Postpartum Hemorrhage (PPH) - Definition, Risks & Management

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’.

Tone

Tissue

Trauma

Thrombosis

Tone

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

Tissue

Retain whole or part of the placental or fragmentize the membrane.

Trauma

Laceration of vulva, vagina, or cervix

Hematoma of vulva, vagina, or broad ligament

Uterine rupture or uterine inversion

Trauma associated with instrumental delivery

Thrombin

Anticoagulant use and bleeding tendency are common causes here.

What are the Complications of PPH?

There are many complications we anticipate in PPH.
Such as

Anemia

Shock

Blood transfusion and risk associated with it

Infection

Panhypopituitarism

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

Surgically

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.

Postpartum Hemorrhage (PPH) – Definition, Risks & Management