PPH

1. Prevention and medical
management of uterine atony
By Cheong Lu Jeat,
Laow Yee Kean
Supervised by Dr Munis

2. Definition
 Postpartum hemorrhage is
 1) loss of 500mls or more during vaginal delivery;
 2) more than 1000mls during caesarean section
 3) blood loss significant enough to cause
hemodynamic instability
 Primary PPH – first 24H of delivery
 Secondary PPH from 24H to 12 weeks after delivery

3.  Total blood volume at term is approximately 100 ml/kg
 (an average 70 kg woman-total blood volume of 7000)
 loss of more than 40% of total blood volume (approx 2800 ml)
is generally regarded as ‘life-threatening’.
 aim of management is to prevent hemorrhage escalating to the
point where it is life-threatening.

4. Causes
 Primary
 Uterine atony - 80%
 Retained placenta
 Morbidly adherent placenta
 Abruptio placentae
 Low placental implantation
 Extended tears, broad ligament haematoma
 Cervical tears, vulvovaginal haemotoma
 Defects in coagulation
 Uterine inversion
 Amniotic fluid embolism
 Secondary
 Retained products of conception
 Infection
 Inherited coagulation defects

5. Risk Factors for Postpartum Hemorrhage
 Prolonged labor
 grandmultipara
 Augmented labor
 Precipitated labor
 History of postpartum hemorrhage
 Overdistended uterus (macrosomia,
twins,polyhydramnios)
 Operative delivery
 Chorioamnionitis

6. Prevention
 Active management of 3rd stage
 IM syntometrine 1ml during delivery of
anterior shoulder
 Controlled cord traction
 Early cord clamping - controversial
 For high risk patients (eg grandmultipara) -IV
pitocin 40 units @125ml/H

7. Simple measures in district
hospital
 Identify all high risk patients – antenatal risk
stratification– deliver in tertiary centre
 Strict adherence to partogram
 Scan for placental location of patients with previous
scar!!
 BE careful during second stage caesarean section
 No fundal pressure!!
 Know your guidelines!! Ensure flowchart is placed in
labour room
 Know the Sarawak PPH box


8. drug
Medical management Dose/route Frequency comment
Oxytocin (pitocin) IV: 5-40 U in 1L NS continuous Avoid undiluted rapid IV
IM: 5IU infusion, which causes
hypotension
Syntometrine (ergometrine IM 1 ml WHO recommendation
500mcg + oxytocin 5U) unless contraindicated
(hypertension)
15-methyl IM: 0.25mg Every 15-90min, 8 doses Avoid in asthmatic patients;
PGF2a(carboprost) maximum relative CI if hepatic, renal
(hemabate) and cardiac disease.
Diarrhea, fever, tachycardia
can occur
Misoprostol (cytotec, 800-1000mcg rectally
PGE1)

9. Physiology of fluids
Blood loss (% of MAP Clinical effects
blood volume)
500 – 1000 ml (10 – Normal Postural hypotension
15%) Mild tacchycardia
1000 ml – 1500 ml (15 Slight fall Tacchycardia
– 30%) Thirst
Weakness
1500 ml – 2000 ml ( 30 50 – 70 mmhg Tacchycardia
– 40%) Pallor
Oligouria
Confusion
Restlessness
> 2000 ml (> 40%) < 50 mmhg Tacchycardia
Anuria
Air hunger
Coma
Death

10. Fluid therapy and blood product
transfusion
 Crystalloid Up to 2 litres Hartmann’s
solution
 Colloid up to 1–2 litres colloid until
blood arrives
 Blood Crossmatched
 FFP 4 units
 Platelets 2 units
 Cryoprecipitate 6units

11. ‘the golden first hour’
 Isthe time at which resuscitation must be
commenced to ensure the best of survival
 use of the ‘shock index’ (SI) is invaluable in
the monitoring and management of women
with PPH. It refers to HR divided by the SBP.
The normal value is 0.5–0.7.
 With significant haemorrhage,it increases to
0.9–1.1

12. Coagulopathy(DIVC)
 occurs due to the consumption of clotting
factors (disseminated intravascular
coagulation or DIC) or due to the dilutional
effects of massive blood loss on clotting
factors, platelets and fibrinogen (‘washout
phenomenon’)

13. Monitoring and investigation
 Blood ix – FBC, PT/PTT/INR
 V/S monitoring
 To start DIVC regime based clinical judgment!!
Biochemical confirmation takes time!!
Aims:
Haemoglobin > 8 g/dl
Platelet count > 75 109/l
Prothrombin time < 1.5 mean control
Activated prothrombin time < 1.5 mean control
Fibrinogen > 1.0 g/l

14. Blood component therapy
product Volume (ml) contents Effect(per unit)
Packed red cells 240 RBC, WBC, Increase
Plasma hematocrit 3%,
Hb 1g
platelets 50 Platelets, RBC, Increase plt count
WBC, Plasma 5k-10k per unit
FFP 250 Fibrinogen,antithr Increase
ombin 3,f V and fibrinogen by
VIII 10mg/dl
cryoprecipitate 40 Fibrinogen, f VIII Increase
and XIII, Von fibrinogen by
willebrand factor 10mg/dl

15. Recombinant activated Factor VII
 Natural initiator of coagulation cascade
 Lead to stable formation of fibrin clots at site
of injury
 Indications: life-threatening massive
postpartum hemorrhage which fails to
respond to surgical and medical mx
 Refractory DIVC
 Dosage: 60-120mcg/kg

16. Other measures
 Uterine packing
 Bakri balloon
 Rusch catheter
 Sengstaken-blakemore tube

17. Surgical management
technique comment
B-lynch suture
Uterine artery Bilateral; also can ligate uteroovarian vessels
ligation
Internal iliac Less successful than earlier though; difficult
artery ligation technique; generally reserved for practitioners
Repair of rupture
hysterectomy

18.  Labour ward manual of SGH
 RCOG Green-top guideline No.52
 ACOG Clinical Guidelines
 O & G and reproductive medicine 20 : 6
 O & G and reproductive medicine 19 : 5