2. Definition
Postpartum hemorrhage is
1) loss of 500mls or more during vaginal delivery;
2) more than 1000mls during caesarean section
3) blood loss significant enough to cause
hemodynamic instability
Primary PPH – first 24H of delivery
Secondary PPH from 24H to 12 weeks after delivery
3. Total blood volume at term is approximately 100 ml/kg
(an average 70 kg woman-total blood volume of 7000)
loss of more than 40% of total blood volume (approx 2800 ml)
is generally regarded as ‘life-threatening’.
aim of management is to prevent hemorrhage escalating to the
point where it is life-threatening.
6. Prevention
Active management of 3rd stage
IM syntometrine 1ml during delivery of
anterior shoulder
Controlled cord traction
Early cord clamping - controversial
For high risk patients (eg grandmultipara) -IV
pitocin 40 units @125ml/H
7. Simple measures in district
hospital
Identify all high risk patients – antenatal risk
stratification– deliver in tertiary centre
Strict adherence to partogram
Scan for placental location of patients with previous
scar!!
BE careful during second stage caesarean section
No fundal pressure!!
Know your guidelines!! Ensure flowchart is placed in
labour room
Know the Sarawak PPH box
8. drug
Medical management Dose/route Frequency comment
Oxytocin (pitocin) IV: 5-40 U in 1L NS continuous Avoid undiluted rapid IV
IM: 5IU infusion, which causes
hypotension
Syntometrine (ergometrine IM 1 ml WHO recommendation
500mcg + oxytocin 5U) unless contraindicated
(hypertension)
15-methyl IM: 0.25mg Every 15-90min, 8 doses Avoid in asthmatic patients;
PGF2a(carboprost) maximum relative CI if hepatic, renal
(hemabate) and cardiac disease.
Diarrhea, fever, tachycardia
can occur
Misoprostol (cytotec, 800-1000mcg rectally
PGE1)
9. Physiology of fluids
Blood loss (% of MAP Clinical effects
blood volume)
500 – 1000 ml (10 – Normal Postural hypotension
15%) Mild tacchycardia
1000 ml – 1500 ml (15 Slight fall Tacchycardia
– 30%) Thirst
Weakness
1500 ml – 2000 ml ( 30 50 – 70 mmhg Tacchycardia
– 40%) Pallor
Oligouria
Confusion
Restlessness
> 2000 ml (> 40%) < 50 mmhg Tacchycardia
Anuria
Air hunger
Coma
Death
10. Fluid therapy and blood product
transfusion
Crystalloid Up to 2 litres Hartmann’s
solution
Colloid up to 1–2 litres colloid until
blood arrives
Blood Crossmatched
FFP 4 units
Platelets 2 units
Cryoprecipitate 6units
11. ‘the golden first hour’
Isthe time at which resuscitation must be
commenced to ensure the best of survival
use of the ‘shock index’ (SI) is invaluable in
the monitoring and management of women
with PPH. It refers to HR divided by the SBP.
The normal value is 0.5–0.7.
With significant haemorrhage,it increases to
0.9–1.1
12. Coagulopathy(DIVC)
occurs due to the consumption of clotting
factors (disseminated intravascular
coagulation or DIC) or due to the dilutional
effects of massive blood loss on clotting
factors, platelets and fibrinogen (‘washout
phenomenon’)
13. Monitoring and investigation
Blood ix – FBC, PT/PTT/INR
V/S monitoring
To start DIVC regime based clinical judgment!!
Biochemical confirmation takes time!!
Aims:
Haemoglobin > 8 g/dl
Platelet count > 75 109/l
Prothrombin time < 1.5 mean control
Activated prothrombin time < 1.5 mean control
Fibrinogen > 1.0 g/l
14. Blood component therapy
product Volume (ml) contents Effect(per unit)
Packed red cells 240 RBC, WBC, Increase
Plasma hematocrit 3%,
Hb 1g
platelets 50 Platelets, RBC, Increase plt count
WBC, Plasma 5k-10k per unit
FFP 250 Fibrinogen,antithr Increase
ombin 3,f V and fibrinogen by
VIII 10mg/dl
cryoprecipitate 40 Fibrinogen, f VIII Increase
and XIII, Von fibrinogen by
willebrand factor 10mg/dl
15. Recombinant activated Factor VII
Natural initiator of coagulation cascade
Lead to stable formation of fibrin clots at site
of injury
Indications: life-threatening massive
postpartum hemorrhage which fails to
respond to surgical and medical mx
Refractory DIVC
Dosage: 60-120mcg/kg
17. Surgical management
technique comment
B-lynch suture
Uterine artery Bilateral; also can ligate uteroovarian vessels
ligation
Internal iliac Less successful than earlier though; difficult
artery ligation technique; generally reserved for practitioners
Repair of rupture
hysterectomy
18. Labour ward manual of SGH
RCOG Green-top guideline No.52
ACOG Clinical Guidelines
O & G and reproductive medicine 20 : 6
O & G and reproductive medicine 19 : 5