Postpartum hemorrhage is considered an important topic for the NEET PG exam. It is a common cause of maternal morbidity and mortality and is considered one of the leading causes of maternal death worldwide. As a result, it is a frequently asked topic from Obstetrics and Gynecology in medical exams and is likely to be covered in the NEET PG exam as well.
Therefore, a comprehensive understanding of postpartum hemorrhage is crucial for effective NEET PG exam preparations.
Read this blog further to get an overview of the causes, prevention, and management of postpartum hemorrhage.
Postpartum Hemorrhage (PPH) is defined as excessive bleeding in genital tract following the delivery of a baby. It is considered a significant medical emergency and can lead to severe maternal morbidity and mortality if not properly managed.
Causes of PPH
There are various causes of PPH, including the 4T -
Atonic uterus (MC): Normal contraction of uterus postpartum compresses vessels by acting as living ligatures
Trauma (cervical, uterine, vaginal injuries)
Thrombin deficiency (coagulation defect)
Retained Tissue (placental bits)
Any bleed > 500 ml in Normal delivery or 1000 ml in CS in PPH
If > 2000 ml of blood loss: Severe PPH
1000-2000 ml is moderate PPH
Any bleed which reduces Hb by 1gm % is PPH
Prevention of PPH
Oxytocin 5-10 IU / IM or IV drip
Control cord Traction
Active management of 3rd stage of labor
Massage of uterus
Mx of PPH
DOC: oxytocin 10-20 IU by IV drip
Methyl ergometrine: IV / IM 0.2mg; it is C/l in Pre - Eclamptic toxemia, HTN, twins (before delivery of 2nd baby), Rh -ve pregnancy, heart disease (MR, MS, VSD)
Carboprost (PGF2 α): 250ug IM only (upto 8 injections in 24 hours)
Misoprostol (PGE1): Orally 200 - 400 ugm or rectal 600-800 ug
Activated factor VII
Prophylactically: Uterine artery Embolization and intra - aortic balloon (In cases like placenta accrete where there is risk of severe PPH)
B. Lynch sutures
Uterine artery ligation
Internal iliac artery ligation: Anterior division ligature is done - sluggish blood flow, so promotes thrombosis (Reduces Pulse pressure)
Dinoprostone is not given/regular drug used to control PPH (so if all other drugs given along with dinoprostone in management of PPH exception mark dinoprostone)
Types of PPH
There are several types of PPH, including -
Primary PPH: PPH within 24 hours of delivery; mostly because of atonic uterus
Secondary PPH: PPH after 24 hours of delivery up to 12 weeks of delivery; It is mostly due to retained placental bits.
Retained placental bits: Curettage (S/E of curettage is Asherman's syndrome)
REMOVAL OF PLACENTA
Removal of placenta: Best method is controlled cord traction / Brandt Andrews method.
Forcible separation by squeezing fundus and pulling placenta: Crede's Method (obsolete): It causes lot of retained bits of placenta and that are managed by curettage: If overly done it results in Asherman's Syndrome
If no delivery of placenta > 30 min (retained placenta): Manual removal of placenta (MRP) under general anesthesia
INVERSION OF UTERUS
If the placenta is pulled with force without giving counter traction: Acute inversion of placenta occurs
Hemorrhagic shock: M/C cause of death
PPH management involves:
Reposition of uterus manually or Hydrostatic method
Last part goes first inside
Reposition is done under general Anesthesia / Terbutaline (to relax uterus)
Once reposition is done Oxytocin is administered
Previous Year Questions
Q. A Primigravida underwent a normal vaginal delivery by an Intern. Patient had minimal bleeding but an out of proportion shock and eventually she died. What is the likely cause of death?
B. Amniotic Fluid Embolism
D. Uterine Rupture
Q. A pregnant lady was given an oxytocin bolus for induction of labor by the nurse instead of an infusion. What will be the side effects of giving oxytocin bolus?
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