1. UNDERSTANDING
POSTPARTUM
HAEMORRHAGE
Dr AHMAD MUZAMIR A.MUSTAFA
O&G Department
HOSPITAL ALOR SETAR
05/03/2004

2. A journey of a
thousand miles
begins with
the first step

3. PROBLEM GIVING LECTURE AT THIS HOUR…

4. Introduction
 Leading cause of maternal death –
Malaysia and developing countries
 30-40% of maternal deaths every year
 Mostly in grandmultiparas, minority groups
and immigrants, delivered at home by
untrained birth attendants

5. Main Causes of Maternal Mortality
In Malaysia
25
20
15
1995
1996
10
5
0
PPH
HDP
Em b
Traum a Sepsis
Unsp
Source : CEMD 1995-1996

8. PPH - definition
 Bleeding
from the genital tract after
delivery of the baby exceeding 500 mls
or enough blood loss to cause
hypotension and shock
 PRIMARY
– WITHIN 24 HOURS
 SECONDARY
– AFTER 24 HOURS
(includes all cases of excessive or
abnormal bleeding from the genital tract
occuring after 24H of delivery up to 6
weeks postpartum

9. CAUSES
 UTERINE ATONY
 RETAINED PRODUCT OF CONCEPTION
 INJURY OF THE GENITAL TRACT
 COAGULATION DISORDER
 UTERINE INVERSION/RUPTURE

10. PPH……. CAUSES
(CEMD 1996)
CAUSES
NUMBERS
PERCENTAGE
RETAINED
PLACENTA
UTERINE ATONY
26
59.1
17
38.6
SECONDARY PPH
1
2.3
COAG.DEFECT
0
0
UTERINE
RUPTURE
UTERINE
INVERSION
CERVICAL
LACERATION
PELVIC
HAEMATOMA
7
46.7
2
13.3
4
26.7
2
13.3

11. Uterine Atony
Uterus fails to contract – vessels at the placental
bed not obliterated – excessive bleeding

12. Uterine Atony
 Risk factors:
 Grandmultiparity
 Overdistension
of uterus – twin,
polyhydramnios, macrosomic baby
 Exhausted
uterus - Prolonged labour,
Instrumental delivery
 Severe
anaemia

14. Retained POC
 Failure
of contraction of uterus over
where products are retained
 Partial separation of placenta – bleeding
from retroplacental space

15. Genital tract injury/
Obstetric Trauma
Types of tear:
Perineal
tear
Ruptured vulval varicosities
Vaginal lacerations
Cervical lacerations
Uterine rupture

16. Uterine inversion
 Inverted
uterus
– unable to
contract –
bleeding from
placental bed

17. Coagulation disorder
 1-2% of maternal death
 Chronic – von Willebrand’s disease,
idiopathic thrombocytopenia, patients on
anticoagulant therapy
 Acute – eclampsia, HELLP syndrome,
Amniotic fluid embolism

18. EFFECTS OF PPH
 Death
 Anaemia, poor recovery from delivery,
prone to infection
 Complications from blood and blood
products transfusion
 Late complications – Sheehan’s syndrome
(necrosis of pituitary gland) – failure of
endocrine function, needs replacement
Rx.

19. CONCLUSION







PPH LEADING CAUSE MATERNAL MORTALITY
Access to blood and blood products at
maternity centres
RED ALERT SYSTEM
PPH training manual
Improving emergency obstetric care at health
facilities
All high risk women should be delivered in a
hospital with appropriate facilities and
personnel
Obstetric flying squads in appropriate
circumstances