An approach to management of PPH in West Africa

1. •POST PARTUM
HAEMORRHAGE
•BY SELALI BLEWUSI

2. POST PARTUM HEMORRHAGE
Obstetric haemorrhage continues to account for an estimated 25%
of global maternal deaths(comprehensive obstetrics) despite
considerable scientific advances made at discerning its causation,
prevention and treatment.
Obstetric haemorrhage covers haemorrhages incurred antepartum,
intrapartum and post partum, however Post partum haemorrhage
accounts for about 60% of all.
PPH is the leading cause of maternal mortality in developing
countries and severe maternal morbidity in the advanced countries.

3. • PRIMARY PPH
• It is blood loss of 500ml or more in the first 24 hours after vaginal delivery, or 1L or more
after C/S or any amount likely to compromise the patient’s hemodynamic status.
• It is also defined as 10% drop in haematocrit between antenatal and postpartum periods
• SECONDARY PPH refers to a blood loss of >500ml or more that occurs after the first day of
delivery but within 6 weeks of childbirth
• The severity PPH is categorized into minor, if blood loss is 500ml or more but less than
1000ml, and major if its 1000ml or more
• Major PPH is furthur divided into moderate(greater than or equal to 1000ml but less than or
equal to 2000ml and severe if greater than or equal to 2000ml
PPH is defined as blood loss of 500ml or more occuring from
the genital tract within 6 weeks of childbirth.

4. •PHYSIOLOGY
• Following the successful expulsion of the fetus in the second stage of labour, the
uterus retracts for some minutes before engaging in a further contraction that
sheers off the placenta from its site of application to the uterine decidua and leads
to its spontaneous expulsion from the birth canal.
• This contraction causes a concomitant compression of the spiral arteries and veins
that had previously supplied the placenta bed from the maternal circulation. The
physical obliteration of these vessls is soon followed by the formation of clots within
their lumens, both of which limit maternal bleeding at childbirth and prevent
haemorrhage. Failure or delay of any of these critical physiological steps leads to
continued bleeding into the uterus and PPPH

5. • *TONE -Uterine atony(accounts for about 70%-90% cases of PPH)
• *TISSUE. -Retained placental tissue/clots
• *TRAUMA -Laceration of genital tract, ruptured uterus, inversion
of uterus
• *THROMBOPATHY. -Coagulopathy
• SECONDARY PPH- most common include infection and retained products of conception,
and sometimes endometritis
AETIOLOGY

7. SS
• 1.Uterine distention from multiple pregnancy, polyhydraminos, fetal macrosomia
• 2.uterine exhaustion in labor predisposed to by Prolonged second stage, high parity
• 3.Oxytocin augmentation/induction of labour
• 4.Mismanagement of 3rd stage of labour
• 5.Magnesium Sulphate treatment
• 6.Chorioamnionitis
• 7.Halogenated anesthetic agents
• 8.Anatomical distortion of uterus by congenital uterine anomalies, previous uterine
surgeries, fibroids or placenta previa
• 9.Exposure to drugs like Beta-adrenergic agonsists.
CAUSES OF UTERINE ATONY

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

9. POST PARTUM CAUSES
• Lacerations or episiotomy
• Retained placenta
• Uterine rupture
• Acquired coagulopathy

10. •DIAGNOSIS
• Determining the amount of blood loss is no easy task, methdods used include direct
visualization, gravimetry, photometric and miscellaneous methods
• Direct visualization is the cheapest and most used method, but least accurate, photometric
method is the most accurate but expensive and only used for research purpose
• A combinaion of direct measurements, that is collection of blood in suction machines, blood
collecting drapes and bed pans and gravimetric methods ie weighing blood soaked swabs is
most practical and advocated to use
• Again, diagnosis of PPH is very difficult in clients who delivered outside the health facility,
those with co morbidities eg: Pre-eclampsia, eclampsia and anemia
• In such difficult cases, diagnosis will depend on clinical features

11. SEVERITY OF
SHOCK
FINDNGS % OF BLOOD
LOSS
None None <15%-20%
Mild Tachycardia <100bpm
Mild hypotension
Peripheral vasoconstriction
20%-25%
Moderate Tachycardia (100-120bpm)
Hypotension (systolic 80mmhg-
100mmhg)
Restlessness
Oliguria
25%-35%
Severity Tarchycardia > 120bpm
Hypotension (systolic BP < 60mmhg)
Altered consciousness
Anuria
>35%

12. • Symptoms
• Excessive or prolonged vaginal bleeding after delivery
• Lower abdominal pains
SIGNS AND SYMPTOMS
Signs
• Active bleeding from the genital tract
• Conjunctival pallor
• Rapid pulse
• Blood pressure may be low or normal
• Deterioration of maternal levels of consciousness
• Flabby poorly contracted uterus
• Obvious tears in birth canal and/or perineum
• Obvious retained placenta
• Suprapubic tenderness

13. • INVESTIGATIONS
• History of the patient gives hints on the likely cause of the hemorrhage and the type of investigations to do
• An emergency of this sort requires blood transfussion and hence a grouping and cross matching, full blood
count, clotting time and a bedside clotting time
• Throrough investigation of the lower genital tract under direct visual light to exclude lacerations, in case of
uncertainties and in suspision of laceration of upper genital tract, examination under anesthesia in theatre is
required
• Any patient with hypovolemic shock should have continous monitoting of Pulse, BP, RR.
• A urinary catheter should also be placed for an hourly monitoring of urinary output
• In managing PPH, efforts should be made to rule out other morbidities that could have predisposed to
haemorrhage, aggravate or impede treatment
• As soon as patient has been resucitated, efforts should be made to r/o Pre-eclampsia, anemia hepatic / renal
pathology.
• Exclusion of HELLP syndrome is of special importance

14. PRE
•PREVENTION
• PPH is one of the most preventable disorders of haemorrhage in pregnancy and can be achieved
by recognizing and avoiding risk factors, institution of additional precautions when risk factors
are identified and administration of AMTSL for every paturient
• Therefore, prevention of PPH starts at ANC, where anemia if existing is detected and treated, birth
preparedness and ensuring every woman is attended to by a skilled birth attendant during child
birth
• Partograph should be used to monitor the Active phase of first stage of labour,adequate pain
relief during first stage of labour, to prevent unecessary bearing down before full cervical
dilatation
• Syntocinum or oxytocin should only be used for induction of labour, when indicated
• Episiotomy should only be done when indicated and maternal perineum should be guarded as
fetal head emerges from the introitus to prevent scars
• AMTSL is the single most effective means of preventing PPH

16. •TREATMENT
• If PPH occurs, treatment outcome depends highly on how healthy the woman is
during onset, especially her HB level, how quickly dx was made and how quickly
effective treatment was given
• Strategy for succussful management includes an initial general mangement and
resucitation, administration of oxytocin, emptying theurinary bladder, fluid
replacement, examination of the birth canal and placenta: sepecific management
uterine atony, for genital laceration, for retained placenta etc

17. M
•MANAGEMENT
Due to uterine atony (70-90% of cases), with no placental retention
Massage fundus of uterus to stimulate contraction
Encourage woman to empty bladder or pass a urethral catheter to empty the
bladder and monitor urine output
Bimanual compression of the uterus and balloon tamponade if
uterus fails to contract with massage
Due to retained placenta
Attempt removal of the placenta by controlled cord traction as soon as a
contraction is felt. If not successful await the next contraction and repeat the
procedure
If the placenta cannot be expelled in this fashion, manual removal under
anaesthesia is indicated
If the placenta has been delivered and is incomplete,exploration of the uterus and
manual removal under anaesthesia is indicated

18. Bleeding with uterus well contracted and placenta completely delivered
Examine the patient in the lithotomy position with adequate analgesia and/or
anaesthesia, good lighting to identify and suture perineal, vaginal and cervical tears
the tear(s)extends in to the uterine body,effective suturing cannot be performed
repair will involve a laparotomy
For ruptured uterus, repair or hysterectomy is required
Bleeding associated with coagulopathy
Bedside clotting test-5ml of blood placed in a 10ml round bottomed glass tube
should clot in 6 minutes

20. • If Bleeding persists after treatment with uterotonincs and other conservative
methods,surgical intervention should be used without delay.
• Options include a B-Lynch, stepwise uterine devascularization, uterine artery
embolization, internal iliac ligation, balloon tamponade, hysterectomy

21. •B-LYNCH
• Involves the use of monocryl suture or vicryl 2 to phyiscally strap the uterus and double up
the uterus
• There are a number of variants to this technique and has an effective rate of 97%
• A large Mayo needle with #2 chromic catgut is used to enter and exit the uterine cavity at A
and B. The suture is looped over the fundus and then reenters the uterine cavity posteriorly
at C, which is directly below B. The suture should be pulled very tight at this point. It then
enters the posterior wall of the uterine cavity at D, is looped back over the fundus, and
anchored by entering the anterior lateral lower uterine segment at E and crossing through
the uterine cavity to exit at F. The free ends at A and F are tied down securely to compress
the uterus. The procedure was originally described by Christopher B-Lynch

22. •Stepwise uterine devasularization
• This technique involves using succesive steps(using a chromic catgut 1), if bleeding
is not controlled by 1 step, the next step is taken, until bleeding stops.
• First step is ligation of uterine arteries, at the lateral border of uterus, junction of
upper and lower uterine segment, 2 cm inside myometrium
• Second step involves ligation of the utero ovarian anastamoses, just below the
ovarian ligament
• Third step is ligation of the internal iliac artery

23. •COMPLICATIONS OF PPH
• Anemia
• Circulatory shock
• Cardiopulmonary failure
• Acute renal failure
• Sheehan’s syndrome
• Hepatorenal syndrome
• Complications of blood transfussion
• Post partum depression
• Disseminated intravascular coagulation

24. •PROGNOSIS
• Prognosis is good if detected early, its cause identifiedd and treated early, patient
promptly and adequately ressucitated
• Failure of any of these worsens prognosis and may even lead to maternal mortality

25. • TAKE HOME
• PPH though a major cause of maternal mortality is very preventable. Prevention
starts from ANC where clients at risk should be identified, and measures put in place
to prevent PPH.
• In the unfortunate case where PPH occurs, timely resucitation (team work) and early
intervention should be taken. A good history will usually point to the cause of the
PPH

26. • REFERENCES
• Comprehensive Obstetrics (PPH by Dr E.Y. Kwawukume/ S.O.Shittu)
• GLOWM-PPH
• WHO recommendation for treatment and prevention of PPH
• Abou-Zahr C. The global burden of maternal death and disability
• Uptodate.com
• Slideshare&slide player
• Standard treatment Guidelines
• 10 teachers obstetrics

27. •THANK YOU FOR YOUR
ATTENTION