POST PARTUM HAEMORRHAGY

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• Postpartum Hemorrhage
• (PPH) ???? ?? ??? ???????

Dr AMISSI Longane MD.
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Purpose of presentation

• At the end of this presentation, participants
  must be able to
• 1. Define the PPH
• 2. know the causes of PPH and management.

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Definition of PPH

• Blood loss gt 500 ml at vaginal delivery
• gt 1000 ml at Cesarean
• ACOG( American College of Obstetricians  Gynecolo
  gists ) 10 drop in hematocrit
• Need for blood transfusion
• Severe PPH gt 1000 ml loss at vaginal delivery
• Any amount of blood loss causes
• S/O Hypovolemic Hemorrhagic Shock
• - Tachycardia - Hypotension - Reduced urine
  out put

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Why it is important?

• PPH remained one of the top
• 3 obstetric causes of direct maternal deaths.

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Why it is important?
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Why it is important?

• Incidence 4 after vaginal delivery
• 6,5 after CS delivery

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We have 4 problems

• Problem 1 almost 50 of deliveries lose gt500 ml
  of blood.
• Problem 2 estimated blood loss is often less
  than half the actual blood loss.
• Problem 3 Most of the serious causes of PPH
  have origins prior to the end of the 3rd Stage of
  labor.
• Problem 4 PPH, as defined, is technically
  misdiagnosed and clinically irrelevant.

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Measuring Blood Loss in PPH THE BRASS-V
DRAPE
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Advantages of Brass-V

• Simple and practical
• Low cost ( Plastic)
• Accurate
• Objective
• Can be used in a wide
• range of settings
• Provides a hygienic delivery surface

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CAUSES OF PPH

• 1. TONE
• 2. TRAUMA
• 3. TISSUE RETENSION
• THROMBIN
• FOUR T (4T)
• BUT MOST IMPORTANT IS

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1.ToneUterine Atony90of causes

• - Uterine over distension
• Polyhydramnios, Multiple gestations, Macrosomia
• Prolonged labor uterine fatigue
• Precipitory labor
• High parity
• Chorioamnionitis
• Retained product of conception
• Halogenated anesthetic

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2.TRAUMA Obstetric OR OPERATIVE 7 of
causes

• Obstetric Trauma
• - Uterine Rupture
• - Lacerations of the Birth Canal
• - Operative Trauma
• Cesarean sections
• Episiotomies
• Forceps, Vacuums, Rotations

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3.Tissue retention Abnormal placentation

• - Placenta Praevia
• - Abruption Placenta
• - Accreta, increta, percreta placenta
• - Vasa previa

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4.Thrombin Coagulation Defects

• - Sepsis
• - Amniotic Fluid Embolism
• - Abruption Placenta associated with
• coagulopathy
• - Dilutional Coagulopathy
• - Inherited Clotting Disorders
• - Anticoagulant Therapy
• - HELLP Syndrome

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4.Thrombin Coagulation Defects

• HELLP Syndrome(Hemolysis, Elevated Liver
  Enzymes, Low Platelet Count)

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Management of PPH

• Postpartum hemorrhage prevention measures

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Thrombin Coagulation Defects2-3 of causes

• - Sepsis
• - Amniotic Fluid Embolism
• - Abruptio Placentae associated
• coagulopathy
• - HELLP Syndrome
• - Dilutional Coagulopathy
• - Inherited Clotting Disorders
• - Anticoagulant Therapy

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• Goals of Therapy (CALL FOR HELP)
• Maintain the following
• Systolic pressure gt90mm Hg
• Urine output gt0.5 mL/kg/hr
• Normal mental status
• Eliminate the source of hemorrhage
• Avoid overload volume replacement that can
  contribute to pulmonary edema

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Management Protocol

• Examine the uterus to rule out atony
• Examine the vagina and cervix to rule out
  lacerations repair if present
• Explore the uterus and perform curettage to rule
  out retained placenta

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On recognition of Hemorrhage

• Initiate volume replacement with lactated ringers
  or normal saline.
• Alert blood bank and surgical team.
• Control the blood loss.
• Initiate decisive therapy.
• Monitor for complications.

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MANAGEMENT of Uterine atony

• Explore uterus for retained placental tissue.
• Uterine massage
• 3.Firm bimanual compression

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management of uterine atony Cont

• 4- uterotonic agents
• Oxytocin infusion, 40 units in 1 liter of D5 RL
• Methergine 0.2 mg IM
• 15-methyl prostglandin F2a, 0.25 to 0.50 mg
  intramuscularly may be repeated
• , PGE1 200 mug, or PGE2 20 mg are second line
  drugs in appropriate patients

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Management of uterine atony Cont

• Use of BAKRY Ballon (UBT uterine ballon
  tamponade)

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Management of other causes

• 2. TRAUMA
• 3. TISSUE RETENSION
• 4. THROMBIN

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SHUKRAN THANKS