Postpartum Hemorrhage (PPH)

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Postpartum hemorrhage (PPH) 

• Postpartum hemorrhage (PPH) is defined as severe vaginal bleeding after childbirth. 
  
• It is a serious condition that can lead to death. 

• Primary PPH occurs within the first 24 hours after delivery, while secondary or late PPH occurs 24 hours to 12 weeks postpartum. 

Background

• Traditionally, PPH has been defined as greater than 500 mL estimated blood loss associated with vaginal delivery or greater than 1000 mL associated with cesarean delivery. 
• PPH is considered an obstetric emergency and is one of the top five causes of maternal mortality in both resource-abundant and resource-limited settings.

Etiology

• The most common causes of PPH are related to the 4T: 
• Tone: Uterine atony is the most common cause of PPH. This occurs when the uterus fails to contract firmly after childbirth, which can lead to excessive bleeding.
• Trauma: Vaginal or cervical tears, or uterine rupture can also cause PPH. These injuries can occur during labor and delivery, especially if the birth is prolonged or difficult.
• Tissue: Retained placenta or clots can also lead to PPH. If the placenta is not completely expelled after childbirth, or if there are large blood clots in the uterus, this can cause continued bleeding.
• Thrombin: Pre-existing or acquired coagulopathy can also contribute to PPH. This occurs when there is a problem with the blood's ability to clot, which can lead to excessive bleeding.

Clinical presentation

• The clinical presentation of PPH can vary based on the severity of bleeding. Common signs and symptoms include:
• Excessive or persistent vaginal bleeding, hypotension, tachycardia, tachypnea, pallor, diaphoresis, altered mental status, and uterine atony, that is, failure of the uterus to contract effectively.

Management of Postpartum Hemorrhage: 

Initial Resuscitation:

• Activate the OB-GYN team immediately.
• Establish two large-bore intravenous lines to ensure adequate fluid resuscitation.
• Activate the massive transfusion protocol as needed to ensure that blood products are readily available.
• Administer uterotonics to stimulate uterine contractions and help control bleeding.
• Administer tranexamic acid 1 gram intravenously every 8 hours for 24 hours to reduce blood loss.
• Administer fibrinogen to correct any clotting abnormalities.

Compression:

• Perform bimanual uterine massage to stimulate uterine contractions and help control bleeding.
• Insert a uterine balloon tamponade to tamponade the bleeding.
• Manually reduce uterine inversion if it has occurred.

Surgery and Intervention:

• If conservative measures fail to control bleeding, surgery may be necessary.
• Hysterectomy may be necessary in severe cases.
• Uterine artery ligation may be performed to control bleeding.
• B-Lynch suture may be used to compress the bleeding site.
• Transarterial embolization (TAE) is a minimally invasive procedure that involves injecting embolic material into the uterine arteries to block blood flow and control bleeding.

Uterotonics for PPH:

• Oxytocin: 
  Initially 10 units intravenously, then 10 to 40 units per minute as needed.

Misoprostol:

• 800 to 1000 micrograms orally, sublingually, or rectally, every 4 to 6 hours as needed.

Methylergonovine: 

• 0.2 milligrams intramuscularly or intravenously, every 2 to 4 hours as needed.

Carboprost: 

• 250 micrograms intramuscularly every 15 min to a maximum of 8 doses as needed.

Active Management of 3rd Stage Labor:

• Identify risk factors such as PPH history, grand multiparity, primigravida, macrosomia, polyhydramnios, multiple gestations, prolonged or augmented labor, and chorioamnionitis.
• Establish 2 intravenous accesses.
• Have blood available for transfusion.
• Have uterotonic and intravenous fluid by the bedside.
• Develop a Mother-Child Care Set. Include essential supplies and medications for both the mother and the newborn, facilitating prompt and organized intervention.
• Administer oxytocin immediately after delivery and provide uterine massage.
• Allow spontaneous delivery of the placenta or perform controlled cord traction.
• Strict follow up in the first 2 hours postpartum.

Take Home Message:

• Consider to transfer PPH patients for definitive management.
• Transfer patient to operating room for hysterectomy or uterine artery ligation.
• This is probably the most readily available option.

• Transfer patient to interventional radiology for uterine artery embolization, for stable patients, as an attempt to maintain fertility.