1. Post Partum Hemorrhage
PPH

3. Definition:
Blood loss in excess of 500 ml with vaginal delivery or in excess of 1000 ml following delivery by caesarian section.

4. Types:
1- Early PPH: more common.
occurs immediately or slowly over the 1st 24 hours.
2- Late PPH: occurs after 24 hours but within 6 weeks post delivery.

5. Causes:
1- Uterine atony.
2- Genital tract trauma.
3- Retained placental tissue.
4- Low placental implantation.
5- Coagulation disorders.
6- Uterine inversion.

6. Uterine atony:
Is the cause of 75 to 80 % of PPH.

7. Factors predisposing to uterine atony:
1- Over distention of the uterus.
2- Multiple gestation.
3- Polyhydraminos.
4- Fetal macrosomia.
5- Prolonged labor.
6- Grand multiparity.
7- Oxytocic augmented labor.
8- Preciptious labor.
9- MgSo4 ttt of pre eclampsia.
10- coriamnionitis.
11- Halagenated Anaesthetics.
12- Uterine Leiomyoma.

8. Genital tract trauma:
Second most common cause of PPH.
1- laceration of the cervix and vagina.
2- laceration over the perineal body, periurethral area, over the ischeal spines.
3- during low transverse c-section.

9. Retained placental tissue:
1- Incomplete placental seperation.
2- Partial placental accreta.
In ½ the patients with delayed PPH, placental reminants are present when uterine curettage is performed.

10. Low placental implantation:
This leads to PPH because the lower uterine segment has less musculature.

11. Coagulation disorders:
1- TTP.
2- Amniotic fluid embolism.
3- Abruptio placentae.
4- ITP.
5- Von Willebrand’s disease.

12. Uterine inversion:
The inside out turning of the uterus during the 3rd stage of labor due to improper management.

13. Obstetric History

14. Obstetric History Personal data: name, age.
Gravidity + parity + abortion + ectopic pregnancy.
Presenting complain.
History of current pregnancy.
- was the pregnancy planned?
- previous booked visit (how many).
- regularity of menstrual cycle.
- LMP EDD.
- GA (40 - “present date – EDD”).

15. Events of pregnancy in 1st, 2nd and 3rd trimester:
A) symptoms of pregnancy.
B) complication of pregnancy.
C) use of drugs and supplement.
D) further tests carried out.
Past obstetric history.
Past gynecological history:
- menstrual history.
- contraceptive \ sexual history.
Gynecological surgical history.
Past medical history.
Surgical history.
Drug history \ allergies.
Family history.
Social history.

16. Obstetric examination
General examination.
Ex. of the chest.
Ex. of the breast.
Ex. of the thyroid.
Abdominal Ex.
Ex. of the lower limb.
Special points in the examination: fundal height.

17. Pelvic examination:
- inspection.
- collection of cytologic specimen.
- palpation.
- rectal and recto-vaginal examination.

18. Examination in active bleeding
Vital signs.
Palpation of the fundus.
Inspection of vagina and cervix.
Pelvic examination.
Manual exploration of uterine cavity.

19. Initial management of PPH

20. check patient status.
early recognition of PPH.
monitor vital signs and oxygen.
establish IV access, place urinary catheter.
Baseline lab value.
Alert anesthesia and blood bank.
Central hemodynamic monitoring.
Correct anemia and coagulation disorders and blood products.

21. Determine underlying cause of PPH
Examine the uterus, placenta and genital tract.
Etiology will determine further management.

22. Uterine Atony
By manual massage and/or compression, exclude retained placental fragments, uterine rupture.
Medical Uterotonic therapy:
1- rapid oxytocin infusion IV, IM or intramyometially.
2- methylergonovine.
3- 15-methyl-prostaglandin F 2 alpha IM or IMM.
4- Dinoprostone PEG2 rectally.

23. If no response to above management consider:
1- uterine packing.
2- angiography and embolization.
3- explorative laparotomy with surgical options:
- vessel ligation.
- hysterectomy.

24. Lower genital tract laceration
Cervical, vaginal or perineal tears.
Determine source of bleeding.
Establish surgical hemostasis.
Evacuate hematoma.
If not responsive to above consider surgical options: - uterine packing
- artery ligation.
- hysterictomy.

25. Retained placental fragments
Manual exploration and removal.
Curettage.

26. Abnormal placentation
Placenta accreta.
Conservative surgery curettage, local repair.
Further surgical management:
- laparotomy.
- artery ligation.
- hysterictomy.
Consider angiography and embolization.

27. Uterine inversion
Immediate intravascular volume expansion with IV crystalloids.
Surgical procedure may be required.
Uterine rupture
Laparotomy.
Repair of scar or hysterectomy.

28. Thank you
Done by.. Group E1