Pph
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"postpartum hemorrhage" management
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Postpartum Hemorrhage (PPH)
Definition
PPH is excessive blood loss after delivery:
- Primary PPH: blood loss ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section, OR any amount causing hemodynamic instability - occurring within the first 24 hours
- Secondary PPH: occurs after the first 24 hours and up to 6 weeks postpartum
A practical clinical marker is a 10% drop in hematocrit, need for packed red blood cell transfusion, or symptoms of hypovolemia.
The 4 T's - Causes
| Cause | Frequency |
|---|---|
| Tone (uterine atony) | ~70-80% of cases |
| Tissue (retained placental fragments, placenta accreta) | ~10% |
| Trauma (cervical, vaginal, perineal lacerations; uterine rupture; inversion) | ~20% |
| Thrombin (coagulopathy - hereditary or acquired) | uncommon |
Risk Factors for Uterine Atony
- Preeclampsia
- Prolonged labor
- Protracted use of uterotonics or tocolytics
- Multifetal gestation / fetal macrosomia
- Multiparity
- Retained placenta
- Uterine infection
Important Physiological Points
- Plasma volume increases by 40% and RBC volume by 25% by the end of the third trimester
- These changes can mask typical hemorrhage symptoms - the first sign may only be a mild pulse rate increase
- Up to 30% blood volume loss may occur before blood pressure drops
Management (Step-by-Step)
1. Immediate Resuscitation
- Monitor vital signs frequently
- Establish adequate IV access
- Fluid resuscitation (lactated Ringer's)
- Prepare for blood transfusion
- Real-time ultrasound to identify retained placenta or blood clots
2. Identify and Treat Cause
Exclude: uterine atony, lacerations (cervical/vaginal/uterine), coagulopathy, placenta accreta, uterine inversion
3. Uterotonic Drugs (for atony)
| Drug | Dose/Route | Notes |
|---|---|---|
| Oxytocin | 20-30 units in 1000 mL IV, max 100 mU/min | First-line; avoid IV bolus (causes hypotension) |
| Methylergonovine / Ergonovine | 0.2 mg IM | Avoid IV route (risk of hypertension, CNS vasospasm) |
| Carboprost (15-methyl PGF2α) | 250 μg IM, repeatable | Avoid in cardiovascular disease or asthma |
| Misoprostol | 800-1000 μg rectally or transvaginally | Used when conventional therapy fails |
4. Mechanical/Surgical Options (if pharmacotherapy fails)
- Bimanual uterine massage - fist in anterior fornix, compress fundus suprapubically
- Bakri balloon / Foley catheter tamponade - especially for low placental implantation site
- Uterine packing with sterile gauze
- Non-pneumatic antishock garment - useful in remote settings
- Selective pelvic vessel embolization (where facilities available)
- Laparotomy - if all above fail:
- Arterial ligation (uterine/internal iliac arteries)
- B-Lynch hemostatic brace sutures
- Peripartum hysterectomy (last resort)
Secondary PPH - Causes
- Failure of uterine lining to subinvolve at placental site
- Retained placental tissue
- Genital tract wounds
- Uterogenital infection
Recent Evidence (2025)
A 2025 Cochrane network meta-analysis (PMID: 40237648) examined uterotonic agents for PPH prevention, and a separate 2025 Cochrane review (PMID: 39911088) evaluated blood and blood product transfusion strategies - both are the most current high-level evidence on PPH management.
Sources: Creasy & Resnik's Maternal-Fetal Medicine; Tintinalli's Emergency Medicine
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