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What defines Postpartum Hemorrhage (PPH)?
PPH is defined as blood loss greater than 500cc after vaginal delivery or greater than 1000cc after cesarean delivery, or decrease in hematocrit (HCT) by ≥10%. It leads to shock, coagulopathy, renal failure, acute respiratory distress, and may require blood transfusion.
What is the most common cause of Primary Postpartum Hemorrhage (1ry PPH)?
The most common cause of Primary PPH (within 24 hours) is uterine atony. Other causes include: Trauma (cervix, vagina, perineum), Retained parts (placenta, membranes), Uterine inversion, Systemic causes (DIC, coagulation disorders).
What are the key clinical signs of Postpartum Hemorrhage (PPH)?
Uncontrolled vaginal bleeding, Decreased blood pressure, Increased heart rate (tachycardia), Bleeding can be concealed, Bradycardia may also be present, Swelling and pain in vaginal and perineal tissues.
What are the risk factors for Postpartum Hemorrhage (PPH)?
Uterine over-distension, Multipara (multiple pregnancies), Anaemia, High blood pressure, Previous PPH, Prolonged labor, Obesity, Genital tract trauma, Maternal bleeding disorders.
What are the 4 T’s to remember when considering the causes of Postpartum Hemorrhage (PPH)?
Tone: Uterine atony (most common cause), Tissue: Retained placenta, membranes, or clots, Trauma: Cervical, vaginal, or uterine trauma, Thrombin: Coagulation failure.
What is the management of Uterine Atony in PPH?
Initial steps: Check the bladder (ensure it is empty to promote uterine contraction), Abdominal uterine massage, Bimanual uterine massage (for severe hemorrhage). Medications: Oxytocin: IV 20 IU/L in 500 mL NS, administer at 250 mL/hr, Prostaglandins (Misoprostol, Carboprost).
What is the management protocol for major PPH (blood loss >1000 mL)?
Airway: Ensure the airway is open, Breathing: Administer oxygen via mask (15 L/min), Circulation: 14-gauge IV cannulas, isotonic fluids, Insert Foley catheter, Blood transfusion: O Rh-negative or group-specific blood, Blood products: FFP, Platelets, Cryoprecipitate.
What should be done if manual uterine massage does not control bleeding in uterine atony?
If manual uterine massage is ineffective, the next steps are: Bakri balloon insertion (intrauterine tamponade), Uterine artery ligation, B-Lynch suture for uterine compression, Embolization of the uterine artery, If all else fails, consider subtotal hysterectomy.
What is the cause and treatment for Retained Placenta in PPH?
Cause: Failure to deliver the placenta within 30 minutes after delivery, Treatment: Ecbolics (e.g., Oxytocin), Brandt-Andrews method (controlled cord traction), If unsuccessful, manual removal of the placenta, If placenta accreta is suspected, consider hysterectomy.
How is Thrombin (coagulation failure) managed in PPH?
Treat underlying disease (e.g., pre-eclampsia, HELLP syndrome), Serial coagulation status monitoring, Blood component replacement: FFP, Platelets, Cryoprecipitate.
What is uterine atony and how does it contribute to PPH?
Uterine atony occurs when the myometrium fails to contract properly, leading to blood vessels at the placental site remaining open. This causes severe bleeding due to the lack of compression on the uterine blood vessels.
What are the initial steps to manage uterine atony in PPH?
- Empty the bladder (prevents uterine relaxation), 2. Trans abdominal uterine massage, 3. Bimanual uterine massage for severe hemorrhage.
What medications are used to treat uterine atony?
Oxytocin (Pitocin, Syntocinon): IV 20 IU in 500 mL NS, then 250 mL/hr, Prostaglandins (Misoprostol, Carboprost), Methylergometrine (Ergometrine).
How do you perform bimanual uterine compression for uterine atony?
One hand is placed in the vagina to compress the posterior uterine wall. The other hand is placed on the abdomen to compress the anterior uterine wall, helping to close the blood vessels and stop the bleeding.
What is the role of oxytocin in uterine atony management?
Oxytocin is used to stimulate uterine contractions and reduce bleeding by promoting uterine tone. Dose: IV 20 IU in 500 mL NS, administered at a rate of 250 mL/hour. Caution: Prolonged use may cause water intoxication due to its effect on ADH.
What is the management for retained placenta?
Ecbolics and controlled cord traction (Brandt-Andrews method) to assist in delivering the placenta. If this fails, manual removal of the placenta should be done. If placenta accreta is suspected, hysterectomy may be necessary.
What are the causes of PPH due to trauma?
C-section (emergency more than elective), Perineal trauma, Operative delivery (forceps, vacuum), Vaginal or cervical tears, Uterine rupture.
What is the cause and treatment for thrombin-related PPH (coagulation failure)?
Causes: Conditions like pre-eclampsia, HELLP syndrome, ITP, TTP, von Willebrand disease, or DIC. Treatment: Correct the underlying condition, monitor coagulation status, and replace blood products such as FFP, cryoprecipitate, and platelets.
What are the clinical features of PPH?
Vaginal bleeding, Abdominal (scar) tenderness, Maternal tachycardia, Abnormal fetal heart rate tracing, Cessation of uterine contractions.
What are the symptoms of retained placental fragments?
Boggy, relaxed uterus, Dark red bleeding, Treatment includes D&E (Dilation and Evacuation), Administration of Oxytocins, and Prophylactic antibiotics.
What is uterine inversion and how is it treated?
Uterine inversion occurs when the uterus turns inside out after delivery, often due to excessive traction on the umbilical cord. Treatment: Immediate repositioning of the uterus (Johnson maneuver), may require IV nitroglycerin or general anesthesia to relax the lower uterine segment.
When is subtotal hysterectomy indicated in PPH?
Subtotal hysterectomy is indicated when all conservative measures fail (e.g., uterine massage, uterotonics, uterine artery ligation), and severe bleeding persists. This procedure removes the uterus while preserving the cervix.
