1. Overview and medical
management of PPH
Dr. Suhas Otiv
Consultant, KEM Hospital, Pune

3. Lancet 2006; l368:1189-200

4. Mortality from PPH
• Half of 500,000 maternal deaths globally
• 28 % of maternal deaths in developing countries
• Risk of death from PPH
1 in 1000 deliveries - developing countries
1 in 100,000 deliveries – developed countries

5. Lancet 2006; l367:1066-72

6. Incidence of PPH
PPH 5 – 17 % of all deliveries
> 500ml
Major PPH 1.3 – 2.5 % of all deliveries
> 1000 ml
ACOG 3.9 % of all deliveries

7. Definition of PPH
Primary PPH: 0 – 24 hours; Secondary PPH: 1 - 84 days
Blood loss > 500 ml at vaginal delivery
> 750 - 1000 ml at Cesarean
Severe PPH > 1000 ml loss at vaginal delivery
ACOG: - Fall in hematocrit 10%
- Need for PRBC transfusion
Rate of blood loss: > 150ml/min or sudden loss > 1.5 – 2 l

8. PPH can occur with minimal
vaginal bleeding !!!!

9. Accuracy of visual estimation of blood loss

10. Modified –WHO
Blood collection method

11. Modified –WHO
Weighing Blood loss

12. Modified –WHO
Measuring volume of blood loss
-Transfer of blood
-Mops squeezed

13. BRASSS-V®
Blood
Collection
Drape with
Calibrated
Receptacle

15. Etiology of PPH
• Uterine Atony > 80 %
• Lacerations of vagina, cervix
• Uterine rupture 10%
• Uterine inversion
• Retained placental fragments
• Placental accreta / increta / percreta 5%
• Coagulopathy 1%

16. Risk factors for PPH
• Nulliparity • Advanced maternal age
• Obesity • PIH
• Large baby • PPH in previous delivery
• Prolonged labor • Augmented labor
• APH • Forceps delivery
• Multiple pregnancy • Use of tocolytics
• Cesarean delivery х Grand multiparity
65 % cases of PPH occur with no risk factors

17. PPH at Cesarean delivery: Risk Factors
• General anesthesia
• Chorio-Amnionitis
• Pre-eclampsia
• Protracted active phase of labor
• Second-stage arrest
• Classic uterine incision
Obstet Gynecol 1991 Jan;77(1):77-82

18. Risk factors for PPH: a case control study
comparing 666 cases with controls in 154311 deliveries
• Retained placenta (OR 3.5, 95% CI 2.1-5.8)
• Failure to progress during the second stage of labor (OR 3.4, 95% CI 2.4-4.7)
• Placenta accreta (OR 3.3, 95% CI 1.7-6.4)
• Lacerations (OR 2.4, 95% CI 2.0-2.8)
• Instrumental delivery (OR 2.3, 95% CI 1.6-3.4)
• Large for gestational age new born (eg, >4000 g) (OR 1.9, 95% CI 1.6-2.4)
• Hypertensive disorders (OR 1.7, 95% CI 1.2-2.1)
• Induction of labor (OR 1.4, 95% CI 1.1-1.7)
• Augmentation of labor with oxytocin (OR 1.4, 95% CI 1.2-1.7)
J Matern Fetal Neonatal Med. 2005;18(3):149

19. Management of PPH
• Scenarios – labor room, OR, wards, peripheral hospital
• Effective management
– Prompt response
– Organized team work
– Clear priorities, decisive
• Help: communication, monitoring,
assistance, documentation

20. Being prepared for PPH
• Team: Nursing, doctors, surgical expertise,
critical care physician / anesthesiologist
• Drugs: Oxytocin, Methergin, Carboprost,
volume expanders, resuscitation
• Equipment: Monitoring, resuscitation, Blood
bank, Lab, ICU, OR

21. Management of PPH at vaginal delivery
First line Management
• Call for help
• Uterine massage
• IV access: X-match, labs
• Infuse NS rapidly,
• BP, Foley catheter, pulse oximeter,
• Prompt Uterotonic drugs
Carboprost 250 mcg, 2 doses 15 minutes apart
Oxytocin infusion 40 units / 500 ml in 30 – 60 min
Methylergometrine 0.2mg i.m. one dose
Misoprostol 400 - 800mcg
• Rapidly evaluate for vaginal / cervical lacerations
• Warmth, oxygen

22. Oxytocic drugs
• Oxytocin
• Methyl ergometrine
• Misoprostol
• Carboprost

23. Oxytocin
• Storage: Between 2-8 *C, avoid freezing
• Adverse effects: anti-diuretic effect,
hypotension, arrhythmias
• Incompatible with noradrenaline, warfarin
• 10 – 40 IU / L of infusate

24. Ergometrine
• Storage: Refrigerate, protect from light, stable for 60-90
days, discoloration – discard
• Avoid : heart disease, hypertension, peripheral vascular
disease, hepatic or renal impairment; with antiretroviral
and macrolide antibiotics
• Adverse : Vomiting, nausea, HT, CVA
• Route: IM preferred, IV dilute in 5 ml NS

25. Carboprost – PGF2 alpha
• Caution : Asthma, cardiac disease, epilepsy, liver
disease
• Storage: Refrigerate
• Adverse: Vomiting, diarrhea, flushing,
• Dosage: 250 mcg IM, repeat every 15 - 90
minutes, maximum 8 doses = 2 mg.
• IV injection - bronchospasm, hypertension,
vomiting, and anaphylaxis

26. Misoprostol
• PGE1 analogue
• Adverse effects – vomiting, shivering at higher
doses. No broncho-constriction.
• Storage: Stable at or below 25*C
• Route: Oral, buccal, rectal, vaginal
• Rapid onset of action lasting 4-6 h

27. Misoprostol as an adjunct to standard
uterotonics for treatment of PPH
Lancet. 2010;375(9728):1808
1422 women with atonic PPH treated with routine
uterotonic agents randomized to
600 mcg misoprostol sublingually
Placebo sublingually
Found no difference in blood loss > 500 ml in next 1
hour

28. Treatment of PPH with sublingual misoprostol versus
oxytocin in women receiving prophylactic oxytocin
Lancet. 2010;375(9710):217
31055 women delivered with prophylactic oxytocin in III stage,
809 (3%) who had atonic PPH were randomized to
Misoprostol 800mcg sl
Oxytocin 40 u infusion in 15 minutes
Similar outcomes in both groups
90% women had bleeding controlled in 20 minutes;
30% women had additional blood loss of > 300 ml after Rx

29. After initial treatment
• Evaluate for
retained placental fragment
uterine inversion
lacerations
coagulopathy
• Check urine output,
response to resuscitation, time
volume of blood lost

30. Volume replacement
• Crystalloid: Ringer Lactate, Hartmann, NS
RL similar to plasma
only 20% retained in circulation
Dextrose: only 10% retained, interferes with X matching
NS avoid in pre-eclamptic patient
• Blood volume changes last for 40 minutes only
• Infuse 3 L for each 1 L of estimated blood loss
• Target 90mm systolic pressure, UOP 30ml/hr
• Give colloids after 2 L of crystalloids given

31. Colloids
• Gelatin polymers - Hemaccel
rapid urinary excretion
anaphylaxis
• Hydroxyethyl starch – Hetastarch, Pentastarch
increases plasma volume by 70 – 230%
dose 20 ml/kg = 1 to 1.5 L
no anaphylactic reactions
well tolerated
lasts for 4 hours in circulation

32. Blood transfusion
• No universally accepted guidelines for trigger
• PRBC x 2 if no improvement after 2-3 L of crystalloids or if
ongoing blood loss likely
• Warm carefully. > 40 *C – severe transfusion reactions
• Admin 1 FFP for every 1-2 units of PRBC, at 12-15ml/kg
• No drugs / injections with blood

33. Target
• Hb > 7,
• Platelets > 50,000 /ml
• Fibrogen > 100mg/dl
• PT < 1.5 times control

34. Massive hemorrhage
• Defined as > 10 units of BT required / 24 h
• Likely when persistent SBP < 90,
Loss more than 1500ml
• Cryoprecipitate if no response to FFP or Fibrogen
level < 100
• Expect platelet count < 50,000 after > 2 L blood loss.
Platelets to maintain counts 25-50,000, 1:1

35. Secondary interventions
• Repeated doses of Carboprost max 8 doses
• Intramyometrial Carboprost - off label
• Carboprost uterine irrigation
• Rectal Misoprostol - high doses >800mcg
• Intra-uterine Misoprostol
• Tamponade – Sengstaken tube,
• Uterine Packing

36. Indications for laparotomy
• Unabated blood loss
• Atony unresponsive to Rx
• Vital signs out of proportion to blood loss
• Vaginal laceration extending above fornix

45. Summary
• Symptoms and vital signs of blood loss are more important
than visual assessment of blood loss
• Team approach with protocols and regular drills
• Prompt, sequential use of utero-tonic agents and
replacement of volume are mainstay of Rx
• Low Fibrinogen, abn PT, tachycardia and abnormalities of
placental implantation and detectable troponin are predictors
of increased morbidity

46. Thank you !