Postpartum Hemorrhage(PPH)

产后出血
 Major causes of death for
pregnancy women
（ maternal mortality)
• Postpartum hemorrhage （ 28%)
• heart diseases
• pregnancy-induced hypertension
• (or Amniotic fluid embolism )
• infection
 Definition of PPH
• be defined as a blood loss exceeding 500ml
after delivery of the infant

• PPH: occurs in 24 hour of delivery

• the late PPH: occurs after 24 hour of delivery
to 6 weeks
 Major causes
• Uterine atony (90%)
• lacerations of the genital tract(6%)
• retained placenta(3%-4%)
• coagulation defects (blood dyscrasia)

• (4T: tone, tissue,trauma,thrombin)

 1. Uterine atony
Local factors
• overdistention of the uterine
(hydramnios 羊水过多 , multiple
pregnancy, macrosomia 巨大儿 )
• condition that interfere with
contraction(leiomyomas 平滑肌瘤 )
• complications(PIHpregnancy induced hypertension
anaemia, placenta praevia
Systemic factors:
• nervous
• drugs(magnesium 镁 sulfate,sedative)
• abnormal labor (prolonged,
precipitous)
• History of previous PPHPostpartum Hemorrhage
• Preeclampsia, abnormal placentation,
 pathology
• Contraction constricting the spiral
arteries
• preventing the excessive bleeding from
the placenta implantation site
• the uterine atony give rise to PPH
when no contraction occur
 Prevention and therapeutic of
uterine atony
• Administration of medicine:
• promotes contraction of the uterine corpus
• decreases the likelihood of uterine atony
• Oxytocin agents
prostaglandin 前列腺素
• Mechanical stimulation of uterine contraction:

• Massage of uterus through the abdomen and

bimanual compression

• intrauterine packing
•Massage of uterus （ through the abdomen
and bimanual compression ）
intrauterine packing
 Surgical methods
• If massage and agents are unsuccessful:
• Ligation 结扎 of the uterine arteries
• ligation of the hypogastric 髂内动脉 arteries
• selective arterial embolization
• Hysterectomy 子宫切除术
taking into account the degree of
hemorrhage,the overall status of patient,her
future childbearing desires
 2. Lacerations of the genital
tract
Causes:
• Instrumented delivery (forceps)
• manipulative delivery(breech
extraction,precipitous labor, macrosomia)
Types:
• perineum laceration
• vaginal laceration
• cervical laceration
 perineum and vaginal laceration

• The first degree tear:

involves only skin and a minor part of the
perineal body
• the second degree tear:
involves the perineal body and vagina
• the third degree tear:
involves the anal sphincter 肛门括约肌 and anal
canal
 management
• Vaginal examination soon after delivery

repair:
• cervical laceration >2cm in length and be
actively bleeding
• laceration of vaginal and perineum
 3. Retained placenta

• Separation and explosion of placenta is

caused by strong uterine contraction

• Placenta tissue remaining in the uterus

prevent adequate contraction and predispose
to excessive bleeding
causes:
• adherence of placenta (previous cesarean
delivery,prior uterine curettage)
• succenturiate placenta
placenta accreta is used to describe any
placental
• placenta accreta implantation
(into in which there is
the decidua)
abnormally firm adherence to the
• placenta increta(into the myometrium)
uterine wall.Placenta villi are attached
to the myometrium in placenta accreta;
• placenta pericreta(through the myometrium
actually invade the myometriumin
to the peritoneal
placenta
腹膜的 ) or penetrate through
increta,
the myometrium in placenta percreta
succenturiate placenta
 Prevention and treatment
• The placenta should be examined to see that it
is complete or not
• part of placenta is missing, removed digitally
• not separated, manual removal of placenta is
done
• hysterectomy is required for placenta
increta(percreta,accreta)
• uterine contraction drugs
 4. Coagulation defects
Acquired abnormality in blood clotting:
• abruptio placenta,
• amniotic fluid embolism
• severe preclampsia
congenital abnormality in blood clotting:
• Thrombocytopenia 血小板减少
• severe hepatic diseases
• Leukemia 白血病
 disseminated intravascular
coagulopathy(DIC)
• if bleeding persists in spite of all other
treatment described, DIC should be
suspected
• the blood passing from the genital tract is
not clotting
• shock: reduction of effective circulation
inadequate perfusion of all tissues
oxygen depletion
depression of functions
Record:
• pulse
• blood pressure
• maternal heart rate
• central venous pressure
• urine output
Lab tests:
• Hb, hemoglobin
• BT(bleeding time), CT( clotting time),
• platelets count
• fibrinogen
• prothrombin time and patial thromboplastin
time
• FDP fibrin degradation product
• women’s group and cross-matching
Treatment:
• the key is correcting the coagulation defect
• resuscitation 复苏 must be started as soon as
possible
• infusion of crystalloid 晶体 (saline) and Dextran 右
旋糖酐 is started firstly while arranging the blood

transfusion
• blood transfusion is essential
• infusion of platelets, fresh frozen plasma, FDP
fibrin degradation product, clotting factors,
• Potential complications of PPH:
• Postpartum infection
• Anemia
• Transfusion hepatitis,
• Sheehan’s syndrome
• Asherman’s syndrome

• The best management of PPH is prevention

 Sheehan syndrome

• Severe intrapartum or early postpartum

hemorrhage is on rare occasions followed
by sheehan syndrome, which in the classical
case is characterized by failure in
laceration, amenorrhea, atrophy of the
breasts, loss of pubic and axillary hair,
superinvolution of the uterus,
hypothyroidism and adrenal cortical
insufficiency.
 Sheehan syndrome
• In some but not all instances of sheehan
syndrome, varying degrees of anterior
pituitary necrosis with impaired secretion of
one or more trophic hormones account for
endocrine abnormalities. Some cases imply
impaired hypothalamic function.
 Key words

• the definition of HHP

• The causes of HHP
• treatment methods of Uterine atony
• the types of retained placenta
• the degrees of the perineal and vaginal
laceration