Postpartum haemorrhage

Introduction

Postpartum haemorrhage (PPH) is an obstetrical emergency. It is a major cause of maternal morbidity and one of the top three causes of maternal mortality globally, though mortality is much lower in high-income nations. Timely diagnosis, appropriate resources, and proper management are key to prevention.

Classification

Three major types of PPH:

1. Primary PPH – Blood loss ≥500 mL (vaginal) or ≥1000 mL (cesarean) within 24 hours of delivery.
2. Major PPH – Ongoing bleeding unresponsive to first-line treatment, or blood loss >1000 mL.
3. Secondary PPH – Bleeding after 24 hours and up to 6 weeks postpartum.

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PRIMARY POSTPARTUM HEMORRHAGE

Pathophysiology

Normal uterine hemostasis depends on:

• Myometrial contraction
• Release of local (tissue factor type-1 plasminogen activator inhibitor)and systemic coagulation factors (platelets, circulating / clotting factors)

Causes of Primary PPH (4 Ts)

1. Tone (Uterine Atony) – ~70%
2. Tissue (Retained placenta) – ~10%
3. Trauma (Lacerations or rupture) – ~20%
4. Thrombin (Coagulopathy) – ~1%

Uterine atony

The most common cause of primary PPH is uterine atony or lack of effective contraction of the uterus after delivery. Blood loss can be much greater than observed because a boggy and dilated uterus may contain a significant amount of blood.             Conditions which predispose to uterine atony include:

• Prolonged labour
• Precipitate labour
• Dysfunctional labour
• Uterine overdistension:
  • Multiple pregnancy
  • Polyhydramnios
  • Macrosomia (baby large for gestational age).
• Grand Multiparity
• Uterine abnormalities: fibroids
• Intrauterine infection
• Uterine relaxing agents:
  • Magnesium sulphate / general anaesthetics/ tocolytic drugs.

Retained placental tissue:

• Retained placental tissue
• Partial separation

Abnormal placental implantation:

•  Placenta previa site
•  Morbidly adherent:
  • Placenta accreta (superficial), Placenta increta (into muscle), Placenta perceta (through muscle).

Trauma (approximately 20%): 

• Lacerations of uterus, cervix or vagina
• Uterine rupture
• At cesarean delivery, haemorrhage from the uterine incision is generally caused      by an excessively lateral extension of the incision.

Coagulopathy:

Coagulopathy is both a cause and result of PPH since persistent heavy bleeding, irrespective of the cause, leads to consumption of clotting factors and hemodilution of remaining clotting factors.

• DIC can be predisposed to by:
  • PET/ eclampsia
  • Abruptions
  • FDIU (greater than 4 weeks)
  • Amniotic fluid embolism.
  • Sepsis
• HELLP Syndrome
• Bleeding disorders
• Drugs (aspirin / heparin)

Complications

 PPH is a major cause of maternal morbidity and mortality. Complications of primary PPH include:

• Haemorrhagic shock and death
• DIC, renal failure, Postpartum hypopituitarism (Sheehan syndrome)
• Abdominal compartment syndrome (with compression of the IVC). This is rare but should be considered in patients with a tensely distended    abdomen and progressive oliguria who are developing multiorgan failure
• Asherman syndrome
• Compartment syndrome, ARDS, hysterectomy

Risk Assessment

Identify at-risk women antenatally. Plan resource access (e.g., blood products, personnel).

Clinical Assessment

• Uterine tone and palpation. Biannual palpation of the uterus may reveal bogginess, or uterine enlargement, with a large amount of accumulated blood or retained placental tissue.
• Inspection for trauma. During suctioning, careful visual inspection of the cervix and vagina under good light may reveal the presence and extent of lacerations.
• Placental completeness. Examine the placenta for missing portions, which suggest the possibility of retained placental tissue.
• Consider coagulopathy if diffuse bleeding

Investigations

• FBE, U&Es, crossmatch
• Coagulation profile (esp. fibrinogen). Fibrinogen as a predictor of worsening hemorrhage/coagulopathy. Fibrinogen falls to critically low levels earlier than other coagulation factors during PPH, thus the fibrinogen level is a more sensitive indicator of ongoing major blood loss than the prothrombin time, activated partial thromboplastin time, or platelet count.
  • The fibrinogen level at the time of diagnosis of PPH is predictive of severity and can be used to guide the aggressiveness of management
  • The normal fibrinogen level in a term pregnancy is 350 to 650 mg/dL, which is nearly double that of nonpregnant adults (200 to 400 mg/dL).
• Importance: Fibrinogen <200 mg/dL = predictor of severity

Management

1. Resuscitation – ABCs, IV fluids, blood products, correct coagulopathy
   • O negative blood/ activate massive transfusion protocol if necessary
   • Note that if the patient is coagulopathic with an extremely low fibrinogen level, cryoprecipitate or high concentration fibrinogen products (e.g., fibrinogen concentrate) are indicated since fresh frozen plasma alone may not increase the fibrinogen level to the normal range without requiring excessive volume infusion.
2. Placenta management – Cord traction, manual removal if >30 min. If the placenta has not been delivered then it will need to be delivered
   • Brandt-Andrews maneuver: developed to avoid inversion of the uterus during the third stage of labour. Controlled cord traction with one hand whilst pushing on the fundus rosterally with ulnar border of the other hand
   • Dublin maneuver: If above is not successful, fundal expulsion may be tried. Give N₂O and push caudally on the fundus
   • Manual removal: If the placenta has not been delivered within 30 minutes then a manual       removal under general anesthesia will be required.  
3. Fundal massage
4. Uterotonics – Oxytocin, ergometrine, misoprostol, PGF2α
   • Uterine atony is the most common cause of PPH. Uterotonic drugs are therefore administered for presumed atony until a therapeutic effect is observed or until it is obvious that these drugs are ineffective.
   • Oxytocin
     • Oxytocin 10 units IV, or 10 units IM
     • Oxytocin infusion; 40 units in 1 liter of Hartman’s solution over 4 hours
   • Ergometrine
     • Ergometrine 0.25 mg IV and repeat up to 1 mg total as necessary, (including 3^rd stage)
     • Avoid ergometrine (or Syntometrine which is a combination of oxytocin and ergometrine) in situations of retained placenta because it causes tonic uterine contraction, which may delay expulsion
   • Misoprostol (synthetic prostaglandin E1 (PGE₁))
     • Misoprostol: 800 – 1000 micrograms P.R. (i.e 4-5 x 200 microgram tablets).
   • Prostaglandin F2α (dinoprost) (alternative to misoprostol treatment of uterine atony)
     • Dilute the 5 mg in 1 ml ampoule into 10 mls saline, (to give 0.5mg per mL). Give an intramyometrial injection of 1mg of Prostaglandin F2α. This can be repeated up to a maximum dose of 3mg. The transabdominal route is preferred
5. Repair trauma – Pack, suture, clamp
6. Compression – Bimanual, aortic
   • Bimanual: One hand is made into a fist and placed vaginally in the anterior fornix, while the other massages the fundus abdominally while firmly compressing it against the vaginal hand.
   • Massage should be maintained while other interventions are being initiated, and continued until the uterus remains firm and bleeding has abated.
   • If the fundus is well contracted but bleeding continues unabated, then further massage is not likely to be effective and progression to other methods of hemorrhage control should occur promptly.
   • Aortic: The aorta may be compressed against the vertebral column at the level                   of the   umbilicus
7. Tamponade – Gauze, Bakri balloon
   • Bakri balloon tamponade: to control haemorrhage due to uterine atony in the upper segment of the uterus, and to control bleeding in the lower uterine segment secondary to placental implantation in the lower uterine segment.
   • The balloon catheter is inserted into the uterus under spinal, epidural or general anaesthesia in theatre. Balloon tamponade is left in situ for 8 to 24 hours to allow time for blood transfusion and coagulopathy correction.
8. Embolization – If stable and appropriate
   • Arterial embolization is an appropriate treatment option for persistent bleeding in a hemodynamically stable patient in whom the capacity for blood replacement exceeds that of the ongoing hemorrhage
9. Surgery – B-Lynch suture, artery ligation, hysterectomy if needed
   • B-Lynch suture: These are uterine compression sutures running through the full thickness of both uterine walls (posterior as well as anterior) for surgical management of atonic PPH.

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SECONDARY POSTPARTUM HEMORRHAGE

Introduction

Bleeding occurring 24 hours to 6 (or 12) weeks postpartum. Peak incidence: 1–2 weeks.

Causes

1. Endometritis – Most common
2. Retained products
3. Rare: GTD, bleeding disorders

Complications

• Sepsis
• Rarely life-threatening hemorrhage

Clinical Assessment

• Check for shock and infection
• Assess for subinvolution or retained products

Investigations

• FBE, CRP, U&Es, crossmatch
• Beta-HCG (rule out GTD or pregnancy)
• Coagulation profile if needed
• Cervical cultures
• Ultrasound for retained tissue

Management

Resuscitation – IV access, fluid resuscitation as clinically indicated

Antibiotics – Oral amox-clav or IV amp/metronidazole. Erythromycin is suitable for penicillin sensitive patients.

Retained products – EUA and curettage

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References

FOAMed

• Miers J, Beech A. Emergency Procedure: Postpartum haemorrhage LITFL

Publications

• Teede HJ, Misso ML, Boyle JA, Garad RM, McAllister V, Downes L, Gibson M, Hart RJ, Rombauts L, Moran L, Dokras A, Laven J, Piltonen T, Rodgers RJ, Thondan M, Costello MF, Norman RJ; International PCOS Network. Translation and implementation of the Australian-led PCOS guideline: clinical summary and translation resources from the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Med J Aust. 2018 Oct 1;209(S7):S3-S8.