Post-Partum hemorrhage

Introduction

Post-Partum Hemorrhage (PPH) or of the 3d stage of delivery, is the bleeding of more than 500ml, just after vaginal delivery or caesarean section until 24 hours following the childbirth. The rate of PPH is as high as 5%, however the heavy bleeding (>1000ml) of the 3d stage of delivery is luckily less than 1%. PPH is responsible for almost 150.000 maternal deaths worldwide every year, which is almost the 30% of the overall maternal deaths during pregnancy.

The main reasons of the PPH are:
  • Uterine atony (70%)
  • Wounding (trauma) of the uterus, cervix, vagina during delivery (20%)
  • Placental retention (partial or total) (10%)
  • Maternal disorders of coagulation (1%)
Treatment

PPH is an emergent Obstetrical event. More than any other condition of Obstetrics and Gynecology multidisciplinary approach is needed (gynecologist, anesthesiologist, hematologist, midwifes, etc), while experience in advance live support is obligatory in such circumstance.
The therapeutic approach of PPH can be medical or surgical. Concerning the medical treatment of PPΗ is included all the conservative options of the PPH hemostasis such as: pharmaceutical and mechanical approaches. Pharmaceutical treatment such as oxytocin, prostaglandins etc, can be used to reduce or to stop the PPH from uterine atony, placenta accreta, increta, percreta or placental retention. For the same reasons uterine compression, or manual placental detachment can be used to treat the PPH, in case of previous unsuccessful medical management (Figure 1 & 2). However, if the former manipulations were ineffective, surgical handling must be used to stop the hemorrhage of the 3d stage of delivery.
aimoragia1
Figure 1
aimoragia2
Figure 2
Surgical manipulations that can be used for the further management of the PPH are:
  • Stitches B-Lynch (Figure 3)
  • Stitches O’ Leary (Figure 4)
  • Stitches Gilstrapp
  • Ligation (bilateral) of the internal iliac artery
In case that hemostasis has succeeded neither with the former stitches nor by the ligation of the arteries, obstetrical hysterectomy (total or subtotal) is the final radical treatment approach.
aimoragia3
Figure 3
aimoragiaf4
Figure 4
The overall rate of obstetrical hysterectomies is not more than 0.5% of pregnancies, mainly because of placenta accrete (50%) and uterine atony (30%). However, obstetrical hysterectomy is not without complication (Table 1). Furthermore, almost 40% of the mothers will be admitted in the Intensive Care Unit (ICU), while maternal mortality after obstetrical hysterectomy because of PPH is as high as 1.5%.

Table 1. Complication after obstetrical hysterectomy
Complication %
Pelvic infection
14
Postoperative fever
12
Ileus (obstructive)
5
Fistula 
3.5
Urinary infection
3
Wound infection
1
Deep venous thrombosis (DVT)
0.5-1

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Kalogiannidis doctor

IOANNIS Α. KALOGIANNIDIS MD, PhD

Associate Professor
Obstetrics Gynecology -
Gynecologic Oncology

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