POST PARTUM HEMORRHAGE PPH POST PERTUM DELIVERY

POST PARTUM HEMORRHAGE IS A CONDITION WHERE A EXCESS BLOOD LOSS FROM THE GENITAL TRACT MORE THEN 500 ML AFTER DELIVERY.

1. PPH (POST-PARTUM HEMORRHAGE )

2. Introduction PPH is defined as blood loss of 500 ml or more within 24 hours after birth, whereas severe PPH is defined as blood loss of 1000 ml or more at the same time, according to the World Health Organization (WHO).

3. DEFINITION QUANTITATIVE PPH- “Quantitative definition is arbitrary and is related to the amount of blood loss in excess of 500 mL following birth of the baby (WHO). It may be useful for statistical purposes”.

4. Cont. CLINICAL DEFINITION- “ Any amount of bleeding from or into the genital tract following birth of the baby up to the end of the puerperium , which adversely affects the general condition of the patient evidenced by rise in pulse rate and falling blood pressure is called postpartum hemorrhage” The average blood loss following vaginal delivery, cesarean delivery and cesarean hysterectomy is 500 mL, 1000 mL and 1500 mL respectively .

5. Cont. Depending upon the amount of blood loss, PPH can be- Minor (< 1L) Major (> 1L) Severe (> 2L)

6. INCIDENCES Severe bleeding after childbirth - postpartum haemorrhage (PPH) - is the leading cause of maternal mortality world-wide. Each year, about 14 million women experience PPH resulting in about 70,000 maternal deaths globally.  (WHO)

7. TYPES Primary Secondary

8. Primary Postpartum Hemorrhage Hemorrhage occurring during the third stage of labor and within 24 hours of delivery .

9. Four basic pathologies are expressed as the four Ts’ (RCOG)- Atonic PPH: TONE – Atonic (70%) Traumatic PPH : TRAUMA - Traumatic (20%) Mixed PPH : TISSUE - Mixed (10%) Increased THROMBIN : Blood Coagulopathy (1%)

10. Prevention Active Management of Third stage of Labour . Examination of Placenta Induced or accelarate Labour by Oxytocin.

11. 1) ATONICITY Causes Grand multipara Overdistension of uterus Malnutrition

12. Management Massaging the uterus, PV examination. Oxytocin up to IV/500 ml. Tranexamic acid 1 gm. Methergin 0.2 mg Prostaglandins Mesoprostol (80  g Anal) Carbaprostol Bimanual compression IU Packing Surgical sutures Hysterectomy Uterine embolization/artery ligation JADA system

13. 2) TRAUMATIC PPH PPH resulting from injury to genital tract. Causes Perineal tear. Cervical Hematoma Rupture of uterus

14. A. Perineal Tear A tear which involves perineum. Causes Over stretching of the perineum (fuse to pubic delivery) Rapid stretching of the perineum (Precipitate Labour ) Inelastic perineum- elderly Primi ( perineal scar)

15. Classification of tear 1  Tear When vaginal mucosa/skin are tom Injury to confined to vaginal mucosa and skin

16. 2 Tear 1  + perineal muscles are tom

17. 3 Tear Injury to perineum and sphincter involved 50 % ≥ 50 % External of external of external Anal anal sphincter anal sphincter Sphincter+ Tear tear Internal Anal Sphincter Tear

18. 3  and 4 Tear- Complete Perineal Tear

19. Management – Repairing of 3  and 4 Tear- If recognized within 24 hrs of delivery Immediate Repair If recognized>24 hrs of delivery wait for 2 weeks Repair after infection and inflammation subsides

20. Techniques of Repair 1  and 2 Tear To be Done in Labour Room Sutures vaginal mucosa ( Continuous suture- using vicryl / polyglactin ) Suture muscles (Interrupted sutures) Vaginal skin (mattress sutures )

21. 3 and 4 Tear Done under OT under General Anesthesia Local Anesthesia Repair rectal mucosa Internal anal Sphincter External anal sphincter

22. 4 Tear Repairing 1  and 2 Tear Vaginal mucosa Mucosa Vaginal skin

23. Most common End to end Anastomosis Best Over lapping Techniques

24. Important point after repairing Pregnancy should be avoided for a year (Ideally)but at-least 6 months after 3rd/4th degree repairs. In future these finalized can have vaginal delivery. ACOG recommended a single shot of antibiotics at the time of repairs.

25. B. Cervical Tear Is the most common cause of traumatic PPH. Cause Iatrogenic Attempted forceps delivery trough incomplete dilated delivery. Strong uterine contraction right Cervix.

26. Complication – Hematoma – Pelvic cellulitis – Thrombophlebitis – Cervical atropia – Mid-Tri abortion in next pregnancy – Colporrhexis – rupture of the vaginal wall

27. Management – Most common site- 3’O Clock> 9’ O Clock – Repairing the Tear

28. C. PELVIC HEMATOMA Collection of blood anywhere in the areas between the pelvic peritoneum and the perineal skin is called pelvic hematoma.

29. Uncommon – Serious morbidity – Localized blood collection of blood outside of blood vessels >2.5cm.

30. Incidence 1 : 1000 deliveries > 4cm: 1/1000 deliveries Supralevator infralevator Surgical intervention 1/1000 deliveries

31. Secondary postpartum hemorrhage Hemorrhage occurring after 24 hours of delivery and within 6weeks of delivery. It is also referred to as puerperal hemorrhage.

32. Causes : Bleeding usually occurs between the 8th and 14th day of birth. Causes of late postpartum hemorrhage are: Stored pieces of cotyledon or membrane (most common) Infection and slough separation over deep laceration of the cervix. Endometritis and transplantation of the placenta - due to delayed healing process. Second hemorrhage from a surgical wound usually occurs within 10-14 days. Probably because Slough separation reveals a bleeding vessel From granulation tissue

33. Bleeding withdrawal follows estrogen treatment for breastfeeding suppression. Other common causes are: chorionepithelioma - occurs 4 weeks after birth; cervical carcinoma; placental poly, infected fibroid or fibroid polyp and puerperal remodeling of the uterus.

34. Management Supportive treatment: Blood transfusions, if necessary. Administration of 0.2 mg methergine intramuscularly, if bleeding is the root of the uterus. Prescribe antibiotics (clindamycin and metronidazole) as usual. Conservative : If bleeding is minimal and no apparent cause has been found, a vigilant watch for 24 hours or more is performed at the hospital.

35. Prevention Postpartum bleeding cannot always be prevented. However, the incidence and especially its magnitude can be greatly reduced by assessing risk factors and following the guidelines as set out below: However, most PPH cases do not have significant risk factors.

36. Antenatal Improvement of the health status of the woman and to keep the hemoglobin level normal (> 10 g/ dL ). High-risk patients, such as twins, hydramnios , grand multipara, APH, history of previous PPH, severe anemia). Blood grouping should be done for all women. Placental localization must be done in all women with previous cesarean delivery (see p. 286) by USG or MRI to detect placenta accreta or percretal . All women with prior cesarean delivery. Women with morbid adherent placenta are at high risk of PPH.

37. Intra-natal Active management of the third stage, for all women in labor should be a routine as it reduces PPH by 60 %. Cases with induced or augmented labor by oxytocin, the infusion should be continued for at least one hour after the delivery. Women delivered by cesarean section, oxytocin 5 IU slow IV is to be given to reduce blood loss. Carbetocin (long-acting oxytocin) 100 µg is very useful to prevent PPH. Exploration of the uterovaginal canal. During cesarean section spontaneous separation and delivery of the placenta reduces blood loss (30%). Examination of the placenta and membranes.

38. Conclusion Around the world everyday About 830 women die from pregnancy or childbirth-related complications. Low and middle socio-economic status countries are having more PPH cases compared with 1% of industrialized nation.

39. SUMMARY

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