MANAGEMENT

OF PPH

Multidisciplinary team consisting of obstetrician ,

anaesthetist, haemotologist, theatre staff and nursing staff

is ideal.

The patients general condition is evaluated and if he/she

is in shock immediate resuscitative measures are

instituted.

A hand on uterus will confirm atonicity and enable

uterine massage which should be done continuously.

PRINCIPLES OF MANAGEMENT

1. GENERAL MEASURES

* Resuscitative measures

* Investigations

* Monitoring

* Confirm the cause of PPH

2. MEDICAL METHODS

3. MECHANICAL METHODS

4. SURGICAL METHODS

5. RADIOLOGICAL ARTERIAL EMBOLISATION

GENERAL MEASURES

RESUSCITATIVE MEASURESFLUID REPLACEMENT

Two intravenous infusions with large 14 gauge cannulaeare started

Aim is to replace 2-3 times the estimated blood lose

Crystalloids (normal saline or Ringer lactate) infused at the rate of 1L in 15-20 min

Colloids can be given until blood is available (1-2L)

Crossmatch blood should be given as rapidly as possible

A central venous pressure line can be introduced

BLOOD COMPONENT THEORY

Correction of RBC deficit is guided by the rule that each

unit of packed cells will restore Hb concentration by

1gm/dl

If there is evidence of coagulation defects fresh frozen

plasma, platelet concentrates, and cryoprecipitate are

made available

For every 6 units of red cells , 4 units of fresh frozen

plasma can be given

Each adult dose of cryoprecipitate will raise fibrinogen

level by 100mg/dl

Each adult dose of platelet concentrates will raise the

platelet count by 20000/L

OTHER MEASURES

Oxygen can be given by a mask or nasal cannula at rate of 10-15L/min

Patients leg may be elevated in order to increase venous return

If unconscious patient should be turned to one side to minimise aspiration in case of vomiting

Important to keep patient warm as hypothermia will exacerbate poor peripheral circulation

INVESTIGATIONS

LABORATORY TESTS

Hb, haematocrit, bloodgrouping and crossmatching must

be done

Platelet count, fibrinogen assay, partial thromboplastin

time, prothrombin time should be measured .

Electrolytes, urea and creatinine needed in severe

hemorrhage

Bedside tests like clot observation test or clotting time

can be done

MONITORING

Pulse and Blood pressure

Heart rate by ECG monitor

Oxygen saturation by pulse oximetry

Central venous pressure line- to assess adequacy of fluid

replacement

Hourly urine output

Fluids and drugs given

CONFIRMATION OF DIAGNOSIS

Genital tract injuries are looked for and if present,

sutured

If placenta is not yet expelled signs of seperation are

looked for

If there are retained placental fragments , they are

removed

Succenturiate lobe should not be missed

Coagulopathy is checked

MEDICAL METHODS

Oxytocin

20-40 units in 500ml of normal saline

Ergometrine

Ergometrine 0.25mg or methergin 0.2mg given

Prostaglandin derivatives

15 methyl analogue of prostodin- 250microgram given.

MECHANICAL METHODS

BIMANUAL COMPRESSION

Abdominal hand massages the posterior aspect of uterus

and the vaginal hand made into a fist presses the anterior

uterine aspect through anterior fornix.

Should be done continuously to promote uterine

contraction

Aortic compression against sacral promontory to reduce

bleeding.

Other mechanical methods include uterine packing and

balloon tamponade

BIMANUAL COMPRESSION

SURGICAL METHODS

UNDER SEWING

CHO’s MULTIPLE BLOCK SUTURES

B LYNCH OR BRACE SUTURE

MODIFIED B LYNCH (HAYMAN)

SYSTEMIC PELVIC DEVASCULARISATION-

HYSTERECTOMY

UNDERSEWING

Undersewing the placental bed with figure of eight or

purse string sutures

Done at caesarean section for placenta praevia

MULTIPLE BLOCK SUTURES

Involve approximation of anterior and posterior uterine

walls with multiple squares until no space is left in uterine

cavity

MULTIPLE BLOCK

SUTURES

BRACE SUTURE

Involves use of vertical brace sutures

Very easy to perform

Commonly performed at caesarean section but can also

be done after vaginal delivery.

MODIFIED B LYNCH(HAYMAN)

Involves use of two vertical compression sutures placed

on either side of fundus

Quicker than brace suture.

Does not require a low transverse incision . Hence it is

useful following a vaginal delivery

BRACE SUTURE

SYSTEMIC PELVIC DEVASCULARISATION

Involve laparotomy and progressive stepwise

devascularisation

Uterine , ovarian and finally the internal iliac arteries are

ligated

Absorbable sutures should be used always

The ascending branch of uterine artery or the anterior

division of internal iliac artery are usually ligated.

UTERINE ARTERY LIGATION

HYSTERECTOMY

Considered as a last resort

Indications include severe atonic hemorrhage, placenta

accreta , placenta praevia and uterine rupture

Subttotal hysterectomy may be easier and quicker but is

inadequate in cases where bleeding is in the lower

segment as in placenta praevia and adherent placenta

Ovaries should be retained

RADIOLOGICAL ARTERIAL

EMBOLISATION

The patient shoud be hemodynamically stable

Under angiographic guidance and percutaneous

transcatheter technique , femoral artery catheterisation is

done

Bleeding vessels are identified

Embolisation carried out with gel foam or microspheres

Management of secondary PPH

High vaginal swab should be taken for culture

Broad spectrum antibiotics should be started

If the ultrasound scan reveals retained products , uterus

should be evacuated

The tissues obtained should be sent for culture and

histopathological studies

If there is evidence of sepsis , evacuation should be

delayed by 12-24 hours to reduce risk of septicemia

If bleeding is severe uterine artery ligation or

hysterectomy is done

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