Dr. Monika Madaan

Specialist

Dept. Of Obstetrics & Gynaecology

ESI HospitalManesar

PPHSingle most important cause of maternal

mortality worldwide.Accounts for 34% of maternal deaths in

developing countries.

DefinitionAny blood loss than has potential to

produce or produces hemodynamic instability

DefinitionBlood loss > 500 ml after deliveryPrimary : Loss within 1st 24 hours after deliverySecondary : 24 hours till 12 weeks postnatally

Minor : 500-1000 mlModerate : 1000-2000 mlSevere : > 2000 ml

PREDICTION AND PREVENTION

Identify pt. at risk

- Pl previa/accreta

- Anticoagulation Rx

- Coagulopathy

- Overdistended uterus

- Grand multiparity

- Abn labor pattern

- Chorioamnionitis

- Large myomas

- Previous history of PPH

PREDICTION AND PREVENTIONActive Management Of Third Stage Of Labor

(AMTSL): Should be offered routinely and includes:

1.Administration of uterotonics soon after birth.

2.Delayed cord clamping.

3.Delivery of placenta by controlled cord traction followed by uterine massage.

PPH DrillClear and logical sequence of steps

essential in the management of PPH.

CALL FOR HELP

Team Effort

•Skilled Obstetric Team•Trained Anaesthesiologist•Clinical hematologist •Supporting staff

ResuscitationAssessA : AirwayB : Breathing C : Circulation Secure 2 wide bore i.v. lines:- 14-16 gauge Draw blood for grouping & cross matching,

CBC, LFT/KFT, SE & Coagulogram.

Position flatKeep the patient warmAdminister oxygen by mask ( @ 10-15 litres/

min)Catheterize the patient for emptying bladder &

monitoring output

Fluid Replacement

RAPID WARMED infusion of fluidsCrystalloids : Fluids of choice until

compatible blood is arranged1 ml of blood loss= 3 ml of crystalloidsTotal volume of 3.5 litres of clear fluids

(upto 2 litres of crystalloids followed by 1.5 litres of warmed colloid )may be given while awaiting compatible blood.

If hemorrhage is torrential & fully cross-matched blood still not available : Uncrossmatched O negative blood may be given

FFP: 4 Units for every 6 Units of red cells OR PT/ APTT > 1.5 X normal

(ie 12-15 ml/kg or total of 1 litres.)Platelet Concentrate: if Platelet count< 50,000/

microlitre.Cryoprecipitate: if fibrinogen < 1 g/ l.

Continuous vital monitoring.Monitor adequacy of replacement with urine

output (0.5 ml/kg/hr) and CVP (4-8 cm water)Main therapeutic goals are to maintain:Haemoglobin > 8gm/dlPlatelet count > 75 × 109 / lProthrombin < 1.5 × mean controlAPTT < 1.5 × mean controlFibrinogen > 1 gm/ l

Establish Etiology Simultaneously4 T’s

Tone (abnormalities of uterine contraction) :70 – 80%

Trauma (of the genital tract) : 20 %Tissue (retained products of conception) : 10

%Thrombin (abnormalities of coagulation) : 1 %

Contd…

Bimanual Compression

If uterus is relaxed : massaging the uterus will expel any retained bits & stimulate uterine contractions

Administer Uterotonic DrugsFIRST LINE

Oxytocin:

Start with 5 units slow iv or im.

Infusion of 20 units in 1 L@ 60 dr/min.

Continue same dose @ 40 dr/min until bleeding stops.

Maximum upto 3 L.SECOND LINE

Ergometrine/ methyl ergometrine:

Dose: 0.2 mg im or slow iv

Repeat 0.2 mg after 15 min.

Maximum 5 doses (1 mg)

Syntometrine im

THIRD LINE PGF 2α: Dose: 0.25 mg im. Can be repeated every 15 min. Maximum upto 2 mg or 8 doses. Misoprostol: 200-800 µg sublingually. Do not exceed 800 µg

WHO GUIDELINES FOR MANAGEMENT OF PPH 2009

Uterine Tamponade• Bakri balloon• Sengstaken Blakemore oesophageal catheter• Condom catheter• Urological Rusch balloon

Success depends upon Positive Tamponade test

Procedure of condom Balloon insertion

Initial Assembly Condoms-2

Foley’s catheter-no.16 Saline with iv set Speculum Sponge holding

forceps

ProcedureLithotomy positionIndwelling Foley’s

catheter.Explore uterus, cervix and

vagina.Inflate balloon with 100-

300 ml warm 0.9% Sodium chloride until bleeding is controlled (Positive Tamponade Test).

Compression sutures

B Lynch Suture•Fundal compression suture•Apposes anterior & posterior wall

Contd…Parallel Vertical compression sutures for placenta praevia

Stepwise Uterine Devascularization

•Uterine arteries

•Tubal branch of ovarian artery

•Internal iliac artery

Uterine Artery EmbolizationPossible only if internal artery ligation has not been done and facility for interventional radiology available

HysterectomyResort to hysterectomy “SOONER RATHER

THAN LATER”High maternal morbidityTiming and adequate replacement is of

utmost importance

Documentation and DebriefingImportant to record:Sequence of eventsTime and sequence of admn of

pharmacological agents, fluids, blood productsThe time of surgical interventionThe condition of mother throughout .

Newer DevelopmentsTranexamic acid : 1 gm i.v slow. Can be

repeated after 30 min if bleeding continues./Recombinant activated factor VII

(Novoseven): 90 µg/ kg . May be repeated within 15-30 minutes. No clear consensus on efficacy.

Carbetocin (oxytocin agonist) : 100 µg i.v or i.m. Produces tetanic uterine contractions.

HAEMOSTASIS ALGORITHMH – Ask for helpA – Assess and resuscitateE – Establish etiologyM – Massage the uterusO – Oxytocic administrationS – Shift to OTT – Tissue n trauma to be excluded and

proceed to tamponadeA – Apply compression suturesS – Systematic pelvic devascularisationI – Interventional radiologyS – Subtotal or total hysterectomy

To Conclude, Management of PPH Has Evolved From:PanicPanicHysterectomy

PitocinProstaglandinsHappiness

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