1. IN THE NAME OF GOD

2. Post partum hemorrage H.GHASEMI.TEHRANI Associated Professor
of ob&gyn departman

3. Major causes of death for pregnancy women （maternal mortality)
Postpartum hemorrhage（28%)
heart diseases
pregnancy-induced hypertension
Amniotic fluid embolism
infection

4. Definition of PPH
be defined as a blood loss exceeding 500ml after delivery of the infant
PPH: occurs in 24 hour of delivery
the late PPH: occurs after 24 hour of delivery to 6 weeks

5. Major causes Uterine atony (90%) lacerations of the genital tract(6%)
retained placenta(3%-4%)
coagulation defects (blood dyscrasia)
(4T: tone, tissue,trauma,thrombin)

6. 1. Uterine atony Local factors
overdistention of the uterine (hydramnios, multiple pregnancy, macrosomia )
condition that interfere with contraction(leiomyomas)
complications(PIH,anaemia, placenta praevia

7. Systemic factors:
drugs(magnesium sulfate,sedative)
abnormal labor(prolonged,precipitous)
History of previous PPH
Preeclampsia, abnormal placentation,

8. Prevention and therapeutic of uterine atony
Administration of medicine:
promotes contraction of the uterine corpus
decreases the likelihood of uterine atony
Oxytocin agents
Methegine
prostaglandin

9. Oxytocin 40 units in 1 liter of normal saline IV or 10units IM
Oxytocin 40 units in 1 liter of normal saline IV or 10units IM. Higher doses of oxytocin (up to 80 units in 1000 mL) Methylergonovine 0.2 mg if no hypertension, Raynaud's phenomenon, or scleroderma. May repeat at two- to four-hour intervals Carboprost tromethamine (15 methyl-PGF2alpha)(Hemabate) 250 mcg IM every 15 to 90 minutes, as needed, to a total dose of 2 mg (8 doses), if no asthma. About 75 percent of patients respond to a single dose

10. Misoprostol (PGE1)
200 to 1000 mcg via oral, sublingual, and rectal routes or using a combination of routes. The sublingual route has rapid onset of effect, prolonged duration of action, and the greatest total bioavailability Dinoprostone (PGE2) 20 mg vaginal or rectal suppository is an alternative PGE to misoprostol (PGE1). It can be repeated at two-hour intervals

11. Mechanical stimulation of uterine contraction:
Massage of uterus through the abdomen and bimanual compression
intrauterine packing

15. Surgical methods If massage and agents are unsuccessful:
Ligation of the uterine arteries
ligation of the hypogastric arteries
selective arterial embolization
hysterectomy
taking into account the degree of hemorrhage,the overall status of patient,her future childbearing desires

16. 2. Lacerations of the genital tract
Causes:
Instrumented delivery (forceps)
manipulative delivery(breech extraction,precipitous labor, macrosomia)
Types:
perineum laceration
vaginal laceration
cervical laceration

18. perineum and vaginal laceration
The first degree tear:
involves only skin and a minor part of the perineal body
the second degree tear:
involves the perineal body and vagina
the third degree tear:
involves the anal sphincter and anal canal

22. management Vaginal examination soon after delivery repair:
cervical laceration >2cm in length and be actively bleeding
laceration of vaginal and perineum

23. 3. Retained placenta
Separation and explosion of placenta is caused by strong uterine contraction
Placenta tissue remaining in the uterus
prevent adequate contraction and predispose to excessive bleeding

24. causes:
adherence of placenta (previous cesarean delivery,prior uterine curettage)
succenturiate placenta
placenta accreta (into the decidua)
placenta increta(into the myometrium)
placenta pericreta(through the myometrium to the peritoneal)

27. Prevention and treatment
The placenta should be examined to see that it is complete or not
part of placenta is missing, removed digitally
not separated, manual removal of placenta is done
hysterectomy is required for placenta increta(percreta,accreta)
uterine contraction drugs

29. 4. Coagulation defects Acquired abnormality in blood clotting:
abruptio placenta,
amniotic fluid embolism
severe preclampsia
congenital abnormality in blood clotting:
thrombocytopenia
severe hepatic diseases
leukemia

30. disseminated intravascular coagulopathy(DIC)
if bleeding persists in spite of all other treatment described, DIC should be suspected
the blood passing from the genital tract is not clotting
shock: reduction of effective circulation
inadequate perfusion of all tissues
oxygen depletion
depression of functions

31. Record:
pulse
blood pressure
maternal heart rate
central venous pressure
urine output

32. Lab tests:
Hb,
BT(bleeding time), CT( clotting time),
platelets count
fibrinogen
prothrombin time and patial thromboplastin time
FDP
women’s group and cross-matching

33. Treatment:
the key is correcting the coagulation defect
resuscitation must be started as soon as possible
infusion of crystalloid(saline) and Dextran is started firstly while arranging the blood transfusion
blood transfusion is essential
infusion of platelets, fresh frozen plasma, FDP , clotting factors,

34. Potential complications of PPH:
Postpartum infection
Anemia
Transfusion hepatitis,
Sheehan’s syndrome
Asherman’s syndrome
The best management of PPH is prevention