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

(a)(i) Causes of postpartum haemorrhage

Postpartum haemorrhage (PPH) is blood loss of 500 mL or more after vaginal delivery, or 1000 mL or more after caesarean section, or any loss that causes haemodynamic instability. The causes are grouped as the four T's, in order of frequency.

Tone (uterine atony, 70% or more): over-distended uterus (twins, polyhydramnios, big baby), grand multiparity, prolonged or obstructed labour, precipitate labour, chorioamnionitis, full bladder, anaesthetic agents and tocolytics, and fibroids. Trauma (about 20%): cervical, vaginal and perineal tears, episiotomy, uterine rupture, broad ligament haematoma, and uterine inversion. Tissue (about 10%): retained placenta or cotyledons, succenturiate lobe, and placenta accreta, increta and percreta, placenta praevia. Thrombin (coagulopathy, about 1%): inherited (von Willebrand disease, haemophilia carriers) or acquired, as in DIC from abruptio placentae, pre-eclampsia and HELLP, amniotic fluid embolism, sepsis and anticoagulant use.

(a)(ii) Management of postpartum haemorrhage

Management is simultaneous: call for help, resuscitate, find and treat the cause. Resuscitation: oxygen, two large-bore cannulas, warm crystalloids, cross-matched blood and blood components (fresh frozen plasma and platelets in massive loss, fibrinogen when low), a catheter to empty the bladder, and monitoring of pulse, pressure, urine output and blood loss. Give tranexamic acid 1 g intravenously within 3 hours of birth, repeated once after 30 minutes if bleeding continues. Atony: Uterine massage and bimanual compression. Oxytocin 10 units intramuscularly or intravenously, then infusion (20 to 40 units in 500 mL); carbetocin 100 μg; ergometrine 0.2 mg (not in hypertension); carboprost 0.25 mg intramuscularly, up to 8 doses (not in asthma); misoprostol 800 μg sublingually. If drugs fail: intrauterine balloon tamponade (Bakri balloon or condom catheter), and a non-pneumatic anti-shock garment as a temporising measure. Trauma, tissue and thrombin: repair tears; examine the genital tract; manual removal of retained placenta or evacuation under anaesthesia; replace an inverted uterus; correct coagulopathy. Surgery for continued bleeding: uterine compression sutures (B-Lynch, Hayman), stepwise devascularisation (uterine and ovarian arteries, internal iliac artery ligation), selective arterial embolisation where available, and peripartum hysterectomy as the final life-saving step. Prevention: active management of the third stage of labour with prophylactic oxytocin.

(b)(i) Signs of lower limb arterial ischaemia

Acute: the six P's: pain, pallor, pulselessness, paraesthesia, paralysis and perishing cold (poikilothermia). Chronic: dry, shiny, hairless skin, thickened brittle nails, wasted muscles, absent or weak distal pulses, delayed capillary refilling, arterial bruit; pallor of the foot on elevation (Buerger's test) with dependent rubor; and painful punched-out ulcers on toes and heel, gangrene, and rest pain.

(b)(ii) Diagnostic workup of atherosclerotic peripheral arterial disease

Clinical: claudication distance, pulses, and risk factors (smoking, diabetes, hypertension, dyslipidaemia). Ankle-brachial index: below 0.9 is diagnostic, 0.41 to 0.9 mild to moderate disease, 0.4 or less critical ischaemia; above 1.4 suggests calcified incompressible vessels, so toe-brachial index is used. Arterial duplex ultrasound: shows site and severity of stenosis or occlusion. CT angiography or MR angiography (digital subtraction angiography when an intervention is planned) maps the lesions. Blood tests: lipid profile, blood glucose and HbA1c, renal function, complete blood count; ECG and cardiac and carotid assessment because of coexisting atherosclerosis.

(b)(iii) Management

Risk factor control: stop smoking, supervised exercise 30 to 45 minutes three times a week, foot care, weight reduction, and control of diabetes and hypertension (ACE inhibitor). Medical: antiplatelet (aspirin 75 to 150 mg or clopidogrel), high-intensity statin, and cilostazol for claudication; low-dose rivaroxaban with aspirin in selected patients. Revascularisation for disabling claudication that fails treatment, or for rest pain and tissue loss (chronic limb-threatening ischaemia): endovascular angioplasty with stent or drug-coated balloon for short lesions (TASC A and B); bypass surgery (preferably with great saphenous vein) or endarterectomy for long, multilevel lesions (TASC C and D). Amputation for a non-salvageable limb with gangrene or infection.

(c) Major initiatives under the National Rural Health Mission to strengthen rural health infrastructure

The NRHM (launched in 2005, now a part of the National Health Mission) took these steps: Indian Public Health Standards: norms for buildings, staff, drugs and equipment of sub-centres, primary health centres and community health centres, with their upgradation. Upgrading primary health centres to 24×7 services and community health centres to First Referral Units with emergency obstetric care, blood storage and newborn care units. Untied and annual maintenance grants to sub-centres, primary health centres and community health centres, and Rogi Kalyan Samitis (hospital management committees) for local control of funds. Additional human resources: ANMs, staff nurses, doctors and specialists on contract, and mainstreaming of AYUSH. ASHA, one for each village of about 1000 people, with Village Health, Sanitation and Nutrition Committees and village health and nutrition days. Free ambulance services (102 and 108) and mobile medical units for remote and tribal areas. Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram for free institutional delivery, and the free drugs and diagnostics initiative. Conversion of sub-centres and primary health centres into Health and Wellness Centres (Ayushman Arogya Mandir) for comprehensive primary care.