post partum haemorrhage

POST PARTUM HAEMORRHAGE - A Challenge To Safe Motherhood

Apr 12, 2023 PPH- Prof.S.N.panda & Dr.A.Patnaik 2

Taj Mahal-One of the seven wonders of the world, One of the Greatest monuments, dedicated to the memory of

“Queen Mumtaz” who died in child birth, by her husband “Emperor Sahajahan”, is a testimony and a grim reminder of the tragedy of maternal mortality,

that can befall any women in childbirth.

Taj Mahal

WEL COME TOWEL COME TO


POST ARTUM HAEMORRHAGE though preventable, accounts for the majority of the cases of obstetric haemorrhage, the other causes being – antepartum haemorrhage, abortion, ectopic pregnancy and ruptured uterus.

Obstetric Haemorrhage --- Ranks as the First cause of maternal mortality

accounting for 25 – 50 % of maternal deaths


. . . the most common and severe type of obstetric haemmorrhage, is an enigma even to the present day obstetrician as it is sudden, often unpredicted, assessed subjectively and can be catastrophic. The clinical picture changes so rapidly that unless timely action is taken maternal death occurs within a short period.

POST PARTUM HAEMORRHAGE


Direct Causes (%) of Mat.Mort. in selected countries*

MAGNITUDE OF THE PROBLEM

*World watch paper 102Jacobson JL ed, 1991

Country +MMR Haemorrhage Sepsis Toxaemia Abortion Obstructed Labour

INDIA 874 18 14 16 14 03

Bangladesh 600 22 03 19 31 09

Ethiopia 566 6 2 6 25 4

Tanzania 678 18 15 03 17 --

Zambia 118 17 15 20 17 --

USA 15 10 08 17 06 03

+MMR – Maternal Mortality Rate / 100000 live births


Causes of Mat.Mort. In India

Cause Reg.Gen. India (1992) FOGSI (1982)

Haemorrhage 23.7% 22.3%

Toxaemia 15.2 10.7

Puerperal Sepsis 08.1 28.4

Anaemia 19.4 -

Obstructed Labour 07.1 -

Abortion 11.8 -

Others 14.7 -



CAUSES OF 110 MATERNAL DEATHS AT OUR HOSPITAL FROM 1/1996-7/2000

31

23

17

12

754

11

0

20

40

60

80

100

120

CAUSES

NU

MB

ER

OTHERS

MALARIA

ANAEMIA

RUPTURED UERUS

UNSAFE ABORTION

VIAL HEPATIIS

PIH

HAEMORRHAGE



Year Developed DevelopingDevelopingCountries CountriesCountries

1930 1:3000 Births Not AvailableNot Available

1950 1:20,000 Not AvailableNot Available

1980 1:60,000 1:10001:1000

2000 1:100,000 1:50001:5000

PPH - A world of difference



POST PARTUM HAEMORRHAGE

DEFINITION: -

Blood loss of 500ml or more per vaginum

during the first 24hrs after the delivery of the

baby.

Risk of Maternal Mortality & Morbidity are 50 times more after PPH


ASSESSMENT OF BLOOD LOSS AFTER DELIVERY

Difficult Mostly Visual estimation (So, Subjective &

Inaccurate) Underestimation is likely Clinical picture -Misleading Our Mothers-Malnourished, Anaemic,

Small built, Less blood volume


MECHANISM OF HAEMOSTASIS AFTER DELIVERY

• Uterine contraction & retraction

• Platelet aggregation clot

formation


Why PPH ?

1. Uterine atony (80%)

2. Retained Placenta

3. Trauma to genital tract

4. Coagulation disorders

5. Uterine inversion


1. UTERINE ATONY

Over distension of uterus Induction of labour Prolonged / precipitate labour Anaesthesia (halogeneted) & analgesia Tocolytics (Tocolytics (also called anti-contraction medications or

labor repressants) are medications used to suppress premature labor )

APH Grand multiparity Mismanagement of 3rd stage of Labour Full bladder

RISK FACTORSRISK FACTORS


2. RETAINED PLACENTASimple adhesionMorbid adhesion>Accreta, Increta &

Percreta

3. TRAUMATIC Large episiotomy & extensions Tears & lacerations of perineum, vagina

or cervix Haematoma Uterine rupture


4. COAGULATION DISORDERS

Abruptio placentaeSepsis :IUD,PROM(premature rupture

of membrane)Massive blood lossMassive blood transfusionSevere PET (Pre-eclamptic Toxemia)/

EclampsiaAmniotic fluid embolismHepatitis


5. UTERINE INVERSION

Mostly iatrogenic due to mismanagement of 3rd stage - strong traction on the cord with a relaxed uterus / adherent placenta.

Incomplete Inversion- Fundus felt through the Cx

Complete Inversion with placenta accreta attached to the

fundus


SYMPTOMS & SIGNS

Blood loss (% B Vol)

Systolic BP( mm of Hg)

Signs & Symptoms

10-15 Normal postural hypotension

15-30 slight fall PR, thirst, weakness

30-40 60-80 pallor,oliguria, confusion

40+ 40-60 anuria, air hunger, coma, death


PREVENTION Regular ANC Correction of anaemia Identification of high risk cases Delivery in hospital with facility for Emergency

Obstetric Care. Otherwise transport to the nearest such hospital at

the earliest.Keep speedy transport available

Local / Regional anaesthesia ACTIVE MANAGEMENT OF 3RD STAGE OF

LABOUR 4th Stage of labour - Observation, Oxytocin


ACTIVE MANAGEMENT OF 3RD STAGE OF LABOUR (WHO-1989)

Oxytocics - Routine use in third stage blood loss by 30-40% 10 Units Oxytocin IV bolus Syntometrine 1 Amp IV Ergometrine 1 Amp IV Carboprost ( better than Ergometrine) 0.125 – 0.25 Mg IM

Early cord clamping Controlled cord traction Inspection of placenta & lower genital tract


TEAM- Obstetrician, Anesthesiologist, Haematologist and Blood Bank

Correction of hypovolaemiaAscertain origin of bleedingEnsure uterine contractionSurgical managementManagement of special situation

MANAGEMENT OF PPH


CORRECTION OF HYPOVOLEMIA

Large bore IV line (two) Crystalloids (RL)-3ml / ml of

blood loss Urine output (desired) –30ml / hr Whole blood / pack cell

MANAGEMENT OF PPH


ENSURE UTERINE CONTRACTION

Palpate fundus Uterine massage Bimanual compression Compression of Aorta against

sacral promontory Foleys catheters

MANAGEMENT OF PPH


OXYTOCICS Oxytocin:

Bolus of 10 units IV followed by Continuous Infusion 100 mu / min

Ergometrine 0.2 - 0.5mg IV Prostaglandins-

Carboprost- 0.25mg start, Rpt.15-30 min, Maximum 2.0mg, Route-IM / intramyometrial

Sulprostone- 400-600 micro gm

MANAGEMENT OF PPH


OTHER MODES

M.A.S.T (Military Anti Shock Treatment)

UTERINE PACKING

UTERINE TAMPONADE

• Large bulb Foleys

• Sangstaken blakemole tube

MANAGEMENT OF PPH


SURGICAL TREATMENT

Depends on

Extent & cause of haemorrhage

General condition of patient

Future reproduction

Experience & skill

MANAGEMENT OF PPH


SURGICAL TREATMENT Repair of trauma if any Uterine Artery ligation Utero ovarian A. Ligation Internal Iliac A. Ligation Brace suturing of Uterus Hysterectomy Angiographic embolisation

MANAGEMENT OF PPH


RETAINED PLACENTA EUA(examination Under

Anaesthesia & Manual Removal If Placenta accreta-

ObservationCytotoxic drugs- MethotrexateHysterectomy

MANAGEMENT OF PPH


ACUTE INVERSION OF UTERUS

Manual replacement- Under GA / Uterine relaxant

Hydrostatic method

Surgical method ( Usually delayed

procedure)

MANAGEMENT OF PPH


MANAGEMENT OF DIC

Fresh blood transfusion

Blood productsCryoprecipitateFresh frozen plasmaPlatelet concentrate

MANAGEMENT OF PPH


MORBIDITY & MORTALITY from PPH

Shock & DIC Renal Failure Puerperal sepsis Lactation failure Blood transfusion reaction Thromboembolism Sheehan’s syndrome >25% Maternal deaths are due to PPH>25% Maternal deaths are due to PPH


Intelligent anticipation, skilled supervision, prompt detection and effective institution

of therapy can prevent disastrous consequences of PPH.

post partum haemorrhage

Education

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haemorrhagecauses pph

problem pph

live birthspph prof

stage of labour

cases of obstetric haemorrhage

tragedy of maternal

antepartum haemorrhage