Dr. HAIFA’ ALCHALABI
Hawraa Al Hirz
Management of the underlying cause -
Must be romved even if bleeding stopped with the use of
Difficult without general anesthesia.
Resuscitate the patient adequatly & don’t stop uretrotonics
Perform manual exploration, once the placenta is found shear
Keep the vaginal hand in situ to decrease patient’s discomfort,
risk of iatrogenic trauma & infections.
For adherent placental fragments perform curettage.
Reduction of uterine inversion
(A) The protruding fundus is grasped
with fingers directed toward the
(B, C) The uterus is returned to
position by pushing it through the
pelvis and into the abdomen with
steady pressure towards the umbilicus.
Management of the underlying cause
- suspected If bleeding continues even though
the uterus is well contracted and manual
exploration has excluded uterine rupture or
- Confirm the diagnosis : risk factors & abnormal
Management of the underlying cause
- Fresh-frozen plasma : supplies all factors
except platelets. ( 1 U = 1g fibrinogen) .
- Cryoprecipitate : factor VIII, XIII & fibrinogen
are 3-10 X conc.Than in FFP.
-Platelet concentrate :in case of
thrombocytopenia, 1U increase plat. count
- Packed RBCs : 1U raises Hb by 1 g/dl.
Management: Surgical intervention
• 1- lapratomy to remove any free blood and
inspect for any injury & repair it.
• 2- uterine artery ligation
• 3- internal iliac (inferior hypogastric) artery
ligation (reduce bleeding from all sources
within the geintal tract)
• 4- Total hysterectomy (curative treatment)
• 5- selective artirial embolyzation
• The prognosis depends on the cause of the
PPH, it’s duration, the amount of blood loss
and the effectiveness of the treatment.
• Prompt diagnosis and treatment are essential.
It’s commonly presents as prolonged or excessive
bleeding once the woman has returned home after
24 hours to 6 weeks of delivery.
most commonly at the second week : secondary to
the sloughing of the eschar on the placental site >>
increased amount of bleeding.
The extent of bleeding usually is less than that
seen with primary PPH .
Retained products of conception: Which is the most common
cause of secondary PPH.
Infection: (often secondary to retained products) Occurs in 1-
3% after spontaneous vaginal delivery. It is the most common
cause of postnatal morbidity between day 2 and day 10.
Lacerations: including episiotomy.
Trauma: Rupture of vulval haematoma
Preexisting uterine disease: Uterine fibroids
Others (rare): Blood disorders, Carcinoma of the cervix.
# prolonged rupture of membranes
# prolonged labor with multiple examinations
# manual removal of placenta
# Mother’s age at extremes of reproductive span
# low socio-economic status
# maternal anemia
# internal fetal monitoring
# severe meconium staining in liqour
• Diagnosis is obtained clinically by examination &
• Check temperature, pulse and blood pressure
• Assess uterine size
• Assess clinical signs of blood loss.
• Establish intravenous (IV) line as indicated
• Commence oxygen via face mask as indicated
• Cross match 2-4 units red blood cells if marked
• Coagulation profile as indicated
• Speculum examination – check status of
cervical os and obtain endocervical swab.
• Ultrasound: may be used if RPOC suspected.
• Bed rest and intravenous antibiotic therapy are the
mainstays of treatment.
• Curettage is not performed routinely (risk of uterine
• Oxytocics (eg: oral Ergometrine) have almost no part in
• Gentle digital evacuation of the uterus under general
anesthesia should be performed with antibiotic
• Patient may require iron supplementation if Hb has