Postpartum Hemorrhage
Postpartum Hemorrhage:
It is an emergency condition that happens during the first 24 hours after delivery. (Primary)
Hemorrhage from 24 hours to 6 weeks after delivery is called secondary or delayed hemorrhage.
Postpartum Hemorrhage possibility is 1% – 5% of deliveries.
Recurrence possibility is 18%.
Risk factors and etiologies:
1. Retained placenta or membranes
2. Atony: poor contraction of uterine muscles
3. Failure to progress during labor second stage
4. Morbidly adherent placenta
5. Lacerations such as uterine rupture, cervical or vaginal tear
6. Instruments use during delivery
7. Large fetus, > 4 kg
8. High blood pressure, severe preeclamsia
9. Labor induction
10. Prolonged labor (more than 12 hours)
11. Abnormal placenta such as placenta previa
12. Placenta abruption
13. Intrauterine fetal demise
14. Family history of PPH
15. Obesity
16. High Parity (4 and more)
17. Precipitous labor
18. Hispanic or Asian race
19. Multiple gestation
20. inflammation of the fetal membranes (Chorioamnionitis)
21. Polyhydramnios
22. Uterine inversion
23. Blood diathesis
24. Anemia
25. Assisted reproductive technology
26. Leiomyoma and Adenomyosis
Mother is diagnosed with hemorrhage:
– If bleeding is greater than expected
– If blood loss is ≥500 mL, 1000 mL in case of cesarean delivery
– Presence of hypovolemia symptoms such as:
a. Low blood pressure
b. Fast breathing
c. Cold, blue extremities
d. Sweating
e. Weak and fast heart rate
f. Nausea
Management:
Treating postpartum hemorrhage is by treating the cause of bleeding.
Treatment option is decided according to the severity of bleeding.
In case of excessive bleeding:
Mother is given Intravenous fluids, oxygen and sometimes Blood transfusion could be needed.
Treatment options:
If the cause is uterine atony:
– Massage and manual uterine compression to treat atony.
– Uterotonic medications to help the uterus contract to slow down bleeding: such as oxytocin.
– Intrauterine balloon tamponade might be used to put pressure on the bleeding vessels.
– Admission of tranexamic acid to control bleeding.
– A catheter might be put into the bladder to empty it as it may help the uterus to contract.
– Uterine artery embolization could be done for slow but excessive bleeding if other procedures failed.
If the cause is retained placental tissue:
Retained placental tissues should be removed.
If the cause is related to Placenta accreta:
Hysterectomy could be required.
If the cause is Trauma or lacerations:
Bleeding can be controlled surgically (under anesthesia) with sutures in case bleeding due to Trauma or lacerations.
Postpartum Hemorrhage complications:
Possibility of:
1. Intrauterine adhesions, may lead to menstrual abnormalities and infertility
2. Postpartum anemia
3. Maternal mortality
4. Need for blood transfusion
5. Hysterectomy
6. Thromboembolism
7. Hemodynamic instability
8. Postpartum hypopituitarism: rare
Secondary Postpartum Hemorrhage:
When hemorrhage occurs 24 hours to 6 weeks after delivery.
Possibility: 0.2% to 2%
The bleeding presents sometimes with pelvic pain, fever or uterus tenderness.
It is mainly caused by:
– Retained conception products
– Subinvolution of the placental site
– Infection
Other causes:
– Blood diatheses
– Uterine artery Pseudoaneurysm
– Choriocarcinoma
– Cervix carcinoma
– Arteriovenous malformations
– Adenomyosis
– Infected polyp or fibroid
– Estrogen deficiency
Risk Factors:
1. History of secondary PPH
2. History of primary PPH
Diagnosis:
1. Patient history: previous PPH, recurrent PPH, route of deliver, history of menorrhagia
2. Laboratory test for bleeding diathesis
3. CBC, HCG and coagulation profile tests
4. Overview of currently used medications
5. Ultrasound examination for identifying the cause of bleeding
6. Three-dimensional ultrasound examination and saline infusion sonohysterography might be needed
Management:
Bleeding can be managed as the following:
A. If the patient has fever and foul vaginal discharge, this is usually Endometritis and treated with antibiotics.
B. If the cause is retained products of conception, evacuation is done.
C. Uterotonic agents are administered in case of subinvolution of the placental site such as:
– Methylergonovine, intramuscularly
– Carboprost tromethamine, intramuscularly
– Oxytocin infusion
D. Arterial embolization might be done in case of patient refractory to surgical procedures or Uterotonic agents.
