Postpartum Hemorrhage

Primary Postpartum Hemorrhage (PPH)

Synonym

Postpartum hemorrhagic shock

1. Description of the problem

PPH is described as excessive bleeding after 20 weeks of gestation — that is, greater than 500 mL for a vaginal delivery and greater than 1 liter for a cesarean delivery.
PPH is defined as occurring within 24 hours after a vaginal or cesarean delivery.

Secondary postpartum hemorrhage occurs between 24 hours and 12 weeks after delivery.

Postpartum bleeding, regardless of the exact amount of bleeding, that causes maternal hemodynamic instability.
Most commonly, bleeding occurs in the 3rd stage of labor between delivery of the fetus and delivery of the placenta.
Usual signs of tachycardia and hypotension associated with severe bleeding may be masked or occur late because of the relative hypervolemic state of pregnancy.
Concealed pelvic hematomas with ongoing blood loss may also be masked initially.

Risk factors for PPH secondary to uterine atony, the most common cause of PPH
previous episodes of PPH

multiparity

multiple fetuses

prolonged 3rd stage of labor

fetal macrosomia

polyhydramnios

halogenated anesthetic agents

magnesium sulfate infusions
Causes of lower genital tract lacerations
prolonged or tumultuous labor

uterine hyperstimulation with oxytocic agents

spontaneous lacerations

forceps delivery and instrumental deliveries
Placental retention
in utero for more than 30 to 60 minutes after delivery of the fetus

more likely with preterm deliveries of < 24 weeks gestation

secondary to placenta abnormalities including accreta, increta and percreta
Uterine rupture
more frequent in patients with prior cesarean incisions and with any prior operative procedures of the uterus
Coagulopathy
disseminated intravascular coagulation (DIC) associated with placental abruption or other placental abnormalities

HELLP syndrome

intrauterine fetal death

acute fatty liver of pregnancy

sepsis

amniotic fluid embolism syndrome

It is essential to recognize that because of the relative hypervolemic state associated with normal pregnancy, the compensatory reflex tachycardia and tachypnea associated with early hemorrhage may not be seen initially in pregnant women who have ongoing hemorrhage or who may have concealed hematomas with ongoing bleeding. A high index of suspicion should be used for all pregnant patients if there is a possibility of ongoing bleeding.
Massive blood loss can occur from the uterus because of the significantly increased blood flow to the uterus during pregnancy.
Higher mortality rates are seen in postpartum hemorrhage when expeditious and prompt treatment is delayed and/or blood loss is underestimated.

2. Emergency Management

General treatment measures
Expectant management of the 3rd stage of labor involves only gentle fundal massage. Active management of the 3rd stage of labor includes uterine fundal massage, use of an oxytocic drug, and gentle traction of the umbilical cord with countertraction of the uterus to facilitate delivery of the placenta.

Early and aggressive fluid resuscitation with isotonic solutions using the “3:1” rule with 300 mL of crystalloid fluid replacement for every 100 mL of blood loss. Ongoing blood cell replacement is indicated in those patients with ongoing blood loss and/or hemodynamic instability.

Rapid therapeutic response to initial fluid resuscitation indicates <20% of blood volume lost and no additional fluids or blood products are needed.

Transient response to initial fluid resuscitation indicates that 20 to 40% of the blood volume is lost. Hemodynamics initially respond to the fluid rescucitation but later there are worsening vital signs. Continue fluid resuscitation and consider blood transfusions.

If there is no or minimal response to initial fluid rescucitation, there is most likely ongoing severe hemorrhage with more than 40% of blood volume lost. Continue aggressive fluid and blood product replacement.

Oxygen administration

Locate the source of bleeding using ultrasound, CT scans, and angiographic radiographic techniques.

Blood product administration depending on the degree of bleeding and laboratory abnormalities

Packed red blood cells (PRBC)

Fresh frozen plasma (FFP) – give 6-10 units of FFP for every 10 units of PRBC transfusions

Platelet transfusions – give 10-12 units if the platelet count decreases to less than 50 x 10
⁹/L

Cryoprecipitate should be given if fibrogen levels are less than 100 mg/dL (1.0 g/L).
Specific first-tier treatment measures
Manual external uterine massage

Digital exploration of the uterus to look for retained placental fragments

Direct examination and palpation of the vaginal vault and cervix

Compression of the abdominal aorta against the vertebral column as a lifesaving temporizing maneuver

Uterotonic medications

Oxytocin (Pitocin)

5 units IV bolus

add 20-40 units of oxytocin to 1 liter of fluids

10 units intramyometrially

Methylergonovine (Methergine)

0.2 mg intramuscularly (IM) every 2 to 4 hours

Ergonovine (Ergotrate maleate)

100-125 micrograms IM or intramyometrially every 2 to 4 hours

200 to 250 micrograms IM

total dose is 1.25 mg

Carboprost (Hemabate)

250 micrograms IM or intramyometrially every 15 to 90 minutes

total dose is 2 mg

MIsoprostol

800 micrograms rectally or sublingually

Blood product administration

Packed red blood cell transfusions are required if there is:

maternal hemodynamic instability and/or the total blood loss is more than 2 liters

Transfuse crossmatched packed red blood cells or type-specific blood. Type O non-crossmatched blood may be indicated if there is a delay in obtaining type-specific blood.

FFP, platelet, and cryoprecipitate transfusions are given as indicated by laboratory values and the degree of hemorrhage.

Recombinant activated factor VII (rFVIIa) of 60 to 120 micrograms/kg intravenous bolus is recommended in cases of postpartum hemorrhage that has not responded to medical therapy and administration of blood products.

Second-tier measures
Uterine packing – remove in 24 to 36 hours

Selective arterial angiographic embolization and ligation of the ovarian, uterine, hypogastric, and/or internal iliac arteries

Balloon occlusion catheters of the hypogastric and iliac arteries

Uterine compression sutures

Surgical subtotal or total hysterectomy as definitive therapy for:

cases not amenable to medical or angiographic treatments

cases of uterine rupture

highest risk for postpartum hysterectomy are those who are multiparous, had a prior cesarean delivery, or had abnormal placentation.

3. Diagnosis

Uterine atony – palpation of a large and boggy uterus
Vaginal and cervical lacerations – palpation and manual exploration of the vagina and cervix
Known placental abnormalities including abruption, previa, accreta, percreta, and increta

Decrease in the baseline hematocrit greater than 10%
May not show typical signs of tachycardia and hypotension because of pregnancy-related hypervolemia until the blood loss exceeds 1500 mL
Occult bleeding occurs most frequently with retained placental products, uterine atony, and concealed hematomas in the pelvis, perineum, or retroperitoneal space. Should suspect occult concealed bleeding in patients in the 3rd stage of labor with hemodynamic instability but no signs of external bleeding.
Bedside ultrasonography can be used for the detection of clots, hematomas, and retained placental products.
Angiographic techniques can be both diagnostic and therapeutic by identifying the location of the bleed and subsequent treatment by ligation or with balloon occlusion of a specific artery.

Physical examination of the mother’s uterus and lower genital tract and placenta and close monitoring of maternal vital signs is indicated after all vaginal and cesarean deliveries.
If occult bleeding is suspected, laboratory assessment following hemoglobin, hematocrit, and coagulation studies should be performed at regular intervals.
Most cases are straightforward with obvious external and visible vaginal bleeding that is often associated with hemodynamic instability and abnormal hematologic indices.
In cases of concealed ongoing bleeding, the clinician must have a high index of suspicion based on physical examination of the mother, such as the presence of a large, boggy uterus, the patient has known placental abnormalities, or placental retained products are suspected after examination of the placenta. Possible lacerations of the lower genital tract should be investigated with manual and digital exploration after traumatic and tumultuous vaginal deliveries.

Pathophysiology

Most frequent cause of PPH is uterine atony. Risk factors for uterine atony include:
overdistention of the uterus

retained placental products

uterine muscle fatigue

use of halogenated anesthetic agents
Second most frequent cause of PPH is lacerations of the lower genital tract that occur spontaneously or as a result of traumatic labor.
Other less common causes of PPH include disseminated intravascular coagulation (DIC) resulting from placental abnormalities, the HELLP syndrome and the amniotic fluid embolism syndrome (AFES).
Excessive bleeding from the uterus and lower genital tract is directly related to the increase in blood flow to the uterus and placenta.

Complications from postpartum hemorrhage
DIC and dilutional coagulopathy from massive fluid resuscitation and/or massive transfusion requirements of >10 units of PRBC

renal (acute tubular necrosis)

hepatic failure

acute respiratory distress syndrome

multisystem organ failure

pituitary avascular necrosis (Sheehan’s syndrome)
The prognosis of postpartum hemorrhage will depend on many factors related to diagnosis and treatment. Worse prognoses are seen in those cases of delayed diagnosis and treatment. The cause of bleeding and the duration and extent of bleeding will influence the development of potential maternal complications.
Women with a prior history of PPH have a 10% risk of recurrence with a subsequent pregnancy.

Epidemiology

Leading cause of postpartum death worldwide, causing 24% of maternal deaths or an estimated 127,000 maternal deaths annually
In developing countries, PPH may cause up to 60% of all maternal deaths.
Uterine atony occurs in 5% of deliveries.

Special considerations for nursing and allied health professionals.

What’s the evidence?

“ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 76, October 2006: postpartum hemorrhage”. Obstet Gynecol. vol. 108. 2006. pp. 1039-47. (The ACOG (American College of Obstetricians and Gynecologists) Practice Bulletins provide clinicians with current information on diagnostic techniques and clinical management guidelines for a wide variety of clinical scenarios. These guidelines address the etiology, evaluation, and management of postpartum hemorrhage.)

Quinones, JN, User, JB, Gogle, J. “Clinical evaluation during postpartum hemorrhage”. Clin Obstet Gynecol. vol. 53. 2010. pp. 157-64. (This review describes an etiology-based approach to the clinical evaluation of postpartum hemorrhage and guidelines that help expedite rapid diagnosis and management of obstetrical hemorrhage.)

Berg, CJ, Callaghan, WM, Syverson, C. “Pregnancy-related mortality in the United States, 1998–2005”. Obstet Gynecol. vol. 116. 2010. pp. 1302-9. (The objective of this epidemiologic study was to evaluate the trends of risk factors and causes for maternal mortality in the United States and to identify patients at high risk for death. Although the number of deaths has decreased over time, postpartum hemorrhage remains a significant contributing cause of maternal death.)

Rossi, AC, Lee, RH, Chmait, RH. “Emergency postpartum hysterectomy for uncontrolled postpartum bleeding: a systematic review”. Obstet Gynecol. vol. 115. 2010. pp. 637-44. (The objective of this review was to describe factors leading to the need for a postpartum hysterectomy and outcomes after emergency hysterectomy. 981 cases of emergency postpartum hysterectomies were reviewed using multiple databases. Women at highest risk for emergency hysterectomy are those who are multiparous, had a prior cesarean section in either a previous pregnancy or with the present pregnancy, or had abnormal placentation.)

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