
AMTSL includes
1. Administration of an uterotonic drug. (Oxytocin is the drug of choice: 10 units
given IM within one minute of delivery of the baby)
2. Controlled cord traction to deliver the placenta
3. Uterine massage (per abdomen) after delivery of placenta
4. Palpation/Uterine Massage every 15 minutes for 2 hours
The traditional (physiological or passive) method where one had to wait for signs of placental separation before delivering it has been found to last longer (as much as 20 minutes or more). It is also associated with a higher risk of PPH and should not be practiced.
Signs of placental separation
• The cord becomes longer
• The fundus rises in the abdomen
• The uterus becomes more globular
• There is a gush of blood at the vulva

Question 9

SECONDARY POST PARTUM HEMORRHAGE

Answer 9

SECONDARY PPH
This occurs when there is excessive bleeding from the genital tract after the first 24 hours and up to 6 weeks post-delivery.

Question 10

Causes of secondary PPH

Answer 10

Causes of Secondary PPH
• Retained products of conception
• Infection
• Tumors in uterus, eg submucous fibroids, polyps
• dehiscence of caesarean section uterine wound
• rupture of vulval haematoma
• trophoblastic disease

Question 11

Treatment

Answer 11

Treatment
1. Admit patient
2. Set up IV line and administer fluids
3. Give broad-spectrum antibiotics, if needed
4. Perform pelvic ultrasound; if retained products are detected perform EOU ( evacuation of the uterus)
5. Treat any other cause of the PPH