(a) (i) Enumerate the causes for postpartum haemorrhage (PPH). (ii) Discuss the management of PPH. (10+10=20 marks) (b) (i)…

Postpartum Haemorrhage (PPH)

Causes of PPH: Primary postpartum haemorrhage (blood loss ≥500 mL following vaginal delivery or ≥1000 mL following caesarean section within 24 hours) is systematically classified using the 4Ts framework:

1. Tone (Uterine Atony, accounting for >70% of cases): Precipitated by overdistended uterus (multiple gestation, polyhydramnios), prolonged or precipitate labour, grand multiparity, chorioamnionitis, and tocolytic drugs.
2. Trauma (20%): Cervical, vaginal, or perineal lacerations, uterine rupture, broad ligament haematoma, and acute uterine inversion.
3. Tissue (10%): Retained placenta, succenturiate lobes, placental fragments, and morbidly adherent placenta (accreta, increta, percreta).
4. Thrombin (1%): Pre-existing coagulopathies (haemophilia, von Willebrand disease) or acquired coagulopathies including disseminated intravascular coagulation (DIC) from abruptio placentae, severe pre-eclampsia, HELLP syndrome, and amniotic fluid embolism.

Management of PPH: Management follows simultaneous resuscitation, diagnosis, and stepwise intervention aligned with WHO and FIGO guidelines.

Resuscitation and Assessment: High-flow oxygen, rapid establishment of two large-bore (14–16G) IV access lines, fluid resuscitation with warm crystalloids, type-specific cross-matched blood transfusion, early administration of Intravenous Tranexamic Acid (1 g over 10 minutes within 3 hours of birth), and bladder catheterization.

Mechanical and Medical Methods: Initial uterine massage and bimanual uterine compression. First-line uterotonic is Oxytocin (10–20 IU infusion or 10 IU IM). Second-line agents include Methylergometrine (0.2 mg IM, contraindicated in hypertension/cardiac disease), 15-methyl PGF2α / Carboprost (0.25 mg IM every 15 minutes up to 8 doses, contraindicated in asthma), and Misoprostol (800 mcg sublingually or rectally). In non-atony cases, immediate repair of genital tract lacerations, manual removal of placenta under anaesthesia, or manual repositioning of uterine inversion (Johnson’s manoeuvre) is performed.

Tamponade and Surgical Interventions: If medical management fails, intrauterine balloon tamponade (Bakri balloon, condom catheter) is deployed. Refractory bleeding mandates laparotomy: uterine compression sutures (B-Lynch or Hayman sutures), stepwise devascularization via bilateral uterine artery ligation (O’Leary) and internal iliac (hypogastric) artery ligation, or selective pelvic arterial embolization in hemodynamically stable setups. Emergency peripartum hysterectomy serves as the definitive life-saving measure.

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Lower Limb Arterial Ischaemia

Signs of Lower Limb Arterial Ischaemia: Acute limb ischaemia manifests with the classical 6 Ps: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis (denoting impending tissue loss), and Poikilothermia (perishing cold). Chronic ischaemia, categorized by the Rutherford classification (ranging from asymptomatic to mild/moderate/severe claudication, ischaemic rest pain, minor tissue loss, and major tissue loss), presents with dry, shiny skin, loss of hair, thickened brittle nails, muscle atrophy, dependent rubor with pallor on elevation (Buerger’s sign), non-healing punched-out arterial ulcers, and gangrene characteristic of Chronic Limb-Threatening Ischaemia (CLTI).

Diagnostic Workup: In a 62-year-old male with atherosclerotic peripheral arterial disease:

1. Bedside Vascular Testing: Resting Ankle-Brachial Index (ABI) via Doppler; ABI <0.9 is diagnostic, while <0.4 indicates severe ischaemia/CLTI. Toe-Brachial Index (TBI) is assessed if vessels are non-compressible due to medial calcinosis.
2. Duplex Ultrasound: Arterial Doppler to map stenosis, peak systolic velocity ratios, and occlusions.
3. Vascular Imaging: Computed Tomography Angiography (CTA) or Magnetic Resonance Angiography (MRA) from infrarenal aorta to runoff vessels to define anatomic lesion extent and plan intervention. Digital Subtraction Angiography (DSA) remains the gold standard, often reserved for concurrent therapeutic procedures.
4. Metabolic Workup: Fasting lipid profile, HbA1c, renal function tests, and baseline ECG to assess systemic atherosclerotic burden.

Management:

1. Risk Factor Modification and Medical Therapy: Smoking cessation, aggressive control of diabetes and hypertension, single antiplatelet therapy (Aspirin 75–100 mg daily or Clopidogrel 75 mg daily), high-intensity statin therapy (Atorvastatin 80 mg), and Cilostazol (100 mg twice daily) for claudication distance improvement. Supervised exercise therapy is first-line for claudication.
2. Revascularization: Indicated for lifestyle-limiting claudication unresponsive to medical therapy or CLTI. Endovascular intervention (percutaneous transluminal angioplasty, drug-coated balloons, or bare-metal/drug-eluting stenting) is preferred for focal, shorter lesions (TASC II A/B). Surgical bypass (autologous saphenous vein graft or PTFE synthetic graft) or endarterectomy is indicated for extensive, multilevel occlusions (TASC II C/D).

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National Rural Health Mission (NRHM) Initiatives

Launched to restructure the architectural delivery of primary and secondary healthcare, the NRHM (now under the National Health Mission) has strengthened rural healthcare infrastructure through key interventions:

1. Indian Public Health Standards (IPHS): Established quality and infrastructural norms covering physical facilities, human resources, essential drug lists, and diagnostic capabilities across Sub-Centres, Primary Health Centres (PHCs), and Community Health Centres (CHCs).
2. Accredited Social Health Activists (ASHA): Deployment of trained female community health activists at the village level (1 per 1000 population) as the vital link connecting rural households to institutional healthcare facilities.
3. Demand-Side Maternal and Child Health Schemes: Janani Suraksha Yojana (JSY) provides direct cash transfers promoting institutional deliveries, complemented by Janani Shishu Suraksha Karyakram (JSSK), which guarantees zero out-of-pocket expenditure for delivery, caesarean sections, drugs, diagnostics, diet, and emergency transport.
4. Decentralized Management and Untied Grants: Institution of Rogi Kalyan Samitis (Hospital Management Committees) to facilitate local hospital governance, maintenance, and flexible deployment of untied funds.
5. Mobile Medical Units (MMUs) and Emergency Response Systems: Deployment of MMUs to provide outreach clinical care in unserved, hilly, and tribal regions, alongside dedicated Dial 108/102 emergency ambulance networks.
6. Facility Upgradation: Upgrading CHCs into 24x7 First Referral Units (FRUs) equipped with emergency obstetric care, blood storage units, and newborn stabilization units, progressing toward comprehensive primary healthcare via Ayushman Arogya Mandirs (Health and Wellness Centres).

A coordinated way forward requires consolidating clinical emergency protocols with strengthened decentralized rural health infrastructure to deliver equitable, continuum-based care.