pph in obs

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"postpartum hemorrhage" management

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Postpartum Hemorrhage (PPH) in Obstetrics

Definition

Primary (early) PPH: Blood loss >500 mL after vaginal delivery, or >1000 mL after cesarean delivery, within 24 hours of delivery
Secondary (late) PPH: Abnormal bleeding occurring 24 hours to 6 weeks after delivery
Clinically, any bleeding causing signs/symptoms of hemodynamic instability - or that would cause instability if untreated - qualifies as PPH, regardless of measured volume

Causes - The "4 Ts"

Cause	Examples	Frequency
Tone (atony)	Failed uterine contraction	~70-80%
Trauma	Cervical/vaginal/uterine lacerations, uterine rupture, uterine inversion
Tissue	Retained placenta/membranes, placenta accreta
Thrombin	DIC, hereditary coagulopathy, pre-eclampsia

Late PPH causes: Subinvolution of the placental site, retained placental fragments, infection, hereditary coagulopathy.

Risk Factors

For uterine atony:

Uterine overdistension (polyhydramnios, multiple gestation, macrosomia)
High parity
Prolonged or rapid labor
Oxytocin use
Intraamniotic infection (chorioamnionitis)
Uterine-relaxing agents (magnesium, tocolytics)

For cesarean delivery hemorrhage:

Preeclampsia
Active labor disorders
Obesity
General anesthesia
Prior PPH history

Initial Assessment & Stabilization

Monitor vital signs frequently
Establish two large-bore IV lines
Start IV crystalloid (lactated Ringer's)
Prepare for blood transfusion (type and crossmatch)
Supplemental oxygen
Labs: CBC with platelets, fibrinogen, fibrin split products, PT, PTT
Real-time ultrasound - identify retained placenta or blood clots

Management by Cause

1. Uterine Atony (most common)

Step 1 - Uterotonic agents (first-line):

Drug	Dose/Route	Notes
Oxytocin	20-30 units in 1000 mL IV at ≤100 mU/min	No IV bolus (causes hypotension). Risk of water intoxication with large volumes.
Methylergonovine / Ergonovine	0.2 mg IM q2-4h	Contraindicated in hypertension (causes vasoconstriction). Never IV (risk of severe HTN, CNS vasospasm, hemorrhage).
Carboprost (15-methyl PGF2α / Hemabate)	250 μg IM q15-90 min; max 8 doses	Caution in asthma and cardiovascular disease. Monitor O₂ saturation.
Misoprostol	800-1000 μg rectally or transvaginally	Used when conventional pharmacotherapy fails.

Bimanual uterine compression is performed alongside uterotonics.

Step 2 - Tamponade (if uterotonics fail):

Bakri balloon or large Foley catheter - especially for low placental implantation site bleeding
Uterine packing with sterile gauze

Step 3 - Interventional radiology:

Selective embolization of pelvic vessels (where facilities are available)

Step 4 - Surgery (laparotomy):

Patient positioned in semilithotomy
Goals: identify occult bleeding sources, ligation of uterine/hypogastric (internal iliac) arteries
B-Lynch suture or other compression sutures
Hysterectomy as last resort

Internal iliac (hypogastric) artery ligation: reduces pulse pressure in pelvic vessels. Collateral circulation is ample; subsequent pregnancies are possible after this procedure.

2. Lacerations (Trauma)

Inspect cervix, vagina, and perineum with good lighting and assistance
Repair any identified lacerations
Firm fundus + ongoing bleeding = suspect occult laceration or retained placenta

3. Retained Placenta / Placenta Accreta (Tissue)

Manual exploration of uterine cavity
Curettage for suspected retained fragments
Placenta accreta: high suspicion required if previous uterine surgery; may require hysterectomy

4. Uterine Inversion

Uncommon but life-threatening; associated with fundal placentation
Do not remove placenta before reinversion if using the Johnson technique (easier without placenta in place)
Johnson technique: firm upward pressure on fundus through vagina to elevate uterus into abdomen; hold several minutes
Tocolysis aids reinversion: magnesium sulfate, β-mimetics, nitroglycerin (to relax the cervical ring)
Surgical options if Johnson fails: Huntington procedure (traction on round ligaments via laparotomy) or Haultain procedure (posterior longitudinal incision through inverted fundus)

5. Coagulopathy (Thrombin)

Treat underlying cause (DIC, preeclampsia, HELLP)
Blood product replacement: packed RBCs, FFP, platelets, cryoprecipitate
Tranexamic acid (TXA) - antifibrinolytic, recommended early in hemorrhage

Active Management of Third Stage of Labor (AMTSL) - Prevention

Early administration of oxytocin (10 units IM at delivery of anterior shoulder, or after delivery)
Early cord clamping
Controlled cord traction

AMTSL reduces PPH by approximately two-thirds compared to expectant management.

Monitoring in Severe PPH

In extensive PPH, central venous pressure (CVP) monitoring or Swan-Ganz catheter placement helps guide fluid resuscitation and avoids pulmonary edema.

Recent Evidence (2025)

A 2025 Cochrane network meta-analysis (PMID 40237648) found that carbetocin and combination uterotonic regimens may be superior to oxytocin alone for preventing PPH. A separate 2025 Cochrane systematic review (PMID 39911088) addresses blood product transfusion strategies in PPH management.

Sources: Creasy & Resnik's Maternal-Fetal Medicine, 8e; Textbook of Family Medicine, 9e

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PPH Obstetrics

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The deck has 11 slides with a deep red medical theme:

Slide	Content
1	Title slide
2	Definition & Classification (primary/secondary, vaginal/CS thresholds)
3	The 4 Ts - Tone, Trauma, Tissue, Thrombin (with % frequency cards)
4	Risk Factors (atony / CS / general)
5	Initial Assessment & Stabilization (6-step numbered layout)
6	Uterotonic Agents table (oxytocin, methylergonovine, carboprost, misoprostol)
7	Stepwise Management (Medical → Tamponade → IR → Surgery)
8	Management of specific causes (Trauma, Tissue, Thrombin)
9	Uterine Inversion (recognition + Johnson/Huntington/Haultain techniques)
10	Prevention - AMTSL (4 components with efficacy badge)
11	Key Points summary (dark closing slide)

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PPH Obstetrics

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