Post-Partum Hemorrhage:

Management and
Complications

Max Mongelli
Clinical Associate Professor
Western Clinical School
University of Sydney
Nepean Hospital
 Third stage of labour

From delivery of the baby to delivery of the

placenta < 20minutes.

Cessation of umbilical artery pulsation,
placenta separates from uterine wall through
the decidua spongiosa and is delivered

Capillary haemorrhage and shearing effect
of uterine muscle.
Amount of blood loss depends on:

How quickly the placenta separates from

uterine wall.

How effectively the uterine muscle
contracts around the placental bed during
and after separation.

Intact coagulation system.
Active management

“Standard practice”

Administration of an oxytocic at the
delivery of the anterior shoulder/after the
baby has been delivered.

Early cord clamping and cutting

Controlled cord traction of the umbilical
cord
Expectant management

“Conservative” “Physiological”

Waiting for the umbilical cord to cease
pulsation

Waiting for signs of placental separation

Allowing placenta to deliver spontaneously

Aided by gravity/nipple stimulation/breast
feeding
 Active vs Expectant
Management

Reduced maternal blood loss

Reduced PPH rates (0.38, CI 0.32 to 0.46)


Shortening of 3rd stage of labour
(-9.77, CI –10.0 to –9.53)


Increased maternal nausea
(1.83, CI 1.51 to 2.23)


Increased vomiting and raised BP
(probably due to use of ergometrine)

Cochrane Database of Systematic Reviews 2000

PPH

Definition –
primary >500ml
secondary

PPH rates

Maternal risks
 mortality

 morbidity

Risk factors

Prevention

Management
Definition

Blood loss from the genital tract >500ml in
the first 24 hours following delivery

“normal blood loss” (Bonnar 2000)
- at vaginal delivery: 600ml
- at Caesarean section: 1000ml
PPH

Haemorrhage is the main cause of death in a
number of countries

At least 25% of maternal deaths worldwide
due to haemorrhage – the majority
postpartum haemorrhage

Vast majority in the developing world

Most important complication of the 3rd stage
of labour
Massive haemorrhage

>1500ml

Blood loss requiring replacement of the
patient’s total blood volume

Transfusion >10 units blood within 24 hours

Replacement of 50% circulating blood
volume in <3hours

Loss of >150ml/minute
 PPH rates

Depend on the definition used

KEMH >500ml 12%, >600ml 9.45%, >1000ml
5.5%

Similar rates in Australasian tertiary institutions

Most of Australasia:
 >500ml 8%,

 >1000ml 4.27%,

 >1500ml 1.83%,

 >2000ml 0.6%
Maternal risks

Mortality

Triennial reports from UK 1985-96 show no
significant reduction in the number of deaths from
haemorrhage (30 each triennia)


Majority due to substandard care

DELAY in - correction of hypovolaemia,
- diagnosis and treatment of defective
coagulation
- surgical control of bleeding

“TOO LITTLE TOO LATE”
Mortality

Developing countries PPH 125,000 deaths/yr

28% of maternal deaths

Risk 1 in 1000

Australia 1 in 100,000 deliveries die of PPH

Life threatening haemorrhage 1 in 1000 deliveries

Risk increases with increasing maternal age
especially >35 years
 Morbidity

Coagulopathy (DIC)


Fluid overload/Pulmonary edema

Left ventricular failure
 Morbidity

Injury to ureter and bladder from surgical

intervention

Sheehans syndrome
 permanent hypopituitarism caused by
avascular necrosis of the anterior
pituitary gland,
 failure of lactation, amenorrhoea,
hypothyroidism and adrenocortical
insufficiency
Blood Changes in Pregnancy

Normal adult blood volume 70ml/kg
eg 50kg 3.5L
60kg 4.2L
70kg 5.0L,
etc

The healthy pregnant woman has a blood
volume of 6-7L in late pregnancy
Blood Changes in Pregnancy

During pregnancy:

40% increase in blood vol
-increase in red cell mass

Lowering of haematocrit by 10%

Marked increase in fibrinogen
and factors VII,
VIII and X
Adaptation to blood loss

Blood loss <1000ml induces little or no
change in pulse or BP

Catecholamine – induced vasoconstriction
maintains perfusion of the maternal heart
and brain at the expense of diminished
utero-placental blood flow

Tachycardia may be absent in up to 25% of
cases with severe blood loss.
 Haemorrhagic shock
and blood loss
Blood volume BP Symptoms and Degree of
loss signs shock
10-15% Normal Palpitations, Compensated
(500-1000ml)
dizziness, HR incr

15-25% Slight fall Weakness, sweating, Mild

(1000-1500ml)
tachycardia

25-35% 70-80mmHg Pallor Moderate

(1500-2000ml)

35-45% 60-70mmHg Collapse, air hunger, Severe
(2000-3000ml)
anuria
Disseminated Intravascular Coagulation

Depletion of fibrinogen, coagulation factors and

circulating platelets

Haemostatic failure

Microvascular bleeding

Increased blood loss

Unlikely if platelet count is normal
 Risk Factors for PPH (1)

Placenta praevia, especially if associated with

accreta/percreta/increta

Previous history of PPH

Previous history of retained placenta, Ashermans
syndrome, endometrial ablation

Hypertensive disorders

Manual removal of retained placenta

Refusal of blood transfusion
 Risk Factors for PPH (2)

Maternal obesity

Large baby

APH/abruption

Multiple pregnancy

Previous PPH (recurrence rate 8-10%)


Operative delivery – Emergency CS
substantially increases the risk
 Risk Factors for PPH (3)

Anaemia

Induction/augmentation of labour

Instrumental delivery

Prolonged labour (1st or 2nd stage)


Grand multiparity (>5)

Bleeding disorder (eg Von Willebrandt’s)


Use of anti-epileptic medications
 Prevention of PPH:
Antenatal period

Identification and correction of anemia in

pregnancy

Detection of sub-clinical bleeding disorders

Detection of placenta accreta/percreta

Care plan for management of third stage if
risk factors detected
Prevention of PPH (2)


Oxytocic policy

Venous access, G+H, active management of
third stage, oxytocin infusion in those
identified as at risk

Senior obstetrician/anaesthetist at placenta
praevia CS

+/-gynae oncologist at placenta accreta CS
Management of PPH

Call for help

Resuscitate

Restore circulating blood volume

Identify and treat the cause
Resuscitation

Massage fundus

Venous access, 16 gauge cannula, x2

Tilt head down, O2 by face mask

Bloods:FBC, Coags, X-match

IDC

Monitoring
Volume replacement

Crystalloids
 80% infused fluid leave the intravascular space

AVOID DEXTROSE

O negative blood if torrential loss

Packed cells

4 units FFP for every 6 packed cells

Platelets/cryoprecipitate

Involve haematologist early on

Avoid colloids
 Monitoring

Pulse, BP

Respiratory rate

Temperature

Urine output 0.5 ml/kg/hour (30ml/hour)


Pulse oximetry

HDU: Arterial catheterisation
Identify and treat the cause

Tone
Bimanual compression,
oxytocics

Tissue
Remove retained
placenta/membranes

Trauma
Repair genital tract tears

Thrombin
Correct/prevent
coagulopathy
 Uterine atony

Most common cause of PPH

Oxytocin infusion (as per local protocol)


Ergometrine IM

Rectal misoprostol (up to 800mcg)


Rectal PGE2 (20 mg)


Intra-myometrial PG F2 alpha (250 mcg)

Examination under anaesthetic

Remove retained placental tissue ensuring
the uterus is empty

Detailed examination of cervix and vagina
to exclude and repair any lacerations

More oxytocics

Antibiotic cover

Medical – PgF2alpha
 Case Scenario

You are the SR/consultant called to theatre.

Junior registar has a patient who has lost
1500ml has done EUA, given oxytocics
including PgF2alpha and the patient is
continuing to bleed.

What are you going to do?
 Continued bleeding

Uterine tamponade
 Foley catheter

 Double balloon catheter

 Uterine packing

 Sengstaken-Blakemore tube

Consider calling gynae oncologist

Consider arterial embolisation – interventional
radiologist
Laparotomy

Uterine haemostatic suture
 B Lynch suture

 Modified B Lynch

Arterial ligation
 Bilateral internal artery ligation

 Bilateral uterine/ovarian artery

ligation

Hysterectomy
 Total

 Subtotal
Technique

70mm round bodied No.2 CCG

3cm from the right lower edge and 3cm
from the right lateral border of the incision

Thread through into the uterine cavity and
emerge the needle 3cm above the incision

Pass the CCG over the fundus 3-4cm from
the right cornual border
Technique

Feed CCG posteriorly and vertically.

Enter uterine cavity posteriorly at same site
as superior anterior entry point

Pull CCG under moderate tension, assistant
applies manual compression

Pass suture horizontally to emerge on
posterior wall at the same level but on the
left posterior side of the uterus
 Technique

Suture knot using two or three throws whilst

assistant maintains bimanual compression

Close the lower transverse incision in the
uterus
 B Lynch suture

Advantages
 Effective control of haemorrhage

 Conservation of the uterus for fertility

 Avoidance of more radical procedure

(hysterectomy) and its potential

morbidity
 Relatively simple

Disadvantage:
-paralytic ileus
Hayman compression sutures

 Does not require a lower uterine incision

 Uses 1-vicryl x 4

 Bladder has to be reflected down

 Simpler than B-Lynch

 Balloon Tamponade

Various methods available:

Sengstaken tube

SOS-Bakri tamponade balloon
catheter

Condoms

Foley’s catheters

Surgical glove
SOS – Bakri Balloon Tamponade
 SOS – Bakri Balloon Tamponade

The indications for use:

 Temporary management of lower uterine

segment bleeding.

 Indicated in about one third of all PPH

cases.
Sengstaken-Blakemore Balloon Tamponade
Sengstaken-Blakemore Balloon Tamponade

 Esophageal balloon inflated to 250 ml with

normal saline
 Prophylactic antibiotics
 Prevented major surgery in more than 70%
of cases
 May help reduce bleeding if transfer is
required.
Balloon Tamponade with Condoms

The idea was first introduced by Professor Sayeba Akhter

(Dhaka, Bangladesh) to save the life of a woman who had
severe jaundice with intractable PPH.

Condom is inflated with isotonic saline of 250 – 500 ml
(sometime >500 ml – 1 L)


When the bleeding is reduced considerably, further
inflation is stopped. then outer end of the catheter is
folded and fixed to the thigh.

To keep the inflated balloon within the uterus, the post
vagina is packed with sterile pack
 Uterine Artery Ligation -
“O’ Leary Stitch”

Requires downward bladder reflection to reduce

risk of ureteric injury.

Bilateral ligation effective in 90% of cases

High ligature may be required.

Low risk of long-term complications
 Interventional Radiology

Percutaneous transcatheter embolisation

Must be performed before uterine artery
ligation

Performed under fluoroscopic guidance

Gelfoam is the preferred agent

Angiographic occlusion balloon catheters

Success rate 95-97%

Useful for vulvovaginal hematomas
 Interventional Radiology:
Disadvantages

There may be a significant delay before
personnel and equipment are in place

Not widely available

Contraindicated if coagulopathy is present

Minimal data on subsequent pregnancy
outcomes
 Interventional Radiology:
Complications

Procedure related morbidity of 6%

Post-embolisation fever

Buttock ischemia

Vascular perforation

Infection
 Case scenario

You are a GP obstetrician delivering a low
risk woman in a country hospital.

You are delivering the placenta and note
that her BP has suddenly fallen to 80/40,
pulse 40. She is bleeding profusely

What do you do?

What is your differential diagnosis?
 Concealed PPH

If hypovolaemic……..and no overt bleeding
consider

Broad ligament haematoma

Ischiorectal fossa haemorrhage/haematoma

Paravaginal haematoma

Intra abdominal bleeding
 Previous uterine scar – uterine rupture

 Rupture of vascular aneurysms

 Liver/spleen rupture
Conclusions

Relevance of PPH worldwide

Increasing incidence of PPH

Prophylaxis

Don’t forget the basics

Good luck!