2. Antepartum & Postpartum Hemorrhage
• Obstetrics is "bloody business."
• Death from hemorrhage still remains a leading
cause of maternal mortality.
• Hemorrhage was a direct cause of more than
18 percent of 3201 pregnancy-related
maternal deaths.
3. Postpartum Hemorrhage
• In spite of marked improvements in management, PPH
remains a significant contributor to maternal morbidity and
mortality both in developing and developed countries.
• One of the most challenging complications a clinician will face.
• Prevention, early recognition and prompt appropriate
intervention are the keys to minimizing its impact.
4. DEFINITION:
The loss of >500ml of blood from the genital tract in
the first 24 hrs after delivery
(or)
< 500 ml with haemodynamic changes in the mother.
(or)
>1000 ml – cesarean section within 24 hrs.
(or)
> 1400 ml – Elective cesarean hysterectomy
(or)
> 3000 ml – Emergency cesarean hysterectomy
5. - In a recent ACOG study PPH is defined as Haematocrit change of 10% or the
need for red cell transfusion.
Severe PPH - > 1500ml blood loss
or
Drop in Hb concentration 40g/l.
or
units of blood transfusion.
4
Secondary PPH - Blood loss between 24 hrs and 6 weeks
Post-delivery.
In general, early PPH involves heavier bleeding and greater morbidity.
7. Haematological Changes in Pregnancy
• 40% expansion of blood volume by 30 weeks
• 600 ml/min of blood flows through intervillous space
• Appreciable increase in concentration of Factors I (fibrinogen),
VII, VIII, IX, X
• Plasminogen appreciably increased
• Plasmin activity decreased
• Decreased colloid oncotic pressure secondary to 25%
reduction in serum albumin
8. Reduced Maternal Blood Volume
• Small stature
• Severe preeclampsia/eclampsia
• Early gestational age
10. PPH
• The etiologies of early PPH are most easily understood as abnormalities of
one or more of four basic processes.
• The four “T” processes.
• Previous PPH!!
12. PPH Risk Factors
• Many factors affect a woman’s risk of PPH.
• Each of these risk factors can be understood
as predisposing her to one or more of the four
“T” processes.
17. PREVENTION OF PPH
• Although any woman can experience a PPH, the
presence of risk factors makes it more likely.
• For women with such risk factors, consideration
should be given to extra precautions such as:
– IV access
– Coagulation studies
– Crossmatching of blood
– Anaesthesia backup
– Referral to a tertiary centre
18. PREVENTION OF PPH
• UTEROTONIC DRUGS
– Routine oxytocic administration in the third stage of labour
can reduce the risk of PPH by more than 40%
– The routine prophylaxis with oxytocics results in a reduced
need to use these drugs therapeutically
– Management of the third stage of labour should therefore
include the administration of oxytocin after the delivery of
the anterior shoulder.
19. Intranatal:
• Hasty delivery of the baby is to be avoided.
• Adequate amount of blood should be cross matched and
available when haemorrhage is anticipated.
• Coagulation studies are done in cases of Abruptio
placenta and retained dead fetus.
20. Active Management of 3rd Stage of Labour:
1. Uterotonic Agents:
• 10 units of oxytocin IM or
• Syntometrine (5 units of oxytocin and 0.5mg
ergonovine maleate).
• Misoprostol, a prostaglandin E1 analogue, 600g
orally.
2. Early cord clamping
3. Controlled cord traction.
21. MANAGEMENT OF PPH
• Early recognition of PPH is a very important factor in
management.
• An established plan of action for the management of
PPH is of great value when the preventative
measures have failed.
• Lab:
- CBC / BG / Cross match of 4-6 units of blood
- KFT / Coagulation profile
- Give FFP / cryoprecipitate if coagulation test results are abnormal
- Give platelet concentrates if the platelet count is < 50 X 109/L & bleeding continues
33. Evaluation of response
- Monitor pulse, blood pressure, blood gas status, &
acid-base status + monitoring central venous pressure.
- Measure urine output using an indwelling catheter
- Order regular FBC counts and coagulation tests to
guide blood component therapy