4. Definition
Blood loss > 500 ml after delivery
Primary : Loss within 1st 24 hours after
delivery
Secondary : 24 hours till 12 weeks postnatally
Minor : 500-1000 ml
Moderate : 1000-2000 ml
Severe : > 2000 ml
5. PREDICTION AND PREVENTION
- Pl previa/accreta
- Anticoagulation Rx
- Coagulopathy
- Overdistended uterus
Identify pt. at risk
- Grand multiparity
- Abn labor pattern
- Chorioamnionitis
- Large myomas
- Previous history of PPH
6. PREDICTION AND PREVENTION
Active Management Of Third Stage Of Labor
(AMTSL): Should be offered routinely and
includes:
1.Administration of uterotonics soon after birth.
2.Delayed cord clamping.
3.Delivery of placenta by controlled cord
traction followed by uterine massage.
7. PPH Drill
Clear and logical sequence of steps
essential in the management of PPH.
11. Position flat
Keep the patient warm
Administer oxygen by mask ( @ 10-15 litres/
min)
Catheterize the patient for emptying bladder &
monitoring output
12. Fluid Replacement
RAPID WARMED infusion of fluids
Crystalloids : Fluids of choice until
compatible blood is arranged
1 ml of blood loss= 3 ml of crystalloids
Total volume of 3.5 litres of clear fluids
(upto 2 litres of crystalloids followed by 1.5
litres of warmed colloid )may be given while
awaiting compatible blood.
13. If hemorrhage is torrential
& fully cross-matched
blood still not available :
Uncrossmatched O
negative blood may be
given
14. FFP: 4 Units for every 6 Units of red cells OR
PT/ APTT > 1.5 X normal
(ie 12-15 ml/kg or total of 1 litres.)
Platelet Concentrate: if Platelet count< 50,000/
microlitre.
Cryoprecipitate: if fibrinogen < 1 g/ l.
15. Continuous vital monitoring.
Monitor adequacy of replacement with urine
output (0.5 ml/kg/hr) and CVP (4-8 cm water)
Main therapeutic goals are to maintain:
Haemoglobin > 8gm/dl
Platelet count > 75 × 109 / l
Prothrombin < 1.5 × mean control
APTT < 1.5 × mean control
Fibrinogen > 1 gm/ l
16. Establish Etiology Simultaneously
4 T’s
Tone (abnormalities of uterine contraction) :
70 – 80%
Trauma (of the genital tract) : 20 %
Tissue (retained products of conception) : 10
%
Thrombin (abnormalities of coagulation) : 1 %
19. Administer Uterotonic Drugs
FIRST LINE
Oxytocin:
Start with 5 units slow iv or im.
Infusion of 20 units in 1 L@ 60 dr/min.
Continue same dose @ 40 dr/min until bleeding stops.
Maximum upto 3 L.
SECOND LINE
Ergometrine/ methyl ergometrine:
Dose: 0.2 mg im or slow iv
Repeat 0.2 mg after 15 min.
Maximum 5 doses (1 mg)
Syntometrine im
20. THIRD LINE
PGF 2α:
Dose: 0.25 mg im.
Can be repeated every 15 min.
Maximum upto 2 mg or 8 doses.
Misoprostol:
200-800 µg sublingually.
Do not exceed 800 µg
WHO GUIDELINES FOR MANAGEMENT OF PPH 2009
28. Hysterectomy
Resort to hysterectomy “SOONER RATHER
THAN LATER”
High maternal morbidity
Timing and adequate replacement is of utmost
importance
29. Documentation and Debriefing
Important to record:
Sequence of events
Time and sequence of admn of
pharmacological agents, fluids, blood products
The time of surgical intervention
The condition of mother throughout .
30. Newer Developments
Tranexamic acid : 1 gm i.v slow. Can be
repeated after 30 min if bleeding continues./
Recombinant activated factor VII
(Novoseven): 90 µg/ kg . May be repeated
within 15-30 minutes. No clear consensus on
efficacy.
Carbetocin (oxytocin agonist) : 100 µg i.v or
i.m. Produces tetanic uterine contractions.
31. HAEMOSTASIS ALGORITHM
H – Ask for help
A – Assess and resuscitate
E – Establish etiology
M – Massage the uterus
O – Oxytocic administration
S – Shift to OT
T – Tissue n trauma to be excluded and proceed to
tamponade
A – Apply compression sutures
S – Systematic pelvic devascularisation
I – Interventional radiology
S – Subtotal or total hysterectomy
32. To Conclude, Management of
PPH Has Evolved From:
Panic
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness
33. &
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