Postpartum haemorrhage

 What we need to know about PPH??

In the developing world about 1.2% of deliveries are associated with PPH and when PPH occurred about 3% of women died. Globally it results in 44,000 to 86,000 deaths per year making it the leading cause of death during pregnancy. About 0.4 women per 100,000 deliveries die from PPH in the United Kingdom while about 150 women per 100,000 deliveries die in sub-Saharan Africa.

Postpartum bleeding or postpartum hemorrhage (PPH) is often defined either as A) as the loss of more than 500 ml or 1,000 ml of blood within the first 24 hours following childbirthand / and or B) Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist. Therefore,depending on the definition in question, postpartum hemorrhage is defined as more than 500ml following vaginal delivery or 1000ml of blood loss following caesarean section in the first 24 hours following delivery.

What are the Signs and symptoms? These may initially include: an increased heart rate, feeling faint upon standing, and an increased breath rate. As more blood is lost the women may feel cold, their blood pressure may drop, and they may become restless or unconscious. The condition can occur up to six weeks following delivery

The most common cause is 1) poor contraction of the uterus following childbirth.2) Retained placenta”= Not the entire placenta being delivered, 3) Cx tear / Vault tear of the uterus, 4) rarely poor blood clotting are other possible causes. Causes of postpartum hemorrhage are uterine atony, trauma, retained placenta, and coagulopathy, commonly referred to as the "four Ts":

· Tone: uterine atony is the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony. Uterine atony is the most common cause of postpartum hemorrhage.

· Trauma: Injury to the birth canal which includes the uterus,cervix,vagina and the perineum which can happen even if the delivery is monitored properly. The bleeding is substantial as all these organs become more vascular during pregnancy.

· Tissue: retention of tissue from the placenta or fetus may lead to bleeding.

Thrombin: a bleeding disorder occurs when there is a failure of clotting, such as with diseases known as coagulopathies

Who are more prone to develop PPH? Common for whom? It occurs more commonly in those who:

1) Anaemic mothers:-already have a low amount of red blood, are Asian,

2) Twin Preg:-with bigger or more than one baby, are obese or

3) CS delivery :-

4) Elderly :-Those who are older than 40 years of age.5) Injudicious use of Misoprostol/ Syntocinon drip.

5) Use of Oxytocics for inertia of Uterus or in whom in whom medications are used to start labor(induction of labour) , or those who are in active labour for more than 12 hours:-and those who have an episiotomy.

How to prevent??

Prevention involves A) Steps to be taken in Preg: decreasing the known risk factors including:- a) Avoiding and correcting anaemia – Vitamin suppl, deworming, F Acid suppl. Frequent ANC visits, repeated Hb% estimation those who had anemia at first booking visit, b) to -correct the malnutrition it by all means ,if neceeary by I V iron in preg) avoiding prolonged labour by maintaining Friedman curve. Judicious CS ,Correction of nutrition & Anemia , Institutional Delivery i.e if possible procedures associated with the condition and B) Avoid prolonged labour 2) prophylactive methergin after birth of ant shoulder of baby giving the medication like IV oxytocin to stimulate the uterus to contract shortly after the baby is born. All multigravid must have District hospital delivery where Blood Tr service are available round the clock

The advantages of Misoprostol over synocinon??

Misoprostol may be used instead of oxytocin in resource poor settings. Possibly more safe (no rise of BP/can be given in cardiac women too ) More active-can be used orally, sublingually, rectally.

How to treat if PPH occurs? Treatments may include: intravenous fluids, blood transfusions, and the medication methergin (causes sudden rise of BP-in few cases -should not be repeated quite often). Efforts to compress the uterus using the hands may be effective if other treatments do not work. The aorta may also be compressed by pressing on the abdomen. The World Health Organization has recommended non-pneumatic anti-shock garment to help until other measures such as surgery can be carried out.

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