Postpartum Hemorrhage; Prevention and Treatment

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Primary postpartum hemorrhage

Can be defined as

Bleeding from the genital tract of 500mls or more within the first 24hours of delivery following a vaginal delivery
Bleeding from the genital tract of 1000mls or more within the first 24hours of delivery following a caesarean delivery.
Bleeding from the genital tract that cause a decrease of hematocrit by 10% or more within the first 24 hours of delivery
Any degree of bleeding from the genital tract within the first 24hours of delivery that is significant enough to affect the hemodynamic stability of a woman.

Secondary postpartum hemorrhage

Can be defined as abnormal bleeding from the genital tract, occurring 24 hours after delivery until 6 weeks postpartum.

It usually causes moderate bleeding postpartum, though it can also cause life threatening bleeds.

It is usually as a result of postpartum endometritis (uterine infection) or retained products of conception

Some people believe that the postpartum period extend to 12 weeks post delivery

Uterine blood flow reaches 600 mL/minute near term, subjecting the pregnant patient to the risk of devastating blood loss.

10% of maternal death in all deliveries

1% case fatality rate

45% of maternal death in postpartum period occur in the first 24 hours.

2/3 of women with PPH have no identifiable clinical risk factor.

Nigeria is the country where nearly 20% of all global maternal deaths happen.

In 2015, Nigeria’s estimated maternal mortality ratio was over 800 maternal deaths per 100 000 live births, with approximately 58 000 maternal deaths during that year.

In fact, a Nigerian woman has a 1 in 22 lifetime risk of dying during pregnancy, childbirth or postpartum/post-abortion; whereas in the most developed countries, the lifetime risk is 1 in 4900.

By comparison, the total number of maternal deaths in 2015 in the 46 most developed countries was 1700, resulting in a maternal mortality ratio of 12 maternal deaths per 100 000 live births.

Causes

THE FOUR Ts

Tone: Atonic uterus
Trauma: Cervical, vaginal and perineal lacerations, pelvic hematomas, uterine inversion, ruptured uterus
Tissue: Retained tissue (placental fragments and/or membranes), invasive placenta
Thrombin: Coagulopathies from e.g. Von Willebrand’s disease, platelet disorders, consumptive coagulopathy.

Risk Factors

Risk factors for development of uterine atony are as follows:

Overdistension of uterus (multiple gestation, polyhydraminous,fetal macrosomia)
Induction of labor
Prolonged/precipitate labor
Anesthesia (halogenated drugs like halothane) and
Analgesia
Tocolytics (nifedipine, magnesium, beta-mimetics, indomethacin,nitirc oxide donors)
Grand multiparity
Mismanagement of 3rd stage of labor
Full bladder
Antepartum hemorrhage (placenta previa, abruption placenta, couvelaire uterus, etc)
Prolonged labor
Chorioamnionitis
Dystocia

Risk factors for PPH due to tissues

Retained bits of placental tissue
Blood clots that remain inside the uterine cavity and are not expelled out.
Invasive placenta refers to abnormal adherence of the placenta to the uterine wall due to invasion of the uterine wall by the placental trophoblasts.
Adherent placenta can be of three types: Placenta accreta; placenta increta and placenta percreta.

Traumatic causes for PPH are as follows:

Large episiotomy and extensions
Tears and lacerations of perineum, vagina or cervix
Pelvic hematomas
Uterine inversion
Ruptured uterus

Risk Factor for PPH Due To Thrombin (Coagulopathy)

Acquired during pregnancy: thrombocytopenia of HELLP syndrome, DIC (eclampsia, intrauterine fetal death, septicemia, placenta abruptio, amniotic fluid embolism), pregnancy-induced hypertension, sepsis
Hereditary: Von Willebrand’s disease
Anticoagulant therapy: valve replacement, patients on absolute bed rest

Other risk factors that should be elucidated when taking history

Past history of PPH or retained placenta or manual removal of placenta
Operative delivery (use of forceps, ventouse etc.)
Delivery of a large placenta (e.g. due to multifetal gestation)
It is usually dramatic and can occur rapidly
Bleeding PV
Sweating and restlessness
Pallor
Rapid and thready pulse
Low BP
?uterine contraction
Bleeding may be slower, but may still ultimately result in critical loss and shock
There may be no obvious bleeding PV, but patient present with feature of shock

Presentation

There may be no obvious bleeding PV, but patient present with feature of shock (uterine inversion, broad ligament hematomas, vaginal hematomas)

Investigations

CBC (including absolute platelet count)

Grouping & crossmatching (if severe, O negative uncrossmatched blood may be requested for)

Bed side clotting time

Clotting test (PT, PTTK and Fibrinogen level)

Serum U/E Cr and blood gas analysis.

Prevention

Preconception: Family planning, treatment of anemia

Antenatal: Quality antenatal care

Intrapartum: Active management of labor

Postpartum:

Active management of third stage of labor.
Early identification of risk factors
Active management of 3rd stage of labor
Oxytocin infusion of 20IU in 500ml infusion fluid post delivery
Use of prophylaxis dose of misoprostol (600µg)
Prompt repair of genital tract laceration
Continue uterine massage in the 1st 2hrs postpartum

Prevention based on the delay model

These identifies three groups of factors which may stop women and girls from accessing the maternal health they need.

Primary delay (At home) — delay in decision to seek care
Secondary delay (Before presentation at health facility) — delay in reaching care
Tertiary delay (At health facility) — delay in receiving adequate care

Provide 24 hour obstetric care

Upgrade the quality of care at health facilities

Ensure adequate stocks of medical supplies and blood

Enhance referral systems between communities and health facilities

Establish national protocols to treat obstetric complications

Treatment

‘Haemostasis’

Mnemonic that stands for

Help
Access/Assess
Etiology/Empty bladder
Massage
Oxytocics
Shift (EUA plus repair, placenta removal)
Tamponade
Arterial ligation
Sutures
Interventional radiography (angiographic embolization)
Subtotal/Total-Hysterectomy

Principles of management

Resuscitative measures
Medical treatment
Surgical treatment
Monitoring

Medical treatment

Syntocinon/Oxytocin 10/40IU
Syntometrin(0.5mg/5iu)
Ergometrin (0.2-0.25mg)
Misoprostol-1000µg
Carboprost (15-methyl PGF2α) 250 μg given as intramuscular injection every 15 minutes for a maximum of eight doses
Recombinant Factor VIIa (rFVIIa) 40-60µg/kg

Other treatment modalities

Non-pneumatic anti-shock garment

Sengstaken–Blakemore tube

Bakri hydrostatic balloon catheter

Bimanual uterine compression

Artery ligation

B-LYNCH

Interventional radiography

Subtotal and total hysterectomy

Causes

Placental/fetal membrane retention
Infection (puerperal sepsis)
Unidentified / silent uterine rupture
DIC

Clinical features

Bleeding PV
Fever
Feeling of unwell (malaise)
Uterine subinvolution
Offensive vaginal discharge

Management

Evaluation

Clinical history

Examination

Investigation

Blood
Sepsis screening
USS

Treatment

Antibiotic cover
Evacuation of retained products
Blood transfusion

Nigeria is a major contributor to maternal mortality statistics worldwide, and the leading cause of maternal mortality in this environment remains hemorrhage, thus all efforts must be made to prevent and treat postpartum hemorrhage, so that the journey of child-birth for our women will not be a journey to the great beyond.

Practice Questions

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