The document discusses the medical management of postpartum haemorrhage, including definitions, risk factors, etiology, prevention through active management of the third stage of labor, general management principles, choice of uterotonic drugs and their doses and routes of administration, fluid resuscitation, blood product transfusion guidelines, and recommendations from WHO. Prevention of PPH primarily focuses on oxytocin administration and treatment involves oxytocin, carboprost, misoprostol or other uterotonics depending on availability and the clinical situation.

1. MEDICAL MANAGEMENT
OF POST PARTUM
HAEMORRHAGE
DR VIDYA THOBBI
PROFESSOR OF OBG
AL AMEEN MEDICAL COLLEGE
BIJAPUR

2. Magnitude of the Problem
WHO estimates
529,000 maternal deaths occur from complications of
pregnancy and childbirth every year.
99% of maternal deaths occur in the III world countries;
More than 60 % of maternal deaths occur in the
postpartum period, when prevention strategies are often
lacking.
PPH is 50 times commoner in these countries.
14 million cases of PPH per year
•World Health Organization. Global estimates of maternal mortality
for 1995: results of an in-depth review,
& .analysis and estimation strategy Statement . Geneva: World Health
Organization, 1995:2001.
•Network: Summer 1997, Vol. 17, No. 4

4. Definition
Any blood losss from genital tract during
delivery > 500ml. (WHO)
ACOG- decline in haematocrit by 10% or
need of RBC transfusion.
PRIMARY PPH- Within 24 hours
SECONDARY PPH- upto 12 weeks .
is more likely due to infection and
retained placental tissue

5. REMEMBER
Every woman in labor is at risk of PPH.
2/3 of those with PPH –have no identifiable
risk factors.Be prepared in all labors
Active management of third stage of labor
should be practiced on ALL women in labor.
It prevents 60% of atonic PPH
All post partum women must be closely
monitored for PPH. 5

6. Assess risk factors
Ante partum Intrapartum Post Partum
APH/ Previous Operative delivery, Genital tract injury
PPH / MRP Manipulations
Over distended Prolonged labor Retained placenta
uterus
Adherent Infection Uterine inversion
placenta
Congenital or Acquired Coagulopathy
6

7. Etiology
Atonic
Traumatic
Coagulation disorders
Atonic!
Atonic !!
Atonic !!!

8. Easy to miss
Physicians underestimate blood loss by
50%
Slow steady bleeding can be fatal
Most deaths from hemorrhage seen after 5h
Abdominal or pelvic bleeding can be
hidden

9. PREVENTION
ACTIVE MANAGEMENT OF THIRD STAGE
LABOUR
(AMTSL)
Adminstration of
uterotonic drugs within
1min of delivery of baby Uterine massage
OXYTOCIN Controlled after
10 units IM cord traction delivery of placenta

10. Proposed classification. Adapted for Benedetti
Hemorrhage Estimated blood Blood vol Clinical signs & symptoms Treatment
class loss(ml) loss(%)
0(normal loss) < 500 <10 None
ALERT LINE
1 500-1000 15 Minimal Observation ± replacement
therapy
ACTION LINE
2 1200-1500 20-25 ↓ urine output Replacement and oxyticics
↑ pulse rate
↑ respiratory rate
Postural hypotension
Narrow pulse pressure
3 1800-2100 30-35 Hypotension Urgent active management
Tachycardia
Cold clammy extremities
Tachypnea
4 >2400 >40 Profound shock Critical active management

11. Assessment of
Shock
Compensatio Mild Moderate Severe
n
Sympto Palpitation, Weakness, Restlessnes Collapse,
ms & dizziness, sweating, s, pallor, air-hunger,
signs tachycardia tachycardia oliguria anuria
BP Slight fall Marked fall Profound
(Systoli Normal 80- 70-80mmHg fall
c) 100mmHg 50-70mmHg
Blood 500-1000ml 1000-1500ml 1500-2000ml 2000-3000ml
loss 10-15% 15-25% 25-35% 35-45%
Blood
volume
11

12. General Management
 Shout for help.
 Rapid evaluation of vitals.
 Oxygen by mask.
 Uterine massage.
 Oxytocin Draw & Send
lab test
 Site 2 large bore (16G-gray color) IV cannula,
The blood for lab test
Save blood for
 Infuse IV fluid – NS / RL- run it fast.
 Catheterize bladder.
 Check the placenta –
 If it has been expelled
 If it is expelled , re examine & make sure it is
complete.
 Examine vagina, perineum and cervix for tears.
12

13. FLUID RESUCITATATION
Maintanance of tissue perfusion.
Multiple large bore IV access.
Crystalloids[1:3]
Colloids & Blood products to maintain Hb
near 10gm% during active bleeding..
>80% volume replacement causes
dilutional coagulopathy
Coagulopathy&thrombocytopenia-
PLT&FFP.

14. Bimanual Uterine massage

15. MEDICATIONS FOR PPH

16. Other drugs used
Tranexamic Acid
Recombinant Factor VII a
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17. OXYTOCIN
1. Oxytocin promotes rhythmic contractions of
upper uterine segment.
Short plasma half life-3 min.
Continuos I.V.infusion required.
Dose 20 units in 500 ml crystalloid(250ml/hr)
Give IM or IU, not IV. (Can cause ↓ BP)
Max dose 40 units

18. Important side effects of oxytocin
Sudden hypotension
Antidiuresis with hyponatremia, > 100
miu/min
Neonatal jaundice
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19. The Uniject device Single dose—to minimize
wastage
Prefilled—ensuring correct
dose
Nonreusable—to minimize
patient-to-patient transmission
of blood borne pathogens
Easy to use—to allow use by
health workers who do not
normally give injections
Compact size—for easy
transport and disposal

20. Carbetocin- what is it? And what are the
advantages
Long acting ,synthetic octapeptide analogue of
oxytocin
100 mcg of single carbetocin V/s 10 u oxytocin
infusion
-faster involution
-lesser blood loss
- fewer additional oxytocics
- lesser need for uterine massage
Obst & gynae survey, 2010, vol 65:3, 148-149
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21. Carbetocin
Given as IVbolus 100ug Acts within 2 min
Peak concentration within 30min
Longer half life 80-90 min
80% Bioavailability
IM effect lasts twice as long as IV
21
Contraindicated in hepatic and renal dis

22. Methergine
Sustained tonic uterine contraction.
I.M. 0.25 Mg.
Onset of action-2 to 5 min.
Mean plasma half life 30 min.
Clinical effect persists 3 hrs.
Can cause Hypertension, especially IV.
Precautions-in hypertensive,preeclampsia.
Refrigeration storage 2-8c

23. CARBOPROST
0.25mg IM or Intramyometrium.
PGF2
Controls hemorrhage in 86% when used
alone, and 95% in combination with others
Can repeat up to eight times.
Contraindicated in active Br.Asthma
Can cause nausea/vomiting/diarrhea, ↑ BP.

24. MISOPROST
PGE1
Prompt uterine contraction.
Routes-
oral/sublingual/rectal/vg/intrauterine.
Stable at room temp.Long shelf life
Easy to administer.
Cheap.

25. MISOPROSTOL
Routes of Onset of action Duration
administration
Oral Fastest shortest
Rectal Slow prolonged
Sublingual Rapid prolonged

26. MISOPROST
Dose-600 to 800 micrograms.
S/E- minor, dose related.
fever,shivering,diarrhea.
Rectal –longer onset of action.
lower peak levels,
more favourable side effect profile.
FIGO 600mcg orally after delivery of baby if
oxytocin is not available

27. WHO
RECOMMONDATIONS
MISOPROSTOL
Absence of skilled caregivers to offer
controlled cord traction
Non availability of injectables
Difficulties in ensuring safe injection
practices
Difficulties in refrigeration preventing the
use of oxytocin
SBA should not offer sublingual or rectal
misoprostol for prevention of PPH in
preference to oxytocin

28. Pharmacokinetic
Oral misoprostol reaches its peak at 20 minutes. Its action is slow in
comparison to intra muscular oxytocin.
http://www.misoprostol.org/File/news.php

29. TRANEXAMIC ACID
Anti-fibrinolytic agent to reduce blood loss
and the need for blood transfusion.
The WHO panel in systematic review of
randomized controlled trials showed that in
surgical patients tranexamic acid reduced
the risk of blood transfusion by 39%
Tranexamic acid may be offered as a
treatment for PPH if uterotonic options have
failed, or trauma is the cause
Doses of 60-120 ug/kg intravenously were

30. r FVIIa in the management of PPH
It has potential to become universal
hemostatic agent
It is a safe effective hemostatic measure in
severe obstetric hemorrhage , both as
1.adjunctive treatment to surgical
hemostasis and
2.rescue therapy where PPH is refractory to
current medical and uterus sparing surgeries.
Dose 40-90mcg/kg i.v.[NOVOSEVEN]
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31. The WHO has published guidelines for the management of PPH based on a
review of the evidence by an expert panel
For prevention of PPH, syntometrine compared with oxytocin isassociated
with a trend to reduced blood loss >1000ml (odds ratio (OR) 0.78, 0.58-
1.03); no difference in blood transfusion (OR 1.37, 0.89 to 2.10), and less us
of additional uterotonics (risk ratio (RR) 0.83, 0.72-0.96), but more side
effects, particularly hypertension (RR 2.40, 1.58-3.64).1
Oxytocin compared with ergometrine is associated with no statistically
significant difference in blood loss >1000ml (RR 1.09, 0.45-2.66) and use of
additional uterotonics (RR 1.02, 0.67-1.55); and fewer adverse side effects:
vomiting (RR 0.09, 0.05-0.16); elevated blood pressure (RR 0.01, 0.00-0.15)
There were insufficient data to compare the outcome blood transfusion.2,,3
There were no clear benefits for the use of carbetocin4, intramuscular
prostaglandins5 or sulprostone6,7 over oxytocin and/or ergometrine.
For prevention of PPH, misoprostol (400 to 800 mcg) compared with
injectable uterotonics is associated with increased blood loss of ≥ 1000ml
(RR 1.32; 95% CI 1.16-1.51), but no statistical difference in the incidence of
severe morbidity, including maternal death (RR 1.00, 95% CI 0.14- 7.10)55

32. Meta-analysis of trials in the
Cochrane database systemic review
Oxytocin alone reduces PPH by 60% ( 7 trials)
Syntometrine Vs oxytocin More chances of
HTN with former : otherwise both effective (6
trials)
Active Vs Expectant management of 3rd stage
clearly established superiority of AMTSL( 5
trials)
Carboprost/ Misoprostol Vs conventional
(32trials) - conventional preferred
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Carbetocin- not recommended 32

33. Recommendations- Prevention
10 U of Oxytocin IM/ IV infusion I Line
WHO doesnot recommend IV bolus RCOG
does
Methyl ergometrine 0.2 mg IV/IM II Line
if there are no contra indications
Carboprost 250mcg IM III Line
Misoprostol 600mcg oral/1000mcg P/R
when other drugs not available
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34. Recommendations - PPH
40 u oxytocin in 500ml- 125ml/hr ( RCOG)
20u in 1 L - 60 dr/min ( WHO)
Methergine 0.2mg repeat 15 mins followed by 4th
hrly 5 doses
Carboprost once in 15 Mins Maxm 8 doses
Syntometrine more side effects but may be used
Misoprostol Not very beneficial ( WHO)
Tranexamic acid- May help if trauma is the cause
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35. WHO 2012 Recommendations
Based on this direct evidences, the WHO
strongly recommends
Oxytocin alone should be used for the
treatment of PPH in preference to adjunct
misoprostol.

36. Blood/Blood products
Unstable patient
Continued bleeding
Loss > 30%
Severe PPH
Coagulopathy
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37. Choice of Blood /components
O Group Rh –ve in dire emergency
Grouped and cross matched Packed cells
6u of packed cells - give 4 u of FFP
PT/APTT >1.5 of normal - 12-15ml
FFP/KG
Platelets if <50,000 or during surgery
,<80000 give 10 units
Fibrinogen<100mg - cryoprecipitate upto
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10 units

38. CHOICE OF UTEROTONICS
OXYTOCIN ERGOMETRINE MISOPROSTOL CARBOPROST
Dose 10IU IM. or 10- Ergotmetrin 0.5mg 400-600μg 125 μg IM
40U in IV Infusion Methergin 0.2mg IM oral –serum conc in Acts in <5min,
C.S – 5 IU slow IV Acts in 6-7min, acts 7.5-30min(mean 18
followed by infusion systemically on min)
Act in 2-3min, smooth muscle Rectal- serum conc in
specific to uterine 15-60min (mean
smooth muscle 40min)
Short acting Long acting Long acting Long acting
safe Contraindicated in Safe , home delivery Contraindicated in
HT and non skilled asthma
attendent
inexpensive More expensive Inexpensive expensive
Min side effect Nausea, vomiting, HT Shivering, pyrexia Bromchospasm,
vomiting diarrhoea,
flushing
Cold storage more Demands cold storage No cold storage Cold storage
stable to heat and
light

39. Oxytocics
Dose & Maintenance Max frequency Precautio
route dose dose /CI
Oxytocin IV infusion IV infuse Not -Acts
10U/500ml 10U/500ml more within 3
60dpm 40dpm than 3lt min
Ergometrin IM / 0.2mg after 5 doses. 4th hourly PIH, HT,
e/ slow IV of 15 min. (1mg) Heart
Methergin 0.2mg disease.
15methyl IM 250μg 250μg after 8 doses 15 - 90mnts Asthma,
PGF2α ** 15mnts (2mg) heart
disease.
** NEVER GIVE PROSTAGLANDIN INTRAVENOUSLY
IT MIGHT BE FATAL
39

40. 3 Ds causing the 4th D(eath)
1. Delay in recognizing & seeking help.
How to diagnose
2. Delay in transport & reaching medical
facility.
When to shift?
3. Delay in receiving an adequate Rx
comprehensive give early & appropriate treatment ?
What & how to care upon arrival 40

41. WHERE TO SHIFT?
Delay in shifting is an important cause of
Death
Think of shifting as early as possible.
• Shift as quickly as possible.
• Communicate- to patient /attendant
• - to the tertiary care personnel
Shift to a tertiary care centre with:
• OT
• ICU
• Blood bank
• Personnel
41

42. HOW TO SHIFT?
Shift preferably in an ambulance,
With nasal oxygen on flow
With 2 IV lines with fluid on flow (it can be
lifeline)
Document
• The events in sequence
• IV fluids given
• Drugs administered
Communicate to personnel at tertiary care centre.
42

43. NASG Non inflatable anti shock
garment
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44. Crash Kit (Emergency Tray)-
For handling emergencies one must have a crash kit with the
following ,18 ,20)
Brannula (16
Hydrocortisone
Bulbs- grouping and
cross matching Calcium Gluconate
Venesection Set Deriphylline
Syringes/ Gloves Atropine
Roller gauze / mops / Adrenaline
sticking plaster, scissor
Dopamine, Dobutamine
Foley’s catheter
Drip sets
I. V. Fluids- RL, DNS
Hemacel,
Intubation materials
Oxytocin,Misoprostol
PGF2alpha,Methergin
Oxygen with mask

46. Intelligent anticipation, skilled
supervision, prompt detection and
effective institution of therapy can
prevent disastrous consequences of
PPH.

47. THANKYOU
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