Postpartum severe hemorrhage (often called PPH): : ABC of PPH

Year ending exchange of knowledge :-How many members haven’t read PPH chapter after MD ?? Pl be honest to your uncle. Many new deceives have cone in last 2 deadens.  We must brush up or knowledge  on A)   definition of   postpartum hemorrhage B) W must understand that the  most  common cause  of postpartum  hemorrhage   is uterine    atony C) Most  importantly Know    the treatment   for uterine   atony, and the contraindications for the   various   agents.

Urine   atony  is a major cause of severe PPH.  For instance we had a case of atonic PPH on 20/12/19.  Case history in 20^th Dec 2019.  A 26 year old   parous woman at 37 weeks of  gestation with  preeclampsia    delivers vaginally.   . After the placenta   is delivered  , there is     appreciable  vaginal bleeding  , estimated  at 1000 ml.

Most likely diagnosis by SR was  : Urine   atony

Next  step in therapy which 3^rd yr PGT made at 0010 hrs was  : step 1:  Dilute  intravenous   oxytocin, and as that was ineffective , step 2:  she pushed  then intramuscular prostaglandin F2  alpha  as pt had no H/O B asthma . This prostaglandin   compound that   causes smooth  muscle   contraction but contraindicated  in asthmatic patients . So a record must be made at each ANC visit at OPD and a note must be there ,preferably in local language so at L room nurses understand that she is  a case who is unfit for PG  , though seldom PGF are injected even very senior by Nurses.

As a last resort she pushed  step 3:   rectal   misoprostol.(this would have been the prophylaxis part in  our hospital but in any case she missed it). Relatives denied   a family history  of a bleeding   diathesis

Clinical meeting on 30^th Dec at Seminar Room of Obstet Bldg . The concerned SR was allowed to present the case in presence of Faculty members & Postgraduates. She continued to said that the amount of bleeding she had met    the definition of postpartum  hemorrhage , which is  a low of 500 ml or more   after a vaginal   delivery. The most common   etiology is uterine    atony , she added.(SR). Te etiology or causation of ut atony   in which the  myometrium  do  not   contract   to cut off the  uterine spiral   arteries   that are   supplying    the placental bed. step 1 : Catheterization, Uterine message and dilute    oxytocin  are the first therapies. step 2 : If these are ineffective   , then    prostaglandin F2 alpha  or rectal   misoprostol are  the next   agents   were used in this patient she retrievated .  SR continued to argue that   as because  said Pt was  hypertensive step 3 :, methylergonovine  maleate  was  contraindicated  . It should be   noted that  if  the uterus is palpated and found   to be firm and   yet bleeding  continues , a laceration   to the genital   tract would have been    suspected . She firmly said that ut in that case was relaxed and difficult to maintain a contracted state,. In case presenation   she concluded by mentioning that risk factors    for uterine   atony  in her case which she conduced were A)    preeclampsia   , since  she is likely to be treated  with magnesium  sulfate. step  4 Condom for balloon Tapmonade of bleeding lower uterine segment. A Bari balloon would be a much more predictable device in this situation. For placenta previas many are using Bari balloon for about one decade. Step 5: One Sr Faculty member informed the gathering that bin the decades of seventies  in primary  PPH in CS  cases that Abd binder & vaginal Packing:- She said that LSCS  bleed is fairly common. So far she have managed by vaginal pack , along with making uterus forcibly anteverted and tie an abdominal binder ( hoping that body of the uterus will compress LUS . But now switched over to Bari balloon if available at OT, Otherwise she uses   Next time I will try this technique.

High Cx tear may be a rare cause of PPH(Primary) :-Quiet often in pl accreta (LS) -The cut specimen of uterus showed no adherent placenta or membranes and I have asked the pathologist to look for any signs of placental invasion. It appears that she may have had a high cervical tear that couldn't have been diagnosed from below or that she was is consumptive coagulopathy which is likely as she had gone in severe pH. (> 1000 cc blood loss)

Now year ending Questions: members pl do participate abd be a part of teaching programme to PGT/ SR