Shahida Khaliq

Faisalabad, Pakistan IR-021

Obstetrics

Postpartum Hemorrhage
O bstetric hemorrhage is the
world`s leading cause of
maternal mortality, causing 24% of, or
12 weeks post partum.6

Aetiology and Risk Factors

an estimated 127,000 maternal death PPH is commonly due to abnormalities
annually PPH is the most common type of one or a combination of four basic
of obstetric hemorrhage and accounts processes referred to in the 4 T's
for the majority of 14 million causes of mnemonic.
obstetric hemorrhage that occur each
year.PPH accounts for one quarter of Tone-Poor uterine contraction after
all maternal deaths world wide. l delivery.
Ti s s u e - Re t a i n e d Pr o d u c t s o f
Conception or Blood Clots.
In developing countries, PPH
Trauma- To Genital Tract.
accounts for over one third of all
Thrombin- Coagulation
maternal deaths. 2
Abnormalities.
Definition Common risk factors for PPH are
There is no single, satisfactory multiple Pregnancy, Poly-hydramnios,
definition of PPH. PPH is defined as F e t a l m a c r o s o m i a , o b e s i t y,
blood loss more than 500ml following Coagulation disorder, primigravidity,
vaginal delivery or more than 1000ml chorioamnionites, prolonged rupture
following Cesarean delivery.3 of membranes, fibroid uterus,
previous caesarean birth, antpartum
The Scottish confidential audit of hemorrhage, pre eclampsia,
severe maternal morbidity defines as induction of labour, prolonged labour,
major hemorrhage as estimated blood instrumental delivery and prior PPH,7
loss >2500ml or the transfusion of 5 halo-genated anesthetic agents,
or more units of blood or treatment for nitrates, non steroidal, and
Coagulopathy (Fresh Frozen Plasma, inflammatory drugs, magnesium
4
Cryoprecipitate, Platelets). sulfate, beta sympathomimetics,
nifedipine and hypothermia due to
Another definition is any blood loss massive rescuscitatation or prolonged
that causes hemodynamic instability uterus exteriorization.
e.g. a fall in blood pressure as the risk
of dying from PPH depends not only on In UK, there is an overall trend towards
the amount and rate of blood loss but later child bearing, increased
5
also on the health of the woman. maternal age at childbirth with
associated. Increased incidence of
TYPES OF PPH. caesarean and instrumental deliveries
PPH is classified as primary or as well as placenta previa.8, 9, 10
secondary. Primary PPH occurs within
the first 24hrs after delivery and Pathophysiology:-
secondary occurs between 24hr and The blood vessels that supply the

184 April to June 2010 INDEPENDENT REVIEWS

placental bed pass through an inter- include antenatal risk assessment and
lacing network of muscle fibres management that assures that anemia
(myometrium). The spiral arteriolar or other health problems are treated
arrangements in the uterus might lower and women are sufficiently healthy to
the arterial pressure with which the with stand PPH, as well as appropriate
blood enters the uterus. Myometiral management of labour and delivery.
contraction is the main driving force for
placental separation and constriction Components of active
for the blood vessels. This haemostatic management third stage of labor
mechanism is known as physiological The usual components include
sutures or living ligatures. When the 1. Administration of uterotonic
placenta separates, bleeding occurs agents with in 1 min of birth
from the placental bed. Uterine atony 2. Controlled Cord traction and
results in a failure of the living ligatures uterine message after delivery
to stop the bleeding. The active of placenta as appropriate.
management of the third stage of This approach reduces the risk
labour is associated with a reduction of of PPH and postpartum
the risk of PPH and less need for blood anemia, transfusion require-
transfusion by enhancing this ments, prolonged third stage
11
physiological process. of labour and use of thera-
Prevention peutic drugs of PPH.11
The prediction of PPH using antenatal

Clinical findings in obstetric hemorrhage.

Blood Pressure Degree of Shock

Blood Volume Loss Symptoms + Signs
(Systolic)

Palpitations, Tachycardia
500-1000(10-15%) Normal Compensated
Dizziness

Slight Fall Pale, Cool Skin, Weakness,

1500-2000ml(25-35%) Mild
(80-100mmhg) Sweating, Tachycardia

Blood Flow to vital organs

Moderate Fall (liver, Gut, Kidenys), Restlessness
1500-2000ml(25-35%) Moderate
(70-80mmhg) Pallor, Oliguria, Mottling of the skin
in the extremties especially the legs.

Marked Restlessness, Agitation collapse,

2000-3000ml(35-50%) Severe
(50-70mmhg) Air hanger, Anuria

risk assessment is poor only 40% of Use of Oxytocics:

women who develop PPH have an Injectable oxytocin is used mostly. It is
identified risk factor. However, PPH if first line agent because it is effective 2-
often a predictable event, women with 3 mins after injection and has minimal
identified risk factors should be secondary effects, it can be used in all
transferred to centers with transfusion women. Other uterotonics can be used
facilities and an intensive care unit for e.g. ergometrine 500ug 1M with 5 1U
delivery if these are not available / ml.12
locally. Prevention of PPH should

April to June 2010 INDEPENDENT REVIEWS 185

 Misoprostol, it can be used by oral, Treatment
sublingual and rectal routes. The A systematic and step wise
misuse of misoprostol can lead to management of PPH can be achieved
significant maternal morbidity and with the use of the following measures.
even death. A recent Cochrane review
on the use of prostaglandins nor General Medical Management
misoprostal is preferable to Ask for Help
conventional Injectable uterotonics as Massive PPH should be managed with
part of the management of the third multi disciplinary input. Senior
stage of labour especially for low risk obstetricians, anesthetist and theatre
13
women. staff, hematologist and the blood bank
and hospital porters and intensive care
Carbetocin, a long acting oxytocin unit should be alerted.
agonist has been used for prevention of
PPH. Nevertheless, Carbetocin is Assess
associated with reduced need for Vital parameters, monitoring the
additional uterotonics agents and patient's vital signs, Level of
uterine message and there are no Consciousness, blood pressure, pulse,
significant differences in adverse effects Oxygen, saturation, estimation of
between carbetocin and oxytocin. 14 blood loss.
The WHO recommends that: Different methods of estimation have
1. Active management of the third been evaluated and guidelines to
stage of labour include admi- improve accuracy of the visual
nistration of a uterotonic soon estimation of blood loss have been
after birth of the baby, delay suggested.15
cord clamping and delivery of
the placenta by controlled cord
Resuscitation
traction followed by uterine
Two large bore cannula pass. Send
message.
blood for full blood count, group and
2. Active management of the third
cross match. Coagulation Screen.
stage of labour should be
Renal and Liver Profile,
offered by skilled attendants as
I. Raising the legs,
potential risks such as uterine
ii. Administer oxygen at 10-
inversion may result from
151/m.
inappropriate cord traction.
iii. A loss of 1 liter of blood
3. Oxytocin should be offered for
requires replacement with 4-5
prevention of PPH in
liters of crystalloid (0.9%
preference to oral, sublingual
normal saline and lactated
or rectal misoprostol.
ringers solution) or colloids
4. In the absence of active
until cross matched blood is
management of the third stage
available as most infused fluid
of labour, a uterotonic drug
shifts from the intravascular to
(oxytocin or misoprostol) 16
the interstitial space.
should be offered.

186 April to June 2010 INDEPENDENT REVIEWS

 Management of Postpartum Hemorrhage

Abdominal pain Oozing from Massive Bleeding

and shock without venipuncture sites(rare)
vaginal bleeding (rare)

Consultation for consider coagulopathy call for help

possible retroperitoneal or (coagulation studies) Evaluate ABCs
paravaginal hematoma Administer Fluids
Administer oxygen
Consider transfusion

Placenta Delivered?

Yes No
Vigorous fundal message Manual Exploration
Oxytocin 10-30 unit rapidly in 1 litre of uterus
of intravenous fluid

Firm fundus, uterus contracted Indistinct Distinct

still bleeding bleeding stop claeavage plane cleavage plane

Explore for cervical,

vaginal, or vulvar lesions consider placenta Manual extraction
accereta of placenta

Vaginal, or vulvar Vaginal, or cervical No lesion

hematoma leceration consultation for probable
urgent hystrectomy
Manual exploration
of uterus.
Repair
up to 4cm 4cm or later
and stable and expanding bi manual compression
of uterus while awaiting help
Retained uterine uterine uterine
Placenta Repture inversion atony
ice packs incise, or clots
and observe drain+pack

Remove Resuscitation Resuscitation Resuscitation

+ urgent lapororomy Correction of inversion apply uterotonics
Apply tamponade
Uterine artery embolization
Laporotomy with compression
suture

Hystrectomy

April to June 2010 INDEPENDENT REVIEWS 187

 The Golden Hour Negative blood should be transfused
The golden hour is the time at which until cross-matched blood become
resuscitation must be commenced to available. 1 liter of fresh frozen plasma
ensure the best chance of survival. The should be administrated with every 6
probability of survival decreases units of blood transfused.
sharply after the first hour if the patient
is not effectively resuscitated.17 Platelet Concentration should be kept
9
at more than 50* 10 / liter or more
9
A rule of 30 has been used for acute than 80-100* 10 /liter if surgical
management of shock. If the patient's intervention is likely.
systolic blood pressure fall by
30mmHg, heart rate (HR) rises by 30 Cryoprecipitate and other clothing
beats/min, RR increases to > 30 factor (VI11, XIII, Von Willebrand
beats/min and hemoglobin (Hb) or Factor) may be required if there is DIC
haematocrit (HCT) drop by 30% and or if the fibrinogen levels is less than
urinary output is < 30ml/hr, then the 10g/l. Recombinant factor VII may be
patient is most likely to have lost at least used in hemophilic patient's.
30% of her blood volume and is the
moderate shock leading to severe The incidence of thrombotic
shock. Shock index may also be used in complication occur in 1-2% with use of
the monitoring of the woman with PPH. recombinant factor VII.
It refers to heart rate divided by the
systolic blood pressure (SBP). The Treatment of Atony
normal value is 0.5 - 0.7 with In case of uterine atony, following
significant hemorrhage, it increases to measures should be taken to control
0.9 - 1.1.18 postpartum hemorrhage.

Establish aetiology, ecbolic, ensure Message the uterus, either manually

availability of blood. (hand on the fundus) or bimanually
(vaginal hand in the anterior fornix,
Establish Aetiology abdominal hand on the posterior
Identify the cause of bleeding by using aspect of the fundus) is a simple and
mnemonic 4T's. Through assessment of effective first line measure and reduces
the uterine size and tone should be bleeding.
followed by vigorous uterine message
and administration of therapeutic Oxytocin infusion, prostagtandins: I/V
uterotonic agents. bolus 10 units of oxytocin adminis-
tered. 40 units in 500ml of 0.9%
Manually exploration of the uterine normal saline, infused at a rate of
cavity under anesthesia to exclude 125ml/hr.
RPOC's and to look for extended tears
in the cervix and high in the vaginal If the uterus remains atonic after initial
wall excluded Coagulopathy. oxytocic therapy, syntometrine or
ergometrine should be repeated.
Treatment of Coagulopathy Carboprost is a prostaglandin F2α
Group specific or group O, Rh- analogue which is administered

188 April to June 2010 INDEPENDENT REVIEWS

intramuscularly and intramyometrially until a hospital can be reached. A pilot
0.25mg repeated every 15min to a study showed that compared with
maximum dose of 2mg. This is 80-90% women in a control group, bleeding
effective in stopping PPH. It has bronc- decreased by 50% in women
hoconstrictive properties, therefore experiencing various forms of obstetric
contra-indicated in asthma. Side haemorrhage in whom the NASG was
effects include diarrhea, vomiting, used. 21
fever, headache and flushing.
T- Tissue and trauma to be
Dinoprostone is a prostaglandin E2 excluded and to proceed to
analogue which may be used vaginally tamponade with balloon or
or rectally. It has effect on hypothalamic uterine packing.
thermoregulation and can cause
temperature elevation. Previously, uterine packing was
considered that
Misoprostol is a synthetic prosta- I. It was a potentially traumatic
glandin E1 analogue misoprostol use and time consuming proce-
was associated with a significant dure.
increase of maternal pyrexia and ii. Might conceal on-going
shivering.19 A recent Cochrane review hemorrhage.
concluded that there is insufficient iii. Might predispose to the
evidence to show that the addition of develop-ment of infection.
misoprostol is superior to the iv. Non physiological approach.
combination of oxytocin and
ergometrine for the treatment of But now, Maier concluded that unterine
primary PPH20. A combination of these packing is a safe, quick and effective
two agents could provide a sustained procedure for controlling PPH. 22
uterotonic effect.
Uterine balloon tamponade
Surgical Number of devices, including the
When medical treatment fail then foley's catheter, a condom, the
surgical treatment applied. sengstaken-blackmore oesophageal
catheter (SBOC), the rush urological
S- Shift to operating theatre (anti-shock hydrostatic balloon and the bakri
garment, especially if transfer is ballon has been used. The SBOC has
required and bimanual compression). been the most frequently reported
device. Overall, the reported success
23
From low resource settings transfer to a rates vary between 70-100%, Use of
centre with facilities is indicated. balloon tamponade in the successful
Antishock garment can reverse the management of PPH secondary to
effect of shock on the body's blood extensive vaginal lacerations has been
24
distribution by applying external recently been reported.
counter pressure to the legs and
abdomen and returning blood to the Balloon is inserted and uterine fundus
vital organs, thus stablizing women is palpated abdominally and mark.
Then oxytocin infusion administered to

April to June 2010 INDEPENDENT REVIEWS 189

 keep the uterus contracted and monitor artery embolisation done where facili-
vitals every 30mins. Antibiotic cover ties available to control bleeding.
should be given.
Arterial embolisation under fluoros-
After 6-8 hrs, the uterine fundus copic guidance is also used. The
remains at the same level and there is success rates may be as high as 70-
no active bleeding then catheter 100% and the procedure has the
removed, keep the patient fasting for potential to preserve fertility.
2hrs after removing balloon.
Prophylatic embolisation may have a
Apply Compression Sutures role in a planned caesarean section
If the patient is stable and bimanual when the placenta is thought to be
compression sutures may be used. B- morbidly adherent.27
25
Lynch suture techniques is used. The
ease of application of such sutures is a Complications include, hematoma
β-lynch suture major advantage and fertility is formation, infection, contrast related.
conserved. The disadvantage are the Side effects and ischemia resulting in
need for laparotomy and hysterectomy. uterus and bladder necrosis. The need
Complications include erosion through for specialized equipment and an
the uterine wall, pyometra and uterine interventional radiologist with a high
necrosis. degree of expertise are limitations of
this procedure.
Systemic Pelvic devascularisation
Systemic Pelvic devascularisation done Subtotal or total abdominal
where facilities available to control hysterectomy
bleeding. Subtotal or total abdominal hyste-
rectomy as usually the final option in
Pelvic devascularisation requires the management of PPH and should
laparotomy and progressive, step wise not be delayed if the conservative
devascularisation.
26
measures have failed. Hysterectomy is
associated with numerous post-
Whereby the uterine ovarian and finally operative complications, including
internal iliac arteries are ligated. urinary tract injury, fistula formation,
bowel injury, vascular injury, pelvic
Vaginal ligation of the uterine arteries haematoma and sepsis. The loss of
has also been described. Prerequisite child bearing potential and the
include a haemodynamically stable psychological consequences should
patient substantial surgical expertise also be considered.
and a desire to preserve fertility. The
reported success rates are between 90- All these surgical techniques (Uterine
100%. tamponade, devascularisation,
compression sutures and hyste-
Interventional radiology with rectomy) requires the ready availability
uterine artery embolisation. of specific instruments and equipment.
Interventional radiology with uterine For this purpose, an obstetric
hemorrhage equipment tray in the

190 April to June 2010 INDEPENDENT REVIEWS

labour ward will facilitate prompt hysterectomy.28
surgical management of severe
obstetric hemorrhage and may reduce Long Term Complications
the need of blood transfusion and Pa t i e n t ' s w h o h a v e m a s s i v e
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The author :
Shahida Khaliq MBBS, FCPS
is Senior Register
(Gynaecology/Obstetrics)
Independent Medical
College Faisal-abad.

192 April to June 2010 INDEPENDENT REVIEWS