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Postpartum Hemorrhage (PPH): Definition, Management, and Surgical Options

(As per Williams Obstetrics - 10 Mark MS Main Exam Answer)

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1. DEFINITION (New/Revised)

Classical Definition (WHO 2006 / Traditional):

• Vaginal delivery: Blood loss > 500 mL within 24 hours of delivery
• Caesarean delivery: Blood loss > 1000 mL within 24 hours

New ACOG Definition (2017 - Now Standard in Williams Obstetrics):

PPH = Blood loss ≥ 1000 mL, OR any blood loss accompanied by signs/symptoms of hypovolemia within 24 hours of delivery, regardless of mode of delivery.

• Estimated blood loss (EBL) by visual inspection underestimates actual loss by ~50%
• Hypovolemia symptoms reliably appear at ~1000 mL loss
• Quantitative blood loss (QBL) measurement is now mandated (calibrated drapes/weighing)

Classification of PPH:

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2. ETIOLOGY - THE "4 T's" (Williams Obstetrics)

┌─────────────────────────────────────────────────────────────┐
│                    CAUSES OF PPH - 4 T's                    │
├──────────┬─────────────────────────────────────────────────-┤
│  TONE    │ Uterine atony (MOST COMMON - 70-80%)             │
│          │ Over-distended uterus, prolonged labour, MgSO₄   │
├──────────┼─────────────────────────────────────────────────-┤
│  TRAUMA  │ Lacerations (cervix, vagina, perineum), uterine  │
│          │ rupture, uterine inversion, extensions of LSCS   │
├──────────┼─────────────────────────────────────────────────-┤
│  TISSUE  │ Retained placenta, retained cotyledons,          │
│          │ placenta accreta spectrum, abnormal placentation  │
├──────────┼─────────────────────────────────────────────────-┤
│  THROMBIN│ Coagulopathy - DIC, pre-existing bleeding        │
│          │ disorders, anticoagulant use, HELLP syndrome      │
└──────────┴─────────────────────────────────────────────────-┘

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3. MANAGEMENT FLOWCHART

                    POSTPARTUM HEMORRHAGE
                    Blood loss ≥ 1000 mL OR signs of hypovolemia
                              │
                              ▼
               ┌──────────────────────────┐
               │    IMMEDIATE RESUSCITATION│
               │  • Call for help / MICU   │
               │  • 2 large bore IV lines  │
               │  • Oxygen supplementation │
               │  • CBC, coags, crossmatch │
               │  • Foley catheter         │
               │  • Quantify blood loss    │
               └───────────┬──────────────┘
                           │
                           ▼
               ┌──────────────────────────┐
               │  IDENTIFY THE CAUSE (4T's)│
               │  • Uterine examination    │
               │  • Inspect birth canal    │
               │  • Check placenta         │
               │  • Check coagulation      │
               └───────────┬──────────────┘
                           │
              ┌────────────┴────────────┐
              ▼                         ▼
         UTERINE ATONY           TRAUMA/TISSUE/THROMBIN
         (TONE)                  • Repair lacerations
              │                  • Remove retained tissue
              ▼                  • Correct coagulopathy
    ┌─────────────────┐
    │  MEDICAL MANAGEMENT│
    │  (Step 1)           │
    └─────────┬───────────┘
              │
              ▼
    ┌─────────────────────────────────┐
    │         UTEROTONICS             │
    │ 1. Oxytocin 20-40 U in 1L RL   │
    │    infuse @100mU/min            │
    │ 2. Methylergonovine 0.2mg IM    │
    │    (avoid IV; avoid in HTN)     │
    │ 3. Carboprost 250 μg IM q15 min │
    │    (max 8 doses; CI: asthma)    │
    │ 4. Misoprostol 800-1000 μg      │
    │    sublingual/rectal            │
    │ 5. Tranexamic acid 1g IV        │
    │    (within 3 hrs of birth)      │
    └─────────┬───────────────────────┘
              │ FAILS
              ▼
    ┌────────────────────────────────────┐
    │  CONSERVATIVE SURGICAL MANAGEMENT  │
    │         (Step 2)                   │
    └────────────────────────────────────┘
              │
    ┌─────────┴────────────┐
    ▼                      ▼
UTERINE TAMPONADE    COMPRESSION
• Bakri balloon      SUTURES
• Foley catheter     • B-Lynch
• Gauze packing      • Hayman
• SOS Bakri          • Cho square suture
              │
              ▼
       PELVIC VESSEL LIGATION
       • O'Leary Uterine artery ligation
       • Internal Iliac (Hypogastric) artery ligation
              │
              ▼
       ANGIOGRAPHIC EMBOLIZATION
       (where facilities available)
              │ STILL FAILS
              ▼
    ┌────────────────────────┐
    │  PERIPARTUM HYSTERECTOMY│
    │  (Definitive - Step 3)  │
    └────────────────────────┘

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4. MEDICAL MANAGEMENT IN DETAIL

A. Oxytocin (First-line)

• 20-40 units in 1000 mL Ringer's Lactate IV infusion
• Rate: do not exceed 100 mU/min (antidiuretic risk above this)
• Never give IV bolus - causes hypotension, especially with hypovolemia
• Mechanism: direct uterine smooth muscle contraction

B. Methylergonovine / Ergometrine

• 0.2 mg IM only (NOT IV - risk of hypertension, CVA)
• Contraindicated in: hypertension, pre-eclampsia, Raynaud's
• Duration of action: 3 hours IM

C. Carboprost (15-methyl PGF₂α)

• 250 μg IM, repeat every 15 min; maximum 8 doses (2000 μg)
• Contraindicated in asthma (bronchoconstriction)
• Caution in cardiovascular disease

D. Misoprostol (PGE₁ analogue)

• 800-1000 μg sublingually or rectally
• Used when oxytocin fails; safe, no refrigeration needed
• Role in resource-limited settings

E. Tranexamic Acid (TXA) - WOMAN Trial Evidence

• 1 g IV over 10 minutes; repeat 1 g if bleeding continues after 30 min
• Must be given within 3 hours of delivery
• Antifibrinolytic: prevents plasminogen → plasmin conversion
• Reduces PPH-related mortality; does not increase thromboembolism
• Recommended by WHO/FIGO 2022 as part of standard PPH package

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5. CONSERVATIVE SURGICAL MANAGEMENT

A. Uterine Tamponade

• Silicone balloon inserted into uterine cavity
• Inflated with 250-500 mL saline
• Left in place 24-36 hours
• "Tamponade test" - if balloon controls bleeding, avoids laparotomy
• Also: Foley catheter (for low implantation site), SOS Bakri, Sengstaken-Blakemore tube

• Sterile gauze packing of uterine cavity
• Less preferred, but effective in selected cases (Creasy & Resnik)

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B. Uterine Compression Sutures (Williams Obstetrics, Chapter 41)

B-Lynch Suture (1997 - "Brace Suture / Suspenders")

• Introduced by Christopher B-Lynch in 1997
• Purpose: compresses anterior and posterior uterine walls together
• Uses No. 2 chromic catgut suture

Step 1: Needle enters below LSCS incision, 
        pierces lower uterine segment into cavity
Step 2: Brought up and over the fundus anteriorly
Step 3: Passes to posterior uterine wall
Step 4: Enters posterior lower uterine segment
Step 5: Crosses to contralateral side
Step 6: Reversed - suture brought around fundus 
        posterior to anterior
Step 7: Exits through contralateral side of 
        hysterotomy incision
Step 8: Both ends tied in midline, compressing the uterus

• B-Lynch (2005): 948 cases, only 7 failures (99.3% success)
• Kayem et al (2011): 211 women, 25% failure rate (varies by indication)

• Uterine ischemic necrosis + peritonitis (rare)
• Uterine cavity synechiae (subsequent infertility)
• Total uterine necrosis (if combined with bilateral artery ligations)
• Wall defects in subsequent pregnancy

• Hayman suture - simpler, does not require opening the uterus
• Cho square sutures - for localized bleeding areas
• Pereira suture - horizontal and vertical sutures combined
• Nelson modification

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C. Pelvic Vessel Ligation

1. O'Leary Uterine Artery Ligation

• Described by O'Leary and O'Leary
• Series of sutures placed around branches of uterine artery + through myometrium
• Results in vessel compression against uterine wall
• Performed when major uterine laceration is not found at laparotomy
• First step in laparotomy for PPH (before hypogastric ligation)

2. Internal Iliac (Hypogastric) Artery Ligation (Burchell, 1964)

• If uterine artery ligation fails
• Mechanism (Burchell): Transient decrease in blood pressure and flow in regional pelvic vessels → hemostasis through clot formation
• Isolated 3 cm distal to bifurcation with external iliac artery
• Preserves fertility - collateral circulation is ample; women have delivered normally in subsequent pregnancies
• Success rate: Only ~50% (technically difficult, per Williams)
• Drawbacks: Technically demanding; risk to ureter; only 50% success
• Transient complications: mild bladder dysfunction, buttock pain (self-resolving)

Aorta
  └── Common Iliac
          ├── External Iliac → Femoral
          └── Internal Iliac (Hypogastric)
                  ├── Anterior Division
                  │       └── Uterine artery ← LIGATION POINT
                  │       └── Vaginal artery
                  │       └── Inferior vesical
                  └── Posterior Division
                          (Preserved - supplies gluteal region)

3. Stepwise Devascularisation (Abdrabbo's Steps):

1. Unilateral uterine artery ligation
2. Bilateral uterine artery ligation
3. Utero-ovarian ligament ligation
4. Bilateral internal iliac ligation

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D. Angiographic Embolization

• Uterine artery embolization (UAE) via interventional radiology
• Balloon/embolization catheters in anterior divisions of internal iliac arteries
• Placed pre-operatively (in placenta accreta) or intraoperatively
• Requires facility + trained personnel
• Advantage: Fertility-preserving
• Used in haemodynamically stable patients

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6. DEFINITIVE SURGICAL MANAGEMENT

Peripartum Hysterectomy (Last Resort)

• Failure of all conservative measures
• Uterine rupture
• Placenta accreta spectrum (percreta, increta)
• Atony unresponsive to all treatments
• Patient with no further desire for fertility

• Patient in semilithotomy position (allows simultaneous vaginal inspection)
• Sterile drapes permit vaginal/cervical exam by assistant to confirm cessation of bleeding
• Same steps as non-pregnant hysterectomy but DIFFERENT due to:
  • Engorged, friable vessels
  • Pliable, thinned tissues
  • Distorted anatomy

• Total hysterectomy - preferred (removes cervix + body)
• Subtotal (supracervical) hysterectomy - faster, less morbidity; acceptable if bleeding is controlled

1. Identify and protect ureter (crucial - distorted anatomy)
2. Bladder reflection downward
3. Clamp uterine vessels bilaterally (see image above)
4. Ligate uterosacral and cardinal ligaments
5. Close vaginal vault (total) or leave cervix (subtotal)

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7. BLOOD PRODUCT RESUSCITATION (Massive Transfusion Protocol)

• Target Hb: > 8 g/dL in active PPH
• Target fibrinogen: > 2 g/L
• Avoid: Normal saline (hyperchloraemic acidosis); use Lactated Ringer's
• Point-of-care testing: ROTEM/TEG for coagulopathy guidance

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8. COMPLETE MANAGEMENT ALGORITHM (Summary Table)

STEP 1 - MEDICAL (All cases of PPH)
├── Uterine massage (bimanual compression)
├── Oxytocin 20-40 U IV infusion
├── Methylergonovine 0.2 mg IM
├── Carboprost 250 μg IM (if no asthma)
├── Misoprostol 800 μg sublingual/rectal
├── Tranexamic acid 1 g IV (within 3 hrs)
└── IV fluids + blood products

STEP 2 - CONSERVATIVE SURGICAL (If Step 1 fails)
├── A. Uterine Tamponade
│     └── Bakri balloon / Foley / Gauze packing
├── B. Angiographic embolization (if stable + facilities)
└── (If above fail → Laparotomy)
    ├── C. Uterine compression sutures
    │     └── B-Lynch / Hayman / Cho
    ├── D. O'Leary uterine artery ligation
    └── E. Internal iliac artery ligation

STEP 3 - DEFINITIVE SURGICAL (Last resort)
└── Peripartum Hysterectomy
      ├── Total (preferred)
      └── Subtotal (faster, emergency)

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Key High-Yield Points for MS Exam:

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