1. Antepartum &
Postpartum
Hemorrhage (APH &PPH)
Al-Momtan

2. Antepartum & Postpartum Hemorrhage
• Obstetrics is "bloody business."
• Death from hemorrhage still remains a leading
cause of maternal mortality.
• Hemorrhage was a direct cause of more than
18 percent of 3201 pregnancy-related
maternal deaths.

3. Postpartum Hemorrhage
• In spite of marked improvements in management, PPH
remains a significant contributor to maternal morbidity and
mortality both in developing and developed countries.
• One of the most challenging complications a clinician will face.
• Prevention, early recognition and prompt appropriate
intervention are the keys to minimizing its impact.

4. DEFINITION:
The loss of >500ml of blood from the genital tract in
the first 24 hrs after delivery
(or)
< 500 ml with haemodynamic changes in the mother.
(or)
>1000 ml – cesarean section within 24 hrs.
(or)
> 1400 ml – Elective cesarean hysterectomy
(or)
> 3000 ml – Emergency cesarean hysterectomy

5. - In a recent ACOG study PPH is defined as Haematocrit change of 10% or the
need for red cell transfusion.
Severe PPH - > 1500ml blood loss
or
Drop in Hb concentration 40g/l.
or
 units of blood transfusion.
4
Secondary PPH - Blood loss between 24 hrs and 6 weeks
Post-delivery.
In general, early PPH involves heavier bleeding and greater morbidity.

6. Incidence:
Subjective : 2 – 11%
Objective : 20%
Classification of primary PPH
Atonic PPH – 80%
Traumatic PPH – 15%
Retained placenta, membranes,
coagulation failure – 5%

7. Haematological Changes in Pregnancy
• 40% expansion of blood volume by 30 weeks
• 600 ml/min of blood flows through intervillous space
• Appreciable increase in concentration of Factors I (fibrinogen),
VII, VIII, IX, X
• Plasminogen appreciably increased
• Plasmin activity decreased
• Decreased colloid oncotic pressure secondary to 25%
reduction in serum albumin

8. Reduced Maternal Blood Volume
• Small stature
• Severe preeclampsia/eclampsia
• Early gestational age

9. PPH

10. PPH
• The etiologies of early PPH are most easily understood as abnormalities of
one or more of four basic processes.
• The four “T” processes.
• Previous PPH!!

11. The Four “T”
Tone
Tissue
Trauma
Thrombin

12. PPH Risk Factors
• Many factors affect a woman’s risk of PPH.
• Each of these risk factors can be understood
as predisposing her to one or more of the four
“T” processes.

13. PPH Risk Factors

14. PPH Risk Factors

15. PPH Risk Factors

16. PPH Risk Factors

17. PREVENTION OF PPH
• Although any woman can experience a PPH, the
presence of risk factors makes it more likely.
• For women with such risk factors, consideration
should be given to extra precautions such as:
– IV access
– Coagulation studies
– Crossmatching of blood
– Anaesthesia backup
– Referral to a tertiary centre

18. PREVENTION OF PPH
• UTEROTONIC DRUGS
– Routine oxytocic administration in the third stage of labour
can reduce the risk of PPH by more than 40%
– The routine prophylaxis with oxytocics results in a reduced
need to use these drugs therapeutically
– Management of the third stage of labour should therefore
include the administration of oxytocin after the delivery of
the anterior shoulder.

19. Intranatal:
• Hasty delivery of the baby is to be avoided.
• Adequate amount of blood should be cross matched and
available when haemorrhage is anticipated.
• Coagulation studies are done in cases of Abruptio
placenta and retained dead fetus.

20. Active Management of 3rd Stage of Labour:
1. Uterotonic Agents:
• 10 units of oxytocin IM or
• Syntometrine (5 units of oxytocin and 0.5mg
ergonovine maleate).
• Misoprostol, a prostaglandin E1 analogue, 600g
orally.
2. Early cord clamping
3. Controlled cord traction.

21. MANAGEMENT OF PPH
• Early recognition of PPH is a very important factor in
management.
• An established plan of action for the management of
PPH is of great value when the preventative
measures have failed.
• Lab:
- CBC / BG / Cross match of 4-6 units of blood
- KFT / Coagulation profile
- Give FFP / cryoprecipitate if coagulation test results are abnormal
- Give platelet concentrates if the platelet count is < 50 X 109/L & bleeding continues

22. MANAGEMENT OF PPH

23. MANAGEMENT OF PPH

25. DRUG THERAPY FOR PPH

27. MANAGEMENT OF PPH

28. MANAGEMENT OF PPH

32. MANAGEMENT OF PPH

33. Evaluation of response
- Monitor pulse, blood pressure, blood gas status, &
acid-base status + monitoring central venous pressure.
- Measure urine output using an indwelling catheter
- Order regular FBC counts and coagulation tests to
guide blood component therapy

34. Summary: remember 4 Ts
• “TONE” • Palpate fundus.
• Rule out Uterine Atony • Massage uterus.
• Oxytocin
• Methergine
• Hemabate

35. Summary: remember 4 Ts
• “Tissue” • Inspect placenta for
• R/O retained placenta missing cotyledons.
• Explore uterus.
• Treat abnormal
implantation.

36. Summary: remember 4 Ts
• “TRAUMA” • Obtain good exposure.
• R/O cervical or vaginal • Inspect cervix and
lacerations. vagina.
• Worry about slow
bleeders.
• Treat haematomas.

37. Summary: remember 4 Ts
• “THROMBIN” • Check labs if suspicious.

38. Thank you..