Diffuse Dermal Angiomatosis of the Breast

Diffuse dermal angiomatosis is rare and usually considered a variant of reactive angioendotheliomatosis. It generally involves the extremities of patients with severe vascular disease and other comorbidities. Two patients with…Continue readingDiffuse Dermal Angiomatosis of the Breast

Targeted therapy

Targeted therapy is a type of cancer treatment that works differently to chemotherapy. Chemotherapy attacks all rapidly dividing cells in the body, but targeted therapy works by “targeting” those differences that…Continue readingTargeted therapy

Cancer treatment centres in Nepal

1.   B. P. Koirala Memorial Cancer Hospital (BPKMCH): BPKMCH is the first tertiary level cancer hospital in Nepal, which provides all types of cancer treatment services, such as surgical oncology,…Continue readingCancer treatment centres in Nepal

Treatment of breast cancer

Treatments are less invasive when breast cancer is detected at an early stage. Challenges for breast cancer treatment in Nepal include patient’s financial status (given the huge out-of-pocket expenditure), accessibility…Continue readingTreatment of breast cancer


Disclaimer Articles, videos, online books, pictures,online videos, Exam Information, MCQs and Related topics in this medicospase is entirely intended  for study and general information purpose . Medicine and its updates…Continue readingDisclaimer


Postpartum Hemorrhage Study Notes

Postpartum Hemorrhage study notes(PPH)

Postpartum Hemorrhage Study Notes

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,

• 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
• Instrumented delivery (forceps)
• manipulative delivery(breech extraction,precipitous labor, macrosomia)
• 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

• Vaginal examination soon after delivery

• 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

• 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

• 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
• women’s group and cross-matching

• 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

Leave a Reply