Postpartum haemorrhage

Specialties > Obstetrics

Definition:

Postpartum haemorrhage (PPH) is defined as a blood loss of 500 ml or more within 24 hours after birth. It is classified into two types: primary (occurs within 24 hours of delivery) and secondary (or delayed, occurs from 24 hours to 12 weeks postpartum).

Epidemiology:

• PPH is a leading cause of maternal mortality worldwide, especially in low- and middle-income countries.
• The incidence varies but is estimated to affect 1% to 5% of deliveries.

Risk Factors:

• Previous history of PPH
• Prolonged labour or rapid labour
• Uterine atony (failure of the uterus to contract after delivery)
• Retained placenta or placental fragments
• Placenta praevia or accreta
• Overdistended uterus (e.g., multiple gestation, polyhydramnios)
• Operative delivery (e.g., forceps, vacuum, cesarean section)
• Maternal obesity
• Uterine infection or chorioamnionitis

Pathophysiology:

PPH primarily results from four ‘T’s:

1. Tone: Uterine atony is the most common cause of PPH.
2. Tissue: Retained placental tissue or clots.
3. Trauma: Trauma to the genital tract, including tears, episiotomy, or uterine rupture.
4. Thrombin: Coagulopathies, either pre-existing or acquired during delivery.

Clinical Features

Signs and Symptoms:

• Excessive bleeding from the vagina
• Decreased blood pressure and increased heart rate (signs of hypovolaemic shock)
• Pallor
• Cold, clammy skin
• Fatigue or loss of consciousness in severe cases

Management

Immediate Management:

• Initial Steps: Ensure two large-bore intravenous (IV) lines are in place, administer IV fluids, and initiate blood transfusion if necessary.
• Uterine Massage: To stimulate contraction.
• Medications: Administer uterotonics (e.g., oxytocin, misoprostol) to encourage uterine contraction.
• Manual Removal of Placenta: If retained placenta is suspected.

Surgical Interventions:

• Uterine Tamponade: Use of a balloon tamponade system to apply internal pressure and stop bleeding.
• Laparotomy: For cases of uncontrollable bleeding or when the source of bleeding needs to be surgically addressed (e.g., uterine rupture repair).
• Uterine Artery Embolisation: In cases where bleeding does not respond to conventional therapies and the patient is haemodynamically stable.
• Hysterectomy: As a last resort when all other measures fail to control bleeding.

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Prevention

• Active Management of the Third Stage of Labour (AMTSL): Involves the administration of a prophylactic uterotonic, controlled cord traction, and uterine massage after delivery of the placenta to prevent PPH.
• Risk Factor Identification: Early identification and management of risk factors during antenatal care and labour.

Complications

• Hypovolaemic shock
• Sheehan’s syndrome (postpartum pituitary gland necrosis)
• Acute renal failure
• Coagulopathy
• Maternal death

Summary

Postpartum haemorrhage (PPH) is a significant cause of maternal morbidity and mortality, demanding prompt recognition and management. Understanding the risk factors, pathophysiology, and effective management strategies for PPH is crucial for medical students and healthcare professionals. The primary goal in managing PPH is to quickly identify the cause and implement appropriate interventions to control bleeding and stabilise the patient.