POST PARTUM HAEMORRHAGE - A Challenge To Safe Motherhood :POST PARTUM HAEMORRHAGE - A Challenge To Safe Motherhood Dr. Arati Patnaik, M.D. Prof..S.N.panda, M.S. Department of of Obstetrics & Gynaecology M.K.C.G. Medical College, Berhampur, INDIA


Slide 2:30-Jul-08 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 TO


Slide 3:30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 3 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


Slide 4:30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 4 . . . 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* :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 5 Direct Causes (%) of Mat.Mort. in selected countries* MAGNITUDE OF THE PROBLEM *World watch paper 102Jacobson JL ed, 1991 +MMR – Maternal Mortality Rate / 100000 live births


Causes of Mat.Mort. In India :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 6 Causes of Mat.Mort. In India MAGNITUDE OF THE PROBLEM


MAGNITUDE OF THE PROBLEM :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 7 MAGNITUDE OF THE PROBLEM


MAGNITUDE OF THE PROBLEM :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 8 Year Developed Developing Countries Countries 1930 1:3000 Births Not Available 1950 1:20,000 Not Available 1980 1:60,000 1:1000 2000 1:100,000 1:5000 PPH - A world of difference MAGNITUDE OF THE PROBLEM


POST PARTUM HAEMORRHAGE :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 9 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 :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 10 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 :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 11 MECHANISM OF HAEMOSTASIS AFTER DELIVERY Uterine contraction & retraction Platelet aggregation  clot formation


Why PPH ? :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 12 Why PPH ? Uterine atony (80%) Retained Placenta Trauma to genital tract Coagulation disorders Uterine inversion


1. UTERINE ATONY :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 13 1. UTERINE ATONY Over distension of uterus Induction of labour Prolonged / precipitate labour Anaesthesia (halogeneted) & analgesia Tocolytics APH Grand multiparity Mismanagement of 3rd stage of Labour Full bladder RISK FACTORS


2. RETAINED PLACENTA :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 14 2. RETAINED PLACENTA Simple adhesion Morbid adhesion>Accreta, Increta & Percreta 3. TRAUMATIC Large episiotomy & extensions Tears & lacerations of perineum, vagina or cervix Haematoma Uterine rupture


4. COAGULATION DISORDERS :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 15 4. COAGULATION DISORDERS Abruptio placentae Sepsis :IUD,PROM Massive blood loss Massive blood transfusion Severe PET/ Eclampsia Amniotic fluid embolism Hepatitis


5. UTERINE INVERSION :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 16 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 :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 17 SYMPTOMS & SIGNS


PREVENTION :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 18 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) :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 19 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


Slide 20:30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 20 TEAM- Obstetrician, Anesthesiologist, Haematologist and Blood Bank Correction of hypovolaemia Ascertain origin of bleeding Ensure uterine contraction Surgical management Management of special situation MANAGEMENT OF PPH


CORRECTION OF HYPOVOLEMIA :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 21 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 :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 22 ENSURE UTERINE CONTRACTION Palpate fundus Uterine massage Bimanual compression Compression of Aorta against sacral promontory Foleys catheters MANAGEMENT OF PPH


OXYTOCICS :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 23 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 :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 24 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 :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 25 SURGICAL TREATMENT Depends on Extent & cause of haemorrhage General condition of patient Future reproduction Experience & skill MANAGEMENT OF PPH


SURGICAL TREATMENT :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 26 SURGICAL TREATMENT Repair of trauma if any Uterine A. ligation Utero ovarian A. Ligation Internal Iliac A. Ligation Brace suturing of Uterus Hysterectomy Angiographic embolisation MANAGEMENT OF PPH


RETAINED PLACENTA :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 27 RETAINED PLACENTA EUA & Manual Removal If Placenta accreta- Observation Cytotoxic drugs- Methotrexate Hysterectomy MANAGEMENT OF PPH


ACUTE INVERSION OF UTERUS :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 28 ACUTE INVERSION OF UTERUS Manual replacement- Under GA / Uterine relaxant Hydrostatic method Surgical method ( Usually delayed procedure) MANAGEMENT OF PPH


MANAGEMENT OF DIC :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 29 MANAGEMENT OF DIC Fresh blood transfusion Blood products Cryoprecipitate Fresh frozen plasma Platelet concentrate MANAGEMENT OF PPH


MORBIDITY & MORTALITY from PPH :30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 30 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


Slide 31:30-Jul-08 PPH- Prof.S.N.panda & Dr.A.Patnaik 31 Intelligent anticipation, skilled supervision, prompt detection and effective institution of therapy can prevent disastrous consequences of PPH. THANK YOU