Postpartum haemorrhage (PPH) is defined as blood loss associated with signs and symptoms of hypovolemia, regardless of the mode of delivery.
Historically, it was defined as:
- Blood loss > 500 mL in vaginal delivery
- Blood loss > 1000 mL in caeserian delivery
It is an obstetric emergency. A mother can rapidly exsanguinate from PPH since blood flow to the uterus is increased to a rate of ~700 mL/minute, from ~100 mL/minute in the non-pregnant state.
Classification of postpartum haemorrhage
| Classification | Description |
|---|---|
| Primary (early) PPH | Occurs from delivery of the placenta to 24 hours postpartum |
| Late PPH | Occurs between 24 hours and 12 weeks postpartum |
Causes of PPH: The 4 T’s
| Tone | Trauma | Tissue | Thrombin | |
|---|---|---|---|---|
| Examples | Uterine atony | Cervical, vaginal or perineal lacerations, uterine rupture, and uterine inversion | Retained placenta, retained products of conception, and placenta accreta | DIC, HELLP, Von-Willebrand disease |
| Risk factors | Precipitous labour, overdistended uterus | Uncontrolled labour | Accessory lobe or abnormal placentation | Abruptio placentae |
| Diagnosis | Soft and boggy uterus | Visual inspection – bright-red blood in the presence of a well-contracted uterus | Pelvic ultrasound | Bleeding in other sites, laboratory abnormalities |
| Treatment | Uterotonics, mechanical, and surgical methods | Repair of tears and tranexamic acid | Manual removal, ultrasound guided removal | ICU care and blood products |
- Assessment of blood loss
- Visual estimation
- Graduated drapes
- Weighing soaked swabs/sponges
- Measuring suction canisters
- Serial measurement of vital signs
- Investigations
- Complete blood count
- Group and crossmatch
- PT or INR
- aPTT
- Fibrinogen
- Urea and Creatinine
- Blood gas analysis
- Lactate levels
- Ultrasound for retained placenta or products of conception
- Treatment
- Resuscitation
- Oxygen if indicated
- Insert bilateral wide-bore IV catheters
- IV fluids
- Blood tranfusion (massive blood tranfusion may be required)
- Tranexamic acid (TXA)
- Foley catheter to decompress the bladder and measure urine output. A relaxed bladder allows the lower uterine segment to contract, and facilitates uterine massage and compression
- Order investigations: CBC group and crossmatch, and coagulation panel
- Rule out lacerations
- Uterine massage
- Uterotonics
- Bimanual compression
- Manual removal of retained placenta or products of conception
- Balloon tamponade
- Surgery (laparatomy)
- Uterine compression sutures
- Devascularization: uterine artery ligation → internal iliac artery ligations
- Subtotal hysterectomy
- Resuscitation
- Complications
- Hypovolemic shock
- Sheehan syndrome (postpartum hypopituitarism)
- It presents as failed resumption of regular periods, hypothyroidism, and adrenal insufficiency
- DIC
- Acute kidney injury
- Hepatic ischemia
- Myocardial ischemia
- Cerebral ischemia
- Multi-organ failure
- Transfusion-related acute lung injury (TRALI)
- Pulmonary oedema
- Transfusion-associated circulatory overload (TACO)
- Haemolytic transfusion reactions
- Infection
- Asherman syndrome (intrauterine adhesions)
- Infertility
- Preterm birth in future pregnancies after uterine artery embolization
- Prevention
- Healthy practices before to labour
- Prevention, early detection, and treatment of anaemia
- Early detection and management of vaginal bleeding problems
- Complication-readiness preparations.
- Active management of the third stage of labour (AMTSL)
- Intramuscular oxytocin within 1 minute of delivering the child
- Controlled Cord Traction (CCT) and Counter-pressure to the uterus (Modified Brandt-Andrew Maneuver)
- Uterine massage after delivery of the placenta.
- Palpate the uterus every 15 minutes for 2 hours to make sure it is firm.
- Monitor the amount of bleeding
- Prevent prolonged labor
- Prevent dehydration
- Early detection and management of vaginal bleeding problems
- Avoiding vaginal/perineal trauma
- Healthy practices before to labour