POSTPARTUM

HEMORRHAGE
Postpartum Hemorrhage (PPH)

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 PPH

Blood loss after completion of third

stage of labor
• >500 mL in vaginal deliveries
• >1000 mL in cesarean deliveries (CS)
• >1400 mL in an elective CS
hysterectomy
• >3000 mL in an emergency CS
hysterectomy
POGS Clinical Practice Guidelines Nov. 2009

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 PPH
• Leading cause of maternal mortality
• Accounts for nearly one third of all maternal
deaths worldwide
• Accounts for 60% of maternal deaths in
developing country
• Majority of deaths occur within 4 hours of
delivery
• Consequence of events in third stage of
labor
POGS Clinical Practice Guidelines Nov. 2009
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PPH Classification based on Timing
of Bleeding to the Delivery
• Early PPH- within first 24 hours
of vaginal delivery
• Late PPH- after 24 hours , but
within 12 weeks of delivery

B-Lynch et al. A Textbook of Postpartum Hemorrhage 20

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Classification of PPH according to
causative factors

• Tonus
• Tissue
• Trauma
• Thrombin

Wae et al. Female Patient 2005;30:19

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 Risk Factors for PPH
Antenatal risk factors
• Antepartum hemorrhage in this pregnancy
• Placenta previa (12x risk)
• Suspected or proven placental abruption
• Multiple pregnancy (5x risk) Other causes
polyhydramnios or macrosomia
• Preeclampsia or PIH (4x risk)
• Grand multiparity (≥4 preg)

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 Risk Factors for PPH
Antenatal risk factors
• Previous PPH (3x risk) or previous history of
retained placenta
• Asian ethnic origin (2x risk)
• Maternal obesity (BMI >35 kg/m2) (2x risk)
• Existing uterine abnormalities
• Maternal age (40 years or older)
• Maternal anemia Hb <9 g.dL (2x risk)

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 Risk Factors for PPH
Factors Relating to Delivery
• Emergency CS (4x risk)
• Elective CS (2x risk)- esp if >3 repeated
procedures
• Retained placenta (5x risk)
• Mediolateral episiotomy (5x risk)
• Induction of labor (2x risk)
• Operative vaginal delivery (2x risk)
• Labor of >12 hours (2x risk)
• >4 kg baby (2x risk)
• Maternal pyrexia in labor (2x risk)
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 Risk Factors for PPH
Pre-existing maternal hemorrhagic
conditions
• Hemophilia
• Von Willebrand’s disease

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Symptoms related to blood loss with PPH

Blood loss Blood pressure Signs and

% ml (mm Hg) symptoms
10-15 500-1000 normal palpitations,
dizziness,
tachycardia
15-25 1000-1500 slightly low weakness,
sweating,
tachycardia
25-35 1500-2000 70-80 restlessness,
pallor, oliguria
35-45 2000-3000 50-70 collapse, air
hunger, anuria

Booar J. Baillieres Best Pract Res Clin Obstet Gynecol 2000;14:1

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 Proposed Classification of PPH
Hemorrhage Estimated Blood volume Clinical signs and
class blood loss (ml) loss (%) symptoms
0 (normal loss) <500 <10 none
ALERT LINE (Observation ± replacement
therapy)
1 500-1000 15 minimal
ACTION LINE (Replacement therapy,oxytocics,
active management)
2 1200-1500 20-25 ↓ urine output
↑ pulse rate
↑ respiratory rate
postural hypotension
narrow pulse pressure
3 1800-2100 30-35 hypotension
tachycardia
cold clammy
tachypnea
4 >2400 >40 profound shock
Benedetti T. A Pocket Companion to Obstetrics, 4th ed. 2002
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Reason for Overly Conservative Management

• Underestimation of blood loss both in

volume and rapidity
• Patients initially compensating well for
losses (good health and hypervolemia
of pregnancy)
• Concerns of over-resuscitation leading
to pulmonary edema
• Failure to appreciate the dynamics of
fluid shifts in the body

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 Management of Massive Obstetric
Hemorrhage (ORDER)
• Organization (call experience staff OB, Anes; alert
BB and hematologist; designate a nurse to record
VS, UO, fluids and drugs administered); OR on
standby
• Resuscitation (O2; 2-IV lines using 14 gauge;
crossmatch 6 u PRBC, CBC, coagulation screen,
BUN/Creat and electrolytes status; Fluid
replacement NS or LRS; transfuse PRBCs)
• Defective blood coagulation (APTT, Fibrinogen,
Thrombin time, D-dimer; FFP; Cryoprecipitate,
Platelet conc if <50,000)
• Evaluation of response (VS, blood gas; UO; CBC
and Coagulation tests to guide therapy)
• Remedy the cause of bleeding
Bonnar J. Baillieres Best Pract Res Clin Obstet Gynaecol Feb 2000;14(1);1-18
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 CPGS on Uterine Atony (POGS Nov. 2014)

PREVENTION
1. Active management of the third stage of labor is the best
practice in the prevention of uterine atony with the use of
uterotonics being its most important component. (Level I,
Grade A)
Active vs expectant (RR 0.34, 95% CI 0.14-0.87) reduced the
risk of maternal primary hemorrhage
2. All women giving birth should receive uterotonics during
the third stage of labor. Oxytocin is the uterotonic drug of
choice. (Level I, Grade A)
Oxytocin vs placebo
(RR 0.53; 95% CI 0.38-0.74) reduced the risk of PPH >500 ml
(RR 0.56; 95% CI 0.36-0.87) reduced the need for therapeutic
uterotonics

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 CPGS on Uterine Atony (POGS Nov. 2014)

PREVENTION
3. Other injectable uterotonics that can be used are
carbetocin and methylergometrine. (Level I, Grade A)

4. Delayed cord clamping (1 to 3 minutes) is

recommended for all births while initiating
simultaneous newborn care more for benefit to the
newborn and not for prevention of PPH.
(Level I, Grade A)

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 CPGS on Uterine Atony (POGS Nov. 2014)

PREVENTION
5. Controlled cord traction is recommended in both
vaginal and cesarean deliveries for reduction in the
need for manual placental removal and its sequelae.
(Level I, Grade A)
Manual removal of placenta higher incidence of developing
endometritis (RR 1.64, 95% CI 1.42-1.90); more blood
loss (RR 1.81, 95% CI 1.44-2.28)
6. Sustained uterine massage is not recommended for
those who have received uterotonics as it does not
lead to further reduction of PPH. (Level I, Grade A)

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 CPGS on Uterine Atony (POGS Nov. 2014)

TREATMENT OF UTERINE ATONY

1. The use of uterotonics is the primary treatment for PPH secondary
to uterine atony. IV oxytocin is the recommended uterotonic for
the treatment of PPH. (Level I, Grade A)

2. In the absence of oxytocin or response to it, other uterotonics

may be used such as carbetocin, methylergometrine, and
carboprost. (Level III, Grade A)

3. Isotonic crystalloids are preferred for fluid resuscitation. (Level I,

Grade A)

4. Tranexamic acid is recommended if oxytocin and other

uterotonics fail to stop the bleed. (Level I, Grade A)

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 CPGS on Uterine Atony (POGS Nov. 2014)

TREATMENT OF UTERINE ATONY

5. Uterine massage is recommended for the treatment of
PPH secondary to uterine atony. (Level III, Grade C)

6. If there is no response to uterotonics, intrauterine

balloon tamponade is recommended.
(Level I, Grade A)

7. If other measures have failed, uterine artery

embolization (UAE) is recommended as treatment for
uterine atony. (Level II-3, Grade B)

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 CPGS on Uterine Atony (POGS Nov. 2014)

TREATMENT OF UTERINE ATONY

8. Surgical intervention is recommended if all
conservative measures to control uterine atony fail.
(Compression sutures, uterine artery ligation,
hypogastric artery ligation, and subtotal/total
hysterectomy). (Level II-3, Grade A)

9. For women experiencing PPH and awaiting transfer to

a tertiary facility, bimanual uterine compression, and
external aortic compression may be done and non-
pneumatic anti-shock garments may be used. (Level II-
1, Grade A)

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Bimanual Compression or Massage

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 Uterotonic Agents
• Oxytocin
• 5 u IV, 20 u in 1L of NS, 10 u
intramyometrium
• Ergotrate
• IV or Intramyometrium (max 1.25 mg)
• Carboprost
• 250 mcg IM or intramyometrium, max. 8
doses or 2 mg at 15 mins interval
• Carbetocin
• Misoprostol
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 Uterine Artery Ligation
• Provide 90% of blood flow

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Hypogastric Artery Ligation

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Ovarian Artery Ligation

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B-Lynch- transmural uterine compression
sutures; Hayman, Cho multiple squares
suture (Monocryl-1)

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B-Lynch- transmural uterine compression
sutures; Hayman, Cho multiple squares
suture (Monocryl-1)

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 Management
• Fluid resuscitation (raising legs, large-bore
needles, blood transfusion)
• Oxygenation
• Watch out for coagulopathy (DIC-
hypoperfusion of tissues, damage and release
of tissue thromboplastins)
• Manage according to cause

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THANK YOU