Understanding Postpartum Hemorrhage: Definition, Causes, Symptoms, Complications, and Management
Postpartum hemorrhage (PPH) is a medical emergency that occurs when there is excessive bleeding after delivery. It is a leading cause of maternal morbidity and mortality worldwide.
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Definition of Postpartum Hemorrhage
Postpartum hemorrhage (PPH) is the loss of more than 500 milliliters of blood following a vaginal delivery or more than 1000 milliliters following cesarean delivery.
However, PPH can also be defined as any degree of bleeding that places the mother's health or life at risk, regardless of the amount of blood loss.
Types of Postpartum Hemorrhage
There are two types of PPH: primary and secondary. Primary PPH occurs within 24 hours of delivery, while secondary PPH occurs between 24 hours and 6 weeks postpartum.
Primary postpartum hemorrhage (PPH) occurs within the first 24 hours after delivery. It is typically caused by uterine atony, which is the inability of the uterus to contract after delivery. Uterine atony can be caused by a variety of factors, including prolonged labor, multiple pregnancies, large fetal size, and previous uterine surgery. Other causes of primary PPH include vaginal or cervical lacerations, retained placental tissue, and coagulation disorders.
Secondary postpartum hemorrhage (PPH) occurs after the first 24 hours and up to 12 weeks after delivery. It is typically caused by retained placental tissue or infection. Other causes of secondary PPH include uterine subinvolution, cervical or vaginal lacerations, and coagulation disorders.
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Causes of Postpartum Hemorrhage
The most common cause of PPH is uterine atony, which is the failure of the uterus to contract and remain contracted after delivery.
Other causes include:
- Trauma during delivery, such as tearing of the birth canal or uterine rupture.
- Retained placenta or fetal membranes.
- Coagulopathies
- Genital Lacerations
- Abnormal Placentation
- Uterine Rupture
- Uterine inversion, which is when the uterus turns inside out.
- Cervical lacerations.
A.) Uterine Atony
Uterine atony is the most common cause of postpartum hemorrhage, accounting for approximately 70-80% of cases. It is characterized by the inability of the uterus to contract effectively after delivery, resulting in continued bleeding. This may occur due to prolonged labor, overdistension of the uterus, multiple pregnancies, or the use of oxytocin to induce or augment labor.
B.) Retained Placental Tissue
Retained placental tissue occurs when a portion of the placenta remains attached to the uterine wall after delivery. This can prevent the uterus from contracting effectively, leading to postpartum hemorrhage. Retained placental tissue can result from a poorly managed third stage of labor, uterine anomalies, or placenta accreta, where the placenta is abnormally attached to the uterine wall.
C.) Coagulopathies
Coagulopathies refer to abnormalities in blood clotting. Disorders such as von Willebrand disease, thrombocytopenia, and disseminated intravascular coagulation (DIC) can lead to postpartum hemorrhage. DIC is a serious condition that occurs when the body's clotting system becomes overactive, leading to the formation of small clots throughout the blood vessels, resulting in a depletion of clotting factors and bleeding.
D.) Genital Tract Trauma
Genital tract trauma, including lacerations and tears, can lead to postpartum hemorrhage. Tears may occur during vaginal delivery, especially in cases of instrumental delivery or rapid delivery. Episiotomy, a surgical incision made to enlarge the vaginal opening during delivery, can also result in bleeding.
E.) Abnormal Placentation
Abnormal placentation is a condition where the placenta is abnormally attached to the uterine wall. Placenta previa, where the placenta is implanted in the lower uterine segment, can lead to postpartum hemorrhage during delivery. Placenta accreta, where the placenta is attached to the uterine wall, can also lead to postpartum hemorrhage.
F.) Uterine Rupture
Uterine rupture is a rare but life-threatening complication of childbirth. It occurs when the uterus tears, leading to postpartum hemorrhage. Uterine rupture can be caused by previous uterine surgery, such as cesarean delivery, or by uterine anomalies.
G.) Uterine Inversion
Uterine inversion occurs when the uterus turns inside out, essentially reversing its position within the body. This can be a life-threatening emergency and can result in significant blood loss. Uterine inversion is a rare complication of childbirth, occurring in less than 1% of deliveries. It is most commonly seen in women who have had a difficult delivery or who have had a large baby. Other risk factors include uterine abnormalities, excessive traction on the umbilical cord, and rapid delivery.
H.) Cervical Lacerations
Cervical lacerations can also cause postpartum hemorrhage. During labor and delivery, the cervix dilates to allow the baby to pass through the birth canal. However, if the cervix dilates too quickly or if there is a tear in the cervix, it can lead to bleeding. Cervical lacerations are more common in women who have had long and difficult labor or who have undergone instrument-assisted delivery, such as forceps or vacuum extraction. The severity of the bleeding will depend on the size and location of the laceration.
Risk Factors for Postpartum Hemorrhage
Several risk factors can increase the chances of developing postpartum hemorrhage. These include:
- Previous history of postpartum hemorrhage.
- Multiple gestations.
- Large fetus or polyhydramnios.
- Prolonged labor or induction of labor.
- Cesarean section.
- Pre-eclampsia or eclampsia.
- Use of oxytocin to induce or augment labor.
- Placenta previa or accreta.
- Coagulopathy.
Symptoms of Postpartum Hemorrhage
The symptoms of postpartum hemorrhage may vary depending on the severity of the bleeding. Some of the common symptoms include:
- Heavy vaginal bleeding that does not slow down or stop.
- Passing large blood clots.
- Low blood pressure.
- Rapid heartbeat.
- Shortness of breath.
- Pale skin or bluish lips.
- Feeling faint or dizzy.
- Confusion or disorientation.
1.) Heavy vaginal bleeding: Heavy vaginal bleeding is the most common symptom of postpartum hemorrhage. It may occur immediately after delivery or within the first 24 hours. Women may experience continuous bleeding, large clots, or blood that soaks through multiple pads in an hour.
2.) Low blood pressure: PPH can lead to a sudden drop in blood pressure, also known as hypotension. This can cause dizziness, lightheadedness, and fainting. It may also lead to organ failure in severe cases.
3.) Rapid heartbeat: As the body attempts to compensate for the blood loss, the heart rate may increase significantly. A rapid heartbeat is a common symptom of postpartum hemorrhage.
4.) Pale skin: Due to the blood loss, the skin may become pale and cool to the touch. This is a sign that the body is not receiving enough oxygen and nutrients.
5.) Shortness of breath: Shortness of breath is another common symptom of postpartum hemorrhage. As the body struggles to receive enough oxygen, women may experience difficulty breathing or rapid breathing.
6.) Fatigue: Postpartum hemorrhage can lead to extreme fatigue due to the loss of blood and lack of oxygen. Women may feel weak and unable to perform daily activities.
7.) Abdominal pain: Women may experience abdominal pain or cramping due to the uterus attempting to contract and stop the bleeding. This may also be accompanied by the passing of clots.
8.) Loss of consciousness: In severe cases of postpartum hemorrhage, women may lose consciousness due to the significant loss of blood and drop in blood pressure. This is a medical emergency and requires immediate attention.
Complications of Postpartum Hemorrhage
Postpartum hemorrhage (PPH) is a serious and potentially life-threatening complication of childbirth. The following are complications associated with postpartum hemorrhage:
Hypovolemic shock
Postpartum hemorrhage can result in significant blood loss, which can lead to hypovolemic shock. Hypovolemic shock is a medical emergency that occurs when there is a severe loss of blood or fluid, resulting in inadequate oxygen and nutrients to the organs.
Postpartum hemorrhage can cause anemia due to the loss of blood. Anemia can lead to fatigue, weakness, shortness of breath, and other symptoms.
Organ dysfunction
Severe Postpartum hemorrhage can cause organ dysfunction, particularly in the liver and kidneys. This can result in jaundice, renal failure, and other complications.
Disseminated intravascular coagulation (DIC)
DIC is a serious condition that can occur when the body's clotting system becomes overactive in response to severe bleeding. DIC can cause abnormal bleeding and clotting and can lead to organ damage and even death.
Infection
Postpartum hemorrhage can increase the risk of infection, particularly if there is prolonged bleeding or retained placental tissue. Infection can lead to sepsis, which is a life-threatening condition.
Postpartum hemorrhage can also increase the risk of postpartum depression. This is a serious mental health condition that can affect new mothers and can result in feelings of sadness, anxiety, and hopelessness.
Diagnosis of Postpartum Hemorrhage
The diagnosis of Postpartum hemorrhage (PPH) is usually made based on clinical symptoms and physical examination.
A.) Clinical Features
Postpartum hemorrhage is defined as excessive bleeding of more than 500 ml following a vaginal delivery or more than 1000 ml following a cesarean section. The diagnosis of PPH is based on clinical features, including vaginal bleeding, uterine atony, and signs of shock. The clinical diagnosis is essential in the management of PPH, and prompt recognition of the symptoms is crucial in initiating treatment.
Vaginal bleeding is the most common symptom of PPH. It may be bright red or dark, and the amount of bleeding may vary. Uterine atony, which is the inability of the uterus to contract after delivery, is a significant cause of PPH. Signs of uterine atony include a boggy uterus, which feels soft and larger than expected, and excessive bleeding.
Shock is a severe complication of PPH and may develop rapidly. Signs of shock include low blood pressure, rapid heart rate, cold and clammy skin, and decreased urine output. The development of shock is a medical emergency and requires immediate intervention.
B.) Laboratory Tests
Laboratory tests play a critical role in the diagnosis and management of PPH. The primary laboratory test used in the diagnosis of PPH is a complete blood count (CBC). A CBC can detect anemia, which is a common complication of PPH. Other laboratory tests, such as coagulation studies, may be necessary in patients with risk factors for coagulopathy.
C.) Imaging Modalities
Imaging modalities are not routinely used in the diagnosis of PPH. However, they may be necessary in patients with suspected retained products of conception or in cases where the source of bleeding is not apparent. Ultrasound is the most commonly used imaging modality in the diagnosis of PPH. It can detect the presence of retained products of conception, identify the source of bleeding, and evaluate the size and position of the uterus.
D.) Invasive Procedures
Invasive procedures are rarely necessary in the diagnosis of PPH. However, in cases where the source of bleeding is not apparent, diagnostic procedures such as exploratory laparotomy or hysteroscopy may be necessary. These procedures may help identify the source of bleeding and guide management decisions.
Management of Postpartum Hemorrhage
The management of postpartum hemorrhage depends on the severity of the bleeding and the underlying cause. The following is done to manage postpartum hemorrhage:
A.) Emergency Care: ABCD Approach
The ABCs of postpartum management are a set of guidelines that are used to prioritize and manage maternal health in the immediate postpartum period. The ABCs stand for:
A - Airway: Ensure that the mother's airway is open and clear to allow adequate oxygenation. If the mother is unconscious, she may need to have her airway opened and supported with a breathing tube or oxygen mask.
B - Breathing: Check the mother's breathing and ensure that she is adequately ventilated. If the mother is having difficulty breathing or has respiratory distress, she may need supplemental oxygen or mechanical ventilation.
C - Circulation: Check the mother's pulse and blood pressure to ensure that she has adequate circulation. If the mother has signs of shock or is hypotensive, fluid replacement and blood transfusion may be necessary to maintain blood pressure.
D - Disposition: Once the mother's airway, breathing, and circulation have been stabilized, her disposition should be determined. If the mother is stable, she may be transferred to the postpartum unit for further monitoring. If the mother is unstable, she may need to be transferred to the intensive care unit (ICU) for further management.
E - Evaluation: The mother should be continuously evaluated for signs of bleeding, infection, or other complications. Vital signs, urine output, and hemoglobin levels should be monitored regularly to ensure that she is stable and recovering well.
In postpartum hemorrhage, the mother may experience hypovolemic shock due to excessive blood loss, which can compromise the airway, breathing, and circulation. The ABC approach ensures that these critical components are assessed and managed in a timely and effective manner, which can reduce the risk of complications and improve maternal morbidity and mortality.
B.) General Management
After the ABC management of postpartum hemorrhage (PPH), the next steps for managing PPH will depend on the cause and severity of the bleeding. The following are steps for managing PPH:
1.) Identify the cause of bleeding
The first step in managing PPH is to identify the cause of bleeding. The most common causes of PPH include uterine atony, retained placenta or placental fragments, genital tract trauma, and coagulopathy. Once the cause of bleeding is identified, appropriate interventions can be implemented to control the bleeding.
2.) Uterine Massage
Uterine massage is another method used to manage postpartum hemorrhage (PPH). It involves massaging the uterus to stimulate uterine contractions and expel any retained placental tissue or clots. The massage is typically done by a healthcare provider, and can be performed externally or internally through the vagina.
The massage is done using gentle but firm pressure and may be accompanied by medication to further stimulate contractions. The massage should not be painful but may cause some discomfort or cramping.
Uterine massage is often used as a first-line treatment for PPH, especially in cases where the bleeding is not severe. If the bleeding continues despite uterine massage, other interventions may be necessary.
3.) Bimanual Compression
Bimanual compression is another technique used to manage PPH. This method involves manually compressing the uterus with one hand from the outside while the other hand is inserted into the vagina to compress the bleeding vessels. The goal of bimanual compression is to control bleeding and stimulate uterine contractions.
Bimanual compression is typically done by a healthcare provider and may be done in conjunction with uterine massage or other interventions. The procedure may cause some discomfort or pain but is generally well-tolerated.
Bimanual compression is usually reserved for cases where uterine massage alone is not effective in controlling bleeding, or in cases where the uterus is atonic (unable to contract). If bleeding continues despite bimanual compression, more aggressive interventions may be necessary, such as medication or surgery.
4.) Medical Management
Medical management is the first-line treatment for PPH and involves the use of medications to control bleeding. The medications used for PPH include:
4.1) Oxytocin: Oxytocin is a hormone that stimulates uterine contractions and is the first-line medication for PPH. It is usually given as an intravenous (IV) infusion or injection. Oxytocin is effective in reducing bleeding and preventing uterine atony, which is the most common cause of PPH.
4.2) Methylergonovine: Methylergonovine is an ergot alkaloid that causes strong uterine contractions. It is used as a second-line medication for PPH when oxytocin fails to control bleeding. Methylergonovine should be used with caution in women with hypertension, as it can cause a rapid increase in blood pressure.
4.3) Carboprost: Carboprost is a prostaglandin analog that is used when other medications fail to control bleeding. It causes strong uterine contractions and is administered as an intramuscular injection.
4.4) Tranexamic acid: Tranexamic acid is an antifibrinolytic medication that helps to stabilize blood clots and prevent further bleeding. It can be given as an IV infusion or injection.
5.) Fluid Replacement
If the mother has lost a significant amount of blood, fluid replacement may be necessary to maintain blood pressure and prevent shock. Intravenous fluids, blood transfusion, or both may be given depending on the severity of the blood loss.
6.) Surgical Intervention
If conservative measures fail to control bleeding, surgical interventions may be necessary. Some of the surgical options include:
6.1.) Uterine Artery Embolization: This involves injecting a substance into the uterine artery to block blood flow to the uterus and stop bleeding.
6.2.) Uterine Compression Sutures: This involves placing sutures in the uterus to compress bleeding vessels and control bleeding.
6.3.) Uterine Balloon Tamponade: This involves placing a balloon inside the uterus and inflating it to compress bleeding vessels and control bleeding.
6.4.) Hysterectomy: This is the last resort and involves removing the uterus if bleeding cannot be controlled by other methods.
7.) Follow-up
The mother should be monitored closely after the bleeding has been controlled. She may need to stay in the hospital for a few days to ensure that she is stable and to manage any complications that may arise.
C.) Specific Management
Specific management will depend on the cause of the hemorrhage.
1.) Uterine Atony
The management of uterine atony involves a stepwise approach, starting with conservative measures such as bimanual uterine massage, administration of uterotonic medications, and fluid resuscitation. If these measures fail, more invasive interventions such as intrauterine balloon tamponade or uterine artery embolization may be considered. In severe cases, a hysterectomy may be necessary.
Read more: Uterine Atony
2.) Genital Tract Trauma
The management of postpartum hemorrhage (PPH) due to genital tract trauma involves a systematic approach. The first step is to identify and repair the source of bleeding, which may involve suturing lacerations or repairing tears in the vagina or cervix. If the bleeding is from a cervical tear, cervical packing may be necessary.
In more severe cases, intrauterine balloon tamponade or uterine artery embolization may be considered. Close monitoring of vital signs, hemoglobin levels, and fluid resuscitation is essential throughout the management of PPH due to genital tract trauma. Pain management and emotional support should also be provided to the patient. Prevention of genital tract trauma-related PPH includes careful and skilled delivery techniques, as well as prompt recognition and repair of any tears or lacerations.
3.) Retained Placental Tissues
The management of postpartum hemorrhage (PPH) due to retained placental tissue involves prompt diagnosis and intervention. The first step is to perform a manual examination of the uterus to determine if any placental fragments remain. If retained tissue is identified, removal should be attempted using gentle traction on the umbilical cord, or by manual removal under anesthesia.
In more severe cases, intrauterine balloon tamponade or uterine artery embolization may be considered. Close monitoring of vital signs, hemoglobin levels, and fluid resuscitation is essential throughout the management of PPH due to retained placental tissue. Pain management and emotional support should also be provided to the patient. Prevention of retained placental tissue-related PPH includes active management of the third stage of labor, with the administration of a uterotonic agent immediately after delivery, and careful inspection of the placenta to ensure that it is intact.
Prevention of Postpartum Hemorrhage
Preventing Postpartum Hemorrhage (PPH) is critical in reducing maternal morbidity and mortality. The following measures can help to prevent PPH:
1.) Active management of the third stage of labor: This involves the administration of oxytocin after the delivery of the baby to help the uterus contract and expel the placenta.
2.) Timely identification and management of risk factors for PPH.
3.) Early recognition and management of PPH.
Prognosis of Postpartum Hemorrhage
Postpartum hemorrhage (PPH) is a potentially life-threatening complication of childbirth. While the prognosis of PPH depends on various factors, such as the cause, severity, and timely intervention, the overall outlook for women who experience PPH is generally favorable with appropriate management.
The primary goal of managing PPH is to control bleeding and stabilize the patient's condition. This involves identifying and addressing the underlying cause of bleeding and initiating appropriate interventions promptly.
If the PPH is caused by uterine atony, initial management may involve pharmacological interventions such as oxytocin, misoprostol, or ergometrine to stimulate uterine contractions and reduce bleeding. If medical management is unsuccessful, more invasive interventions may be required, such as uterine balloon tamponade, uterine artery embolization, or surgical interventions like uterine artery ligation, hysterectomy, or cesarean hysterectomy.
If PPH is caused by other factors like trauma, retained placenta or tissue, or coagulopathy, management may involve addressing the underlying cause, such as surgical removal of retained tissue, repair of lacerations or tears, or administration of blood products to correct coagulopathy.
Timely diagnosis and management of PPH are crucial to prevent severe complications such as shock, organ failure, or death. With appropriate management, the majority of women with PPH recover completely and can go on to have normal pregnancies and childbirth in the future.
However, in severe cases of PPH, the risk of long-term complications such as pelvic organ prolapse, chronic pelvic pain, or infertility may increase. Women who experience severe PPH may also be at increased risk of developing postpartum depression, anxiety, or post-traumatic stress disorder.
It is essential to note that PPH can have a significant impact on a woman's physical and emotional well-being, and appropriate support and follow-up care are crucial in promoting her overall recovery and mental health. Women who experience PPH may benefit from counseling and support services to help them cope with the experience and any potential long-term effects. Additionally, close follow-up care is necessary to monitor for any potential complications or adverse outcomes and ensure optimal recovery.
Summary
In conclusion, Postpartum hemorrhage (PPH) is a serious complication of childbirth that can have life-threatening consequences. Early recognition and management of PPH are crucial in reducing maternal morbidity and mortality.
