Postpartum Haemorrhage

Contribution by students of Bachelors of Eastern Medicine and Surgery (BEMS) from Hamdard University, Pakistan.

1. Mirza Farjad Ali Baig

2. Categories of PPH Atonic 90% of the cases Due to failure of the uterus to contract Traumatic 10% of the cases Due to damage to genital tract

3. Categories Atonic Hemorrhage Traumatic Hemorrhage The most common cause of uterus bleeding is atony, the inability of the uterus to contract completely after delivery. Causes of atony include: Retention of placental fragments Inadequate myometrical activity Overdistension of the uterus with multiple gestations Macrosomia Polyhydramnios Chorioamnionitis Prolonged obstructed labor It is associated with traumatic delivery, assisted or not, and previous uterine surgery.

4. Primary Postpartum Hemorrhage Excessive bleeding i.e. >500ml. From or into the genital tract within 24 hours of the birth of the child. Ave. blood loss in normal labor is less than 300ml. Incidence: 2% - 3% of all deliveries. 15% are associated with retained placenta requiring manual removal.

5. Aetiology Placental Site Trauma to Genital Tract Uterine inertia or uterine exhaustion as in prolonged labor. Grand multiparity Uterine over distension in multiple pregnancy, hydramnios. Accidental hemorrhage. Prolonged anesthesia Full bladder. Mechanical factors preventing retraction of the uterus Retention of the placenta. Retention of blood clots. Uterine fibroids. Lacerations to the perineum, vagina, cervix Uterine rupture

6. Primary Haemorrhage from Placental Site Causes: Ineffective uterine contractions & retraction. Mismanagement at Third Stage. Abnormally Adherent Placenta: Placenta accreta Placenta increta Placenta percreta Disseminated intravascular coagulation.

7. Other Causes Coagulation defects such as hyperfibrinogenaemia. Mismanagement of third stage (amateur attempts of expressing placenta) Hx of previous PPH Pre-eclampsia Obesity Primigravida

8. Secondary Postpartum Haemorrhage Occurs after 24 hours of puerperium. Uterine haemorrhage occurs within first 2 weeks after delivery up to 6 weeks after delivery. May be severe or life threatening. Common causes: Delayed involution Retained bits of placenta

9. Retained placenta Retention of placenta takes place under two circumstances: The placenta is detached but not completely expelled. Adherent placenta: Simple adhesion Morbid adhesion

10. Adhesive Placenta Simple Adhesion Morbid Adhesion The placenta remains in union with the uterine wall although its attachments are not normal. The condition tends to recur in the same patient. Pathological attachment No line of cleavage between placenta and uterine wall. Placenta accreta Placenta increta Placenta percreta

11. Diagnosis Loss of blood >500ml. Bleeding is external, mostly. Sometimes it is hidden or concealed, due to which uterus becomes distended and vagina shows blood clots. Concealed haemorrhage is confirmed by squeezing of the uterus firmly as there will be a gush of blood immediately. CBC for Hb Blood clotting test Clot observation tests Monitoring BP and pulse of the mother. Angiography U/S LA Assessing the time of bleeding. <24 hours: Primary PPH >24hours: Secondary PPH

12. MANAGEMENT OF PPH Beware of coagulation defects. Accurate monitoring for blood loss and urinary output Timely blood transfusion Monitor CVP for adequate replacement of blood.