Postpartum Hemorrhage(PPH)
产后出血
林建华
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,multiple pregnancy,
macrosomia )
? condition that interfere with
contraction(leiomyomas)
? complications(PIH,anaemia,placenta
praevia
Systemic factors,
? nervous
? drugs(magnesium sulfate,sedative)
? abnormal labor(prolonged,precipitous)
? History of previous PPH
? 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
? Methegine
? prostaglandin
? Mechanical stimulation of uterine contraction,
? Massage of uterus through the abdomen and
bimanual compression
? intrauterine packing
Surgical methods
? If massage and agents are unsuccessful,
? Ligation of the uterine arteries
? ligation of the hypogastric arteries
? selective arterial embolization
? hysterectomy
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 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 (into the decidua)
? placenta increta(into the myometrium)
? placenta pericreta(through the myometrium
to the peritoneal)
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
? severe hepatic diseases
? leukemia
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,
? BT(bleeding time),CT( clotting time),
? platelets count
? fibrinogen
? prothrombin time and patial thromboplastin
time
? FDP
? women’s group and cross-matching
Treatment,
? the key is correcting the coagulation defect
? resuscitation must be started as soon as possible
? infusion of crystalloid(saline) and Dextran is
started firstly while arranging the blood
transfusion
? blood transfusion is essential
? infusion of platelets,fresh frozen plasma,FDP,
clotting factors,
? Potential complications of PPH,
? Postpartum infection
? Anemia
? Transfusion hepatitis,
? Sheehan’s syndrome
? Asherman’s syndrome
? The best management of PPH is prevention
Key words
? the definitio n of HHP
? The causes of HHP
? treatment methods of Uterine atony
? the types of retained placenta
? the degrees of the perineal and vaginal
laceration
产后出血
林建华
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,multiple pregnancy,
macrosomia )
? condition that interfere with
contraction(leiomyomas)
? complications(PIH,anaemia,placenta
praevia
Systemic factors,
? nervous
? drugs(magnesium sulfate,sedative)
? abnormal labor(prolonged,precipitous)
? History of previous PPH
? 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
? Methegine
? prostaglandin
? Mechanical stimulation of uterine contraction,
? Massage of uterus through the abdomen and
bimanual compression
? intrauterine packing
Surgical methods
? If massage and agents are unsuccessful,
? Ligation of the uterine arteries
? ligation of the hypogastric arteries
? selective arterial embolization
? hysterectomy
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 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 (into the decidua)
? placenta increta(into the myometrium)
? placenta pericreta(through the myometrium
to the peritoneal)
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
? severe hepatic diseases
? leukemia
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,
? BT(bleeding time),CT( clotting time),
? platelets count
? fibrinogen
? prothrombin time and patial thromboplastin
time
? FDP
? women’s group and cross-matching
Treatment,
? the key is correcting the coagulation defect
? resuscitation must be started as soon as possible
? infusion of crystalloid(saline) and Dextran is
started firstly while arranging the blood
transfusion
? blood transfusion is essential
? infusion of platelets,fresh frozen plasma,FDP,
clotting factors,
? Potential complications of PPH,
? Postpartum infection
? Anemia
? Transfusion hepatitis,
? Sheehan’s syndrome
? Asherman’s syndrome
? The best management of PPH is prevention
Key words
? the definitio n of HHP
? The causes of HHP
? treatment methods of Uterine atony
? the types of retained placenta
? the degrees of the perineal and vaginal
laceration
