A 22 year G3P1L1A1 with twin pregnency, unbooked case at 36 weeksadmitted with premature rupture of membranes in labour. She delivered twin babies in labor room. Patient developed severe PPH secondary to uterine atony.Conservative and medical management for uterine atony failed, patient was taken up for emergency laparotomy. Pre operative HR – 140/ min, BP – 140/90 mmhg, SPO2 – 100%. Investigations (Hb- 4.2 gms%, Platelet – 82000, coagulation profile- INR 1.3 ) was done. Rapid sequence intubation was performed,trachea was intubated with size 7.0 mm ID ETTorally. Anaesthesia was maintained with N2O and O2 and Inj. Atracurium. ABG showed severe metabolic & respiratory acidosis. Patient had persistent hypotension ,Infusion dopamine &Nor adrenaline started. Subtotal Abdominal Hysterectomy with Left salphingoophorectomy was done. Packed red blood cell, platelets, Fresh frozen plasma ,colloids was given intraoperatively. Patient was electivelyventilatedpost operatively.Ionotropes continued, weaned on 3rd day, extubated after normalization of coagulation profile and haemodynamics.

Conservative and medical management is initial treatment for PPH. patients who failed to respond continue to bleed and become hemodynamicallyunstable. Develop cascade of clotting abnormalities.The treatment is timing of initial surgery, hemostasis,infusion of blood & blood products, inotropes. Hysterectomy should not be delayed in such condition.

Early detection of PPH, prompt surgical & medical intervention with emphasis on invasive hemodynamic monitoring, blood & blood products transfusion help in better outcome.