Post partum haemorrhage in obestric emergencies

Is present all type of post partum haemorrhage

1. MMC.6th Postpartum Hemorrha ge (PPH)

2. Made by: • Ahmed Jameel Shahir • Loay Salem Ali • Osama Abdulrahman Ghazal • Rania Hazim Ghanem • Rafal Abdulrahman Ghazal • Dunya Fares Thamer • Ali Ibrahim Ghazal • Hiba Ayman Saleh • Duha Abdullah Khalid • Sarkar Fawaz Suleiman • Mohammed Mahmood Khasro Supervised by: Dr. HADEEL ANWAR ALSARAAJ

3. By the end of this lecture, participants should be able to: 1. Define Postpartum Hemorrhage (PPH). 2. Explain types and causes of PPH. 3. Identify risk factors. 4. Recognize clinical features (signs and symptoms). 5. Describe diagnosis and assessment methods. 6. Discuss management and emergency protocols. 7. Understand preventive strategies and complications Objectives:

4. Definition of Postpartum Hemorrhage (PPH) PPH is the most common form of major obstetric hemorrhage. The traditional definition of primary pph is: The loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby. Minor pph (500–1000 ml) in the absence of clinical signs of shock or, Major PPH (more than 1000 ml) or in presence of clinical signs of shock associated with a smaller estimated loss. The incidence of pph is about 5% of all pregnancies .

5. PPH is divided into : • Primary PPH: bleeding occurring within 24 hours of delivery. • Secondary PPH: bleeding occurring after 24 hours but before 12 weeks of delivery .

6. Risk factors:

7. Causes: Causes for PPH Causes for PPH “the four T”: • Tone (abnormalities of uterine contraction) • Tissue (retained products of conception) • Trauma: 1. Vaginal/cervical lacerations or haematoma 2.Ruptured uterus 3.Broad ligament haematoma 4.Uterine inversion. Thrombin (abnormalities of coagulation )

8. Prediction & prevention of PPH • Predict risk factors for PPH & counsel about place of delivery. • Active management of 3rd stage of labour . • Prophylactic oxytocics reduce the risk of PPH by about 60%. • Misoprostol is not as effective as oxytocin, but it may be used when the latter is not available. • women with a previous CS must have their placental site determined by ultrasound, (MRI) to determine whether the placenta is accreta or percreta . If placenta accreta or percreta is diagnosed antenatally , there should be consultant-led multidisciplinary planning for delivery, with availability of blood bank facilities.

9. Diagnosis • Early recognition of blood loss and rapid action is vital in the management of PPH. • Appreciation of risk factors, accurate estimation of blood loss. 1. Local/Obvious signs • Excessive vaginal bleeding (often >500 mL after vaginal birth, >1000 mL after C-section). • Blood may be bright red and gush or trickle continuously. • Clots in lochia. Signs and symptoms

10. Signs and symptoms 2. Uterine findings • Soft, boggy uterus (in uterine atony). • Enlarged uterus above the umbilicus if blood is pooling inside. 3. Systemic symptoms of blood loss • Tachycardia (often earliest sign). • Hypotension (late sign if loss is rapid). • Pallor, cold clammy skin. • Dizziness, fainting, restlessness. • Shortness of breath. Dialed Capillary Refill > 2 Sec. 4. Severe/late signs • Confusion or altered consciousness (shock). • Oliguria or anuria (due to poor perfusion).

11. Sign;

12. How should PPH be managed M anagement involves four components, all of which must be undertaken SIMULTANEOUSLY : 1) communication. 2) resuscitation. 3) arresting the bleeding. 4) monitoring and investigation.

13. 1.Communication: Call for help: E xperienced midwife. O bstetric middle grade and alert consultant. A nesthetist middle grade and alert consultant. C onsultant clinical hematologist. B lood transfusion laboratory. P orters for delivery of specimens/blood. O ne member of the team to record events, fluids, drugs and vital signs.

14. 2.Resuscitation: Assess airway, breathing, & circulation. Oxygen by mask 10–15 L/min. IV access (14-gauge cannula x 2, orange cannulae ) 20 ml blood sample should be taken and sent for IX. Position flat. Keep the woman warm. Transfuse blood as soon as possible.

15. . Until blood is available, infuse up to 3.5 liters of warmed crystalloid and/or (1–2 liters) colloid. Special blood filters should NOT be used, as they slow infusions . r VIIa 90 micrograms/kg, repeated within 15–30 min(risk of thrombosis), ineffective if there is no fibrinogen, & thrombocytopenia. If cross matched blood is still unavailable, “O- ve ‟ blood

16. . FFP 4 units for every 6 units of red cells or (12–15 ml/kg or total 1 liter) OR when PT\APTT> 1.5 x normal Platelets concentrates if PLT count < 50 x 10 9 \l Cryoprecipitate If fibrinogen < 1 g/l.

17. therapeutic goals I s to maintain: HB > 8g/dl P latelet count > 75 x 109/l PT < 1.5 x mean control APTT< 1.5 x mean control F ibrinogen > 1.0 g/l.

18. 3. Arresting the bleeding: The most common cause of primary PPH is uterine atony . the following mechanical & pharmacological measures should be used , until the bleeding stops: Bimanual uterine compression. Empty the bladder. Compression of the aorta may be a temporary but effective measure to allow time for resuscitation to catch up with the volume replacement and the appropriate surgical support arrives .

19. . Bimanual uterine compression & aortic compression

20. pharmacological measures Syntocinon 5 units by slow IV injection (may have repeat dose). Ergometrine 0.5 mg by slow IV or IM injection Syntocinon infusion (40 up in 500ml solution at 125ml/hour). Carboprost 0.25 mg by IM injection repeated at intervals of not less than 15 min to a maximum of 8 doses (C\I in women with asthma). Direct intramyometrial injection of carboprost 0.5 mg (C\I in women with asthma )

21. . If bleeding occurs at the time of CS, intramyometrial injection of carboprost should be used Misoprostol 1000 micrograms rectally.

22. . If pharmacological measures fail to control the hemorrhage, initiate surgical haemostasis sooner rather than later: balloon tamponade is an appropriate first line surgical intervention ( Bakri balloon) success rate is (78%).

23. . In most cases, 4–6 hours of tamponade should be adequate to achieve haemostasis and, ideally, it should be removed during daytime hours, in the presence of appropriate senior staff, should further intervention be necessary. Before its complete removal, the balloon could be deflated but left in place to ensure that bleeding does not reoccur.

24. . Haemostatic brace suturing (such as using procedures described by B-Lynch or modified compression sutures). success rate is (81%). complications a case pyometria was reported in 2002 & of partial uterine necrosis in 2004. selective arterial embolization.

25. . bilateral ligation of uterine arteries bilateral ligation of internal iliac ( hypogastric ) arteries, success rate is (61%).

26. . Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture), A second consultant clinician should be involved in the decision for hysterectomy. Subtotal hysterectomy is the operation of choice in many instances of PPH requiring hysterectomy, unless there is trauma to the cervix or lower segment; the risk of neoplasia developing in the cervical stump several years later is not relevant in the context of life-threatening hemorrhage.

27. Management of Trauma Diagnosis: •- Bleeding despite contracted uterus •- Speculum exam to identify site   •Management: •- Cervical tears: repair with absorbable sutures •- Vaginal/ perineal lacerations: suture under anesthesia •- Uterine rupture: laparotomy → repair or hysterectomy

28. Management of Thrombin ( CoagulopathieZ ) •Diagnosis: •- Suspect if bleeding persists despite Tone/Tissue/Trauma control •- Labs: PT, APTT, fibrinogen, platelet count   •Management: •- Correct underlying coagulopathy •- Fresh Frozen Plasma (FFP) if PT/APTT >1.5x normal •- Platelets if <75,000/µL

29. Management of Tissue (Retained Placenta/Clots •Diagnosis: •- Ultrasound for retained products •- Clinical: incomplete placenta, ongoing bleeding   •Management: •- Manual removal of placenta under anesthesia •- Uterine exploration for retained clots •- Surgical curettage if incomplete •- Antibiotic prophylaxis

30. Monitoring &Investigation venepuncture (20 ml) for: crossmatch (4 units), FBC , coagulation screen, RFT, LFT. temperature every 15 minutes. Continuous PR, Bpr , & RR. monitor urine output. CV line for (CVP) monitoring & as route for rapid fluid replacement. arterial line monitoring (if appropriately experienced staff available for insertion). transfer to ICU once the bleeding is controlled Documentation.

31. thromboprophylaxis once the bleeding is arrested and any coagulopathy is corrected, thromboprophylaxis is administered, as there is a high risk of thrombosis. Alternatively, pneumatic compression devices can be used, if thromboprophylaxis is contraindicated in cases of thrombocytopenia.

32. compilcation 1. Hemodynamic and Circulatory Complications Hypovolemic shock → from severe blood loss, leading to multi-organ failure.Hypotension → causing poor tissue perfusion.Cardiac arrest (in extreme cases). 2. Hematologic ComplicationsAcute anemia → weakness, fatigue, poor wound healing, increased infection risk.Disseminated intravascular coagulation (DIC) → consumption of clotting factors due to massive bleeding. 3. Organ Dysfunction / FailureRenal failure → from prolonged hypotension (acute tubular necrosis).Hepatic failure → due to ischemia.Sheehan’s syndrome (postpartum pituitary necrosis) → from severe hypotension/shock. 4. Reproductive System ComplicationsInfection (puerperal sepsis) due to prolonged labor, retained tissue, or invasive procedures.Intrauterine adhesions ( Asherman’s syndrome) if surgical evacuation is required.Infertility secondary to uterine damage or adhesions. 5. Psychological ImpactPostpartum depression or post-traumatic stress disorder (PTSD) from traumatic birth experiences.Anxiety about future pregnancies.6. MortalityIf uncontrolled, PPH remains one of the leading causes of maternal death worldwide.

33. Secondary PPH •Secondary PPH: Bleeding from the genital tract occurring after 24 hours but before 12 weeks of delivery.

34. Epidemiology • Incidence: ~0.5–1.4% of deliveries in developed countries. •Major contributor to maternal morbidity worldwide. •Recurrence risk: ~20–25% if previously affected. •Early recognition and prompt management are critical.

35. Etiology (Causes): •Infection ( Endometritis ): Most common cause. •Retained products of conception (RPOC). • Subinvolution of placental site. •Rare causes: Trophoblastic disease, coagulation disorders.

36. Risk Factors •Previous PPH (primary or secondary). •Retained placenta after delivery. •Prolonged or obstructed labor. •Cesarean section or operative delivery. •Intrauterine infection. • Multiparity and uterine overdistension .

37. Clinical Presentation: •Vaginal bleeding (light spotting to heavy haemorrhage ). •Foul-smelling lochia. •Fever, abdominal pain, uterine tenderness (if infection). •Enlarged or high uterus (retained tissue). •10% of cases: severe haemorrhage → hypovolemic shock.

38. Investigations: If the patient is haemodynamically unstable or is bleeding heavily, then call for help and follow the resuscitation algorithm. Resuscitation should be commenced prior to establishing a cause, and senior staff should be involved at the earliest opportunity .

39. Laboratory Tests: The appropriate laboratory tests include: CBP B-HCG Urea and Electrolytes C-Reactive Protein Coagulation profile BLOOD Group and Save sample Blood cultures (if the patient is pyrexic )

40. Imaging Tests A pelvic ultrasound scan can assist in the diagnosis of retained placental tissue.

41. Initial Management •Resuscitation: IV access, fluids, oxygen, blood products if needed. •Antibiotics: Broad-spectrum (ampicillin + metronidazole ± gentamicin). • Uterotonics : Oxytocin, ergometrine , carboprost , misoprostol. •Monitor vitals and urine output.

42. Surgical/Procedural Management Surgical/Procedural Management •Evacuation of retained products (cautious). •Uterine balloon tamponade ( Bakri balloon, condom catheter). •Surgical options: Uterine artery embolization, compression sutures. •Hysterectomy as last resort.

43. Special Considerations •Low-resource settings: Non-pneumatic anti-shock garment (NASG). •Prevention: Active management of 3rd stage of labor. •Counseling: Inform women about recurrence risk.

44. Case Scenario: A 32-year-old G3P2 woman delivered vaginally at term. Thirty minutes postpartum, she presents with profuse vaginal bleeding, pallor, tachycardia (HR 125 bpm ), and hypotension (BP 80/50 mmHg). On examination, her uterus is soft and poorly contracted, and estimated blood loss exceeds 1200 mL.

45. References: 1. Ten Teachers – Obstetrics, 23rd Edition. 2. World Health Organization (WHO). 3. American College of Obstetricians and Gynecologists (ACOG).