1. Dr Ahmed abdulwahab

2. Hemorrhage is still one of the leading cause of maternal mortality all over the world DEFINITION Primary post partum hemorrhage. It is the loss 500 ml of blood following delivery and but within 24 hours. If less than 500ml and causing hypovlaemic shock.

3. Secondary post partum hemorrhage It is a blood loss of a volume greater than expected after 24 hours within the first 6 weeks of delivery. During caesarian section a blood loss of more than 1000 ml of blood is considered primary post partum hemorrhage.

4. Incidence of primary PPH is 5% of all delivery. The two main causes of primary PPH are ATONIC PPH BIRTH CANAL INJURY. The atonic PPH is 90% of cases, it is due to failure of the uterus to contract Cauese. Retained placental tissues Prolonged labor

5. Over distended uterus. multiple pregnancy Polyhydramnios Big baby. Chorioamnionitis. SEQUENCES OF ANTEPARTUM HAEMORRHAGE. Placenta previa and abruptio placenta

6. BITTH CANAL INJURY. Rupture uterus. Cervical tear. Vaginal tear. After instrumental deliveries or other traumatic deliveries

7. MANAGEMENT. Prevention. Active management of third stage of labor. Syntometrine at delivery of anterior shoulder followed by controlled cord traction will reduce the incidence of PPH

8. When there is PPH Call for help. midwifery, anaethetist,and hematologist. IV access must be secured with a large bore cannula. Blood is withdrawn for hemoglobin, cross matching, coagulation profile and infusion of crystalloid or colloid to maintain the pressure.

9. Atonic PPH Uterine massage Ergometrine,oxytocin prostaglandins Transfuse blood, and if coagulation defect start Fresh frozen plasma,cryprecipitate, platelet transfusion. Uterine backing. Embolization of the pelvic vasculature. Ligation of uterine or internal iliac artery. Hysterectomy.

10. Birth canal injuries. Suturing under anaethethia with good exploration to the whole birth canal. Coagulation defect is frequently encountered because of massive hemorrhage which will lead to consumption of the clotting factors, platelets and fibrinogen and usually occurs if delayed reaction to the event

11. Secondary PPH. Treat the cause removal of placental tissues Treat infection for endometritis

12. Coagulation changes during pregnancy Normal pregnancy is considered as a hypercoagulable state. There is significant increase in the production of the pro-coagulant factors and reduction of plasma fibrinolytic activity. This hyper-coagulable state is needed at the time of placental separation. At term 500 ml of blood flows at the placenta per minute. Without effective haemostasis a woman could die from exsanguition in a few minutes.

13. Disseminated intravascular coagulation DIC This is an inappropriate activation of the clotting cascade. This will lead to wide spread coagulation, increase fibrinolysis and end organ failure. Causes. 1-injury to vascular endothelium. Pre-eclampsia, hypovolaemic shock, septicaemia, 2- release of thrombogenic tissue factors. Placental abruption, amniotic fluid embolism,prolonged intrauterine fetal death IUFD.

14. DIC vary in severity from mild compensated state that evident only in laboratory result through to massive uncontrollable hemorrhage with very low concentration of plasma fibrinogen, raised fibrin degradation products (FDPs) and thrombocytopenia. This result in end organ damage caused by hypotension and fibrin-platelet-clump deposition in small vessels leading to increase vascular permeability

15. Organs mostly affected. 1-Kidneys. Acute tubular necrosis. Glomerular damage. 2- lungs. Pulmonary edema. Adult respiratory adult syndrome. 3- central nervous system. Infarct and cerebral edema

16. Principles of management Maternal resuscitation. Treatment of the cause. Replacement of blood and clotting factors Intensive monitoring. Full coagulation screen which include. 1-FDPs –or D-dimers 2-fibrigen level, thrombin time. 3-activated partial thromboplastin time APTT. 4- partial thromboplastin time PTT

17. Management of DIC Call the hematologist. Stop further blood loss. Resuscitate with appropriate blood products. Fresh frozen plasma FFP this will provide factor V and VIII and some anti thrombin IIIa and fibrinogen. Cryoprecipitate contain fibrinogen. Platelet transfusion