Postpartum hemorrhage (PPH) is losing blood (more than expected) after the delivery of the baby.
It can be early (primary) or late (secondary).
What is Early Postpartum Hemorrhage (Early PPH)?
Blood loss of more than 500 ml for vaginal delivery and more than 1000 ml for C/s delivery within the 1st 24 hours. Or hematocrit decreased at least by 10% or the need for blood transfusion in postpartum.
It further classifies into four classes.
- 1st Class – 900 ml or 15% of blood loss
- 2nd Class – 1200 – 1500 ml or 20 – 25% blood loss
- 3rd Class – 1800 – 2000 ml or 30 – 35% blood loss
- 4th Class – more than 2400 ml or 40% blood loss
What is Late postpartum Hemorrhage (Late PPH)?
It occurs 24 hr up to 6-week postpartum and bleeding should be serious enough that makes the mother seek medical attention.
What are the Risk Factors?
Several risk factors have been identified which increase the risk of PPH. We can summarize it in ‘4T’.
Uterine atony is one of the most common causes of Postpartum hemorrhage. It comprises of 75 – 80% of cases.
Several conditions can cause uterine atony. Some of them are: –
- Uterine overdistension – multiple pregnancies macrosomia, polyhydramnios
- Intrinsic uterine dysfunction – prolonged labor, myoma
- Extrinsic uterine dysfunction – retained placenta, accumulated blood, and clot
- Prolonged exposure to oxytocin – induction, and augmentation
- Uterine and placental abnormality – a surgical scar, placental accreta, endometritis, chorioamnionitis
- Iatrogenic – magnesium sulfate, terbutaline, volatile anesthetics
- Retain whole or part of the placental or fragmentize the membrane.
- Laceration of vulva, vagina, or cervix
- Hematoma of vulva, vagina, or broad ligament
- Uterine rupture or uterine inversion
- Trauma associated with instrumental delivery
- Anticoagulant use and bleeding tendency are common causes here.
What are the Complications of PPH?
There are many complications we anticipate in PPH.
- Blood transfusion and risk associated with it
- Sheehan syndrome
- Acute renal failure due to hypotension
- Asherman syndrome if curettage did
- Sterility from hysterectomy
Management of Postpartum Hemorrhage (PPH)?
The goal of the management is to
- Identify PPH
- Correct cause of hemorrhage
- Resuscitation – 2 iv line site and administer the crystalloid fluid. We can also transfuse blood.
- Prevent further complication and infection
The management of PPH is mainly based on the cause.
For example, if the cause of Postpartum hemorrhage is atony, the management is doing
- Temporalizing method – uterine massage, bimanual compression, aortic compression
- Medical management – oxytocin, PGs, ergometrine to achieve contracted uterus
- Tamponade – pack, inflate pelvic pressure pack
- Uterine brace suture – B-lynch
- Revascularize – uterine or ovarian ligation, iliac artery (internal) ligation
- Arterial embolization
- Hysterectomy – last option
If there is a laceration, repair then evacuate big hematoma and suture.
uterine rupture treated by – hysterectomy, rarely repair
uterine inversion treated by – replacement
Retained tissue managed by – removal (manual or surgical), rarely hysterectomy
Coagulopathy is mainly managed by transfusion.
We should act within 2 hours otherwise the mother will die.
How to Prevent Postpartum Hemorrhage (PPH)?
Prevention is better than cure right? That works in PPH too. We should prevent or at least prepare in high-risk mothers. And there are steps to do that.
- First identify risk factors like previous PPH history, grand multiparity, primigravida, macrosomia, polyhydramnios, multiple gestations, prolonged or augmented labor, chorioamnionitis,…..
- Then provide IV access in 2 site
- Have blood available for transfusion
- Avoid induction and augmentation
- Vigilant management of 3rd stage labor
- Uterotonic and IV fluid by the bedside
- Allow spontaneous delivery of the placenta
- Strict follow up at least in the 1st 2 hours postpartum.
2. HYPERTENSION IN PREGNANCY – HOW TO DIFFERENTIATE 4 TYPES?