1. Postpartum Hemorrhage
Dr. Yasir Katib
MB BS, FRCSC

2. Postpartum Haemorrhage
Introduction
Risk Factors
Prevention
Treatment
Pelvic Haematoma
Umbrella Pack
Uterine Inversion

3. PPH - Introduction
Acute blood loss – most common cause of hypotension in obstetrics
Usually occurs immediately before or after placental delivery
Most commonly results when uterus fails to contract - effective haemostasis dependent on contraction of myometrium (compresses severed vessels)

4. PPH - Introduction Factors Predisposing to Myometrial Dysfunction
Uterine Overdistention
Multiple Pregnancy
Fetal Macrosomia
Hydramnios
Oxytocin-stimulated Labour
Uterine Relaxants
Amnionitis

5. PPH - Introduction Abnormal placentation
Placenta accreta – attaches directly into myometrium
Placenta increta - extends deep into myometrium
Placenta percreta - through the uterine serosa & even into the surrounding organs
PPH occurs b/c myometrial tissue present at implantation site insufficient to constrict spiral arteries of the uterus.
Attempting to remove the abnormal placenta frequently results in uncontrolled haemorrhage because of large open sinuses in the myometrium.

6. PPH – Risk Factors (Obstetric Haemorrhage >1 L)
Placental abruption
Placenta previa
Multiple pregnancy
Obesity
Retained placenta
Induced labour
Episiotomy
Birth weight > 4 kg

7. PPH – Prevention
Active management of 3rd stage of labour & spontaneous delivery of time of C/S
Umbilical cord clamping within 30s of delivery, gentle cord traction, followed by IM or IV oxytocin before delivery of placenta
Oxytocin s length of 3rd stage of labour (~ 5 min) & low incidence of manual removal (2%)
In absence of sig. maternal haemorrhage, additional 30 min of expectant management allow ½ of retained placentas to deliver spontaneously
Spont. Delivery of placenta s risk of endometritis 7x, s blood loss by 30% (RCT)

8. PPH – Tx (Manual)
Manual digital exploration of uterus to r/o possibility of retained placental fragments

9. PPH – Tx (Manual)
If not detected, manual massage of uterus should be started

10. PPH – Tx (Pharmacologic)
At the same time, initial Tx of oxytocin U/1000 mL of NS at rates as high as 500 mL in 10 min.
If oxytocin fails, synthetic prostaglandin (Prostin, Upjohn) is 2nd line (0.25 mg IM in deltoid q1-2h X 5 doses)
Ergovine (0.2 mg IM) used to be 2nd line
Misoprostol (1000 g PR) in patients with refractory uterine bleeding shown (O’Brien et al.)

11. PPH – Tx (Surgical)
Inspection for laceration of maternal tissues could be a likely cause of continued vaginal or cervical bleeding
Repair

12. PPH – Tx (Surgical)
1st degree – involves fourchet, perineal skin & vaginal mucosal membrane
2nd degree – also involves muscles of perineal body; rectal sphincter remains intact

13. PPH – Tx (Surgical)
3rd degree – extends not only through the skin, mucous membrane & perineal body, but includes the anal sphincter

14. PPH – Tx (Surgical)
4th degree laceration – extends through the rectal mucosa

15. PPH – Tx (Surgical)
Cervical laceration – NB to secure base of laceration (often a major source of bleeding); but difficult to suture

16. PPH – Tx (Surgical)
If uterine bleeding not responsive to pharmacologic methods & no vaginal or cervical lacerations present, surgical exploration may be necessary
Laceration of uterine vessels may be found (i.e. longitudinal lacerations of inner myometrium – thought to be an incomplete form of uterine rupture)

17. PPH – Tx (Surgical)
If haemorrhage secondary to atony, vascular ligation often necessary
Hypogastric artery ligation fallen out of favour b/c of prolonged OR time, technical difficulties & inconsistent clinical response
If bilateral uterovarian vessel ligation does not stop bleeding, temporary occlusion of infundibulopelvic ligament (digital pressure or clamps) should be attempted – ligation indicated if this controls bleeding

18. PPH – Tx (Surgical)
Instead, stepwise progression of uterine vessel ligation should be performed
1st – ligation of ascending branch of uterine arteries (in ~10-15% of atony, unilateral ligation of uterine artery sufficient to control bleeding; bilat will control an additional 75%)
If bleeding persists, should attempt to interrupt blood flow between uterus & infundibulopelvic ligament via ligation of anastomosis of ovarian & uterine artery

19. PPH – Tx (Surgical)

20. PPH – Tx (Radiological)
Advantages – d anaesthetic & surgical risks
- identification & selective occlusion of specific vessels
- avoid hysterectomy
Could also use transient transcatheter uterine artery balloon for management of extreme haemorrhage

21. PPH – Tx (Radiological)
Successfully used in postpartum bleeding from atony, bleeding from pelvic vessel laceration, post c-section haemorrhage & bleeding associated with extrauterine pregnancy
Complications - postprocedure fever & pelvic
infection (most common)
- reflux of embolic material in
nontargeted pelvic structures

22. PPH – Pelvic Hematoma Blood loss not always visible
Occasionally, traumatic laceration of blood vessels can lead to pelvic haematoma formation
3 types
Vulvar
Vaginal
Retroperitoneal

23. PPH – Pelvic Hematoma Vulvar
D/t laceration of vessels in superficial fascia of either the ant. or post. pelvic triangle
Usual signs : subacute volume loss & vulvar pain
Blood loss limited by Colle’s fascia & urogenital diaphragm & anal fascia
B/c of fascial boundaries, mass extends to skin & visible haematoma results
Tx – volume support & surgical evacuation of blood & clots, pressure bandage, Foley catheter

24. PPH – Pelvic Hematoma

25. PPH – Pelvic Hematoma Vaginal
Frequently associated with forceps delivery; may be spontaneous
Less common than vulvar
Blood accumulates in plane above level of pelvic diaphragm
Unusual for large amounts of blood to collect
Frequent complaint – severe rectal pressure
Exam – large mass protruding into vagina
Tx – incision of vagina & evacuation (even if delayed Dx)

26. PPH – Pelvic Hematoma

27. PPH – Pelvic Hematoma Retroperitoneal Least common
Most dangerous to mother
May not be impressive until sudden onset of hypotension/shock
D/t laceration of one of vessels originating from hypogastric artery
Tx : surgical exploration & ligation of hypogastric vessels unilaterally or bilaterally if needed

28. PPH – Uterine Inversion
Characterized by partial delivery of the placenta, followed by rapid onset of shock ( usually before sig. blood loss) in the mother in the 3rd stage of labour
Can be mistaken for partially separated placenta or aborted myoma
Uncommon but life-threatening event
Incidence : 1/2000 deliveries

29. PPH – Uterine Inversion
Incomplete – if corpus does not pass through cervix
Complete – if corpus passes through the cervix
Prolapsed – if corpus extends through vaginal introitus
Usually occurs in association with a fundally inserted placenta

30. PPH – Uterine Inversion
Tx : fluid therapy & restoration of uterus to N position immediately upon recognition of inversion, without removing the placenta
If initial efforts fail, use of either -mimetic agents or magnesium sulfate should be tried (esp. if severe maternal hypotension)
Occasionally, impossible to reposition uterus vaginally & laparotomy necessary
Once inversion corrected, oxytocic or prostaglandin agents should be given

31. The End