ATONIC POST PARTUM HEMORRHAGE

• Risk factors :
• The real problem with atonic PPH is that you cannot predict who will bleed excessively after the birth, and
this is because two-thirds of women who develop atonic PPH have no known risk factors. This is why it is
important to remember that all women must be considered at risk and prevention of PPH must be a part of
every birth. The most important known risk factors are summarized below.
a. Placenta Previa or placental abruption.
b. Retained placenta
c. Incomplete separation of the placenta
d. Full bladder
e. High parity
f. Multiple pregnancies
g. Polyhydramnios:
h. Large baby: (over 4.0 kilograms) can also overstretch the uterus.
i. Prolonged labor:
j. Anemia puts the mother at greater risk of postpartum haemorrhage, because her blood does not clot as
easily as in a non-anaemic person. Blood loss is also more serious in someone with anaemia.
DIAGNOSIS
PREVENTION
During pregnancy:
• Detection and correction of anemia.
• Hospital delivery with ready cross-matched blood for high risk patients as Antepartum hemorrhage and previous
postpartum hemorrhage.
• Polyhydramnios and multiple pregnancies.
• Grand multipara.
During labor:
• Proper use of analgesia and anesthesia.
• Avoid prolonged labor by proper oxytocin which should be extended to the end of the 3rd stage if used.
• Avoid lacerations by:
-Proper management of the 2nd stage.
-Follow the instructions for instrumental delivery.
-Routine use of ecbolics in the 3rd stage of labor.
-Routine examination of the placenta and membranes for completeness.
PREVENTION

Postpartum:
1. Exploration of the birth canal after difficult or instrumental delivery as well as
precipitate labor.
2. Careful observation in the fourth stage of labor (1-2 hours postpartum).
 Fluid resuscitation

Management Resuscitation Blood transfusion

Monitoring

Non-surgical
Treat the
underlying cause
Surgical
a. Oxygen mask
b. IV lines: two 14-gauge lines
c. The used fluid: NS or LRS
d. The amount: loss of 1 L of blood requires 4-5 L of crystalloid

• Administration of colloid is associated with higher mortality although it overcomes the

disadvantage of crystalloid.
• Colloid interferes with hemostasis if more than 1-1.5 L/d.

1. Blood loss may be generally underestimated both in volume and rapidity.

2. Women may compensate well for losses because of their good health and the
hypervolemia of pregnancy.
3. Overresuscitation resulting in pulmonary edema.
4. Failure to appreciate the dynamics of fluid shifts in the body.
If blood loss is more than 1.5 L, rapid transfusion is indicated to restore circulating volume
and Oxygen-carrying capacity.

• Patient may develop dilutional coagulopathy if previously ill or may have DIC resulting
from shock and multi-organ failure.
• So,
1. monitor platelet count and coagulation screen.
2. if surgical intervention is indicated, maintain platelet count at more than
80-100 × 109/L.
3. if coagulopathy is encountered, give 1 U FFP for every 5 U PRBCs.
a. During course of management: level of consciousness, pulse, BP, temperature,
urine output (>30 ml/h)
b. Lab: CBC, coagulation profile, ABG
c. Frequently auscultate both lungs for ARDS and pulmonary edema.
 1st line:
Assess by
placing
hand on
fundus

If
boggy Massage
and
Oxytocin 20
U in 1 L
saline

If it
remains
atonic Bimanual
massage
2nd line:
Other • Ergotrate 100 mcg IV, max.: 1.25 mg, CI: HTN
uterogenic • Carboprost 250 mcg IM, max.: 2 mg, CI: Asthma
agents • DON’T give IM if pt. is shocked

If no
response
3rd line
 3rd line:
Explore
manually
for retained
tissues

After uterine
evacuation Resume
Oxytocin &
Bimanual
massage

If no
Packing
response
until • In the past, large bulb Foley’s catheter or Sangstaken tube.
operation • Recently, catheters specially designed for PPH like SOS Bakri
room is tamponade balloon.
ready
Surgical Management:
Uterine artery ligation
• Uterine artery ligation is a relatively simple
procedure and can be highly effective in
controlling bleeding from uterine sources. These
arteries provide approximately 90% of uterine
blood flow.
Internal iliac artery ligation
• Internal iliac artery ligation can be effective to
reduce bleeding from all sources within the genital
tract by reducing the pulse pressure in the pelvic
arterial circulation.
Hysterectomy
• Hysterectomy is curative for bleeding arising from
the uterine, cervical, and vaginal fornices.
Hysterectomy is required if internal iliac artery
ligation is unsuccessful.
B-Lynch
• the use of transmural uterine compression sutures
to rapidly control bleeding.