• Clinical science

Postpartum hemorrhage (Puerperal hemorrhage)

Summary

Postpartum hemorrhage (PPH) is an obstetric emergency and is defined as a blood loss > 500 mL following vaginal birth. The onset may be early, within 24 hours, or late, from 24 hours to 12 weeks postpartum. The most significant causes of postpartum hemorrhage are uterine atony, maternal birth trauma, abnormal placental separation, and coagulation disorders. Mothers present with features of anemia (e.g., lightheadedness, pallor) or hypovolemic shock (e.g., hypotension, tachycardia). Treatment depends on the underlying condition and may include suturing of bleeding lacerations, manual maneuvers to aid in placental separation, and uterotonic agents for uterine atony. A hysterectomy is often considered as a last resort in uncontrolled postpartum hemorrhage.

Overview

The 4 Ts of Postpartum Hemorrhage: Tone, Trauma, Tissue, Thrombin

References:[1][2]

Uterine atony

References:[3][2][4]

Uterine inversion

References:[5]

Abnormal placental separation

Types

Abnormal placental attachment

Retained placenta

Clinical features

Treatment

If the placenta does not separate within 30 minutes after birth or there is evidence of postpartum hemorrhage, the following measures are to be taken:

  1. General measures
  2. Brandt-Andrews maneuver
    • One hand is placed on the abdomen, securing the uterine fundus and preventing uterine inversion.
    • The other hand applies steady downward traction on the umbilical cord.
  3. Uterotonic agents
  4. If only partial removal of placenta is suspected: postpartum inspection of the placenta and fetal membranes → sonography to locate the succenturiate placenta
  5. Manual palpation, followed by dilation and curettage (D&C) or vacuum removal of RPOC under anesthesia/regional anesthesia and high-dose IV administration of uterotonic agents
  6. Last resort: hysterectomy in failed attempts for placental detachment, persistent bleeding, and prostaglandin resistance

Uterine-preserving measures are relatively contraindicated in placental implantation disorders (placenta increta/percreta)!

References:[6][7][8][9]

Birth trauma

  • Etiology: spontaneous or iatrogenic injury (i.e., during instrumental delivery or cesarean section)
  • Clinical features
  • Treatment
    • Following vaginal delivery
      • Supportive measures (fundal massage, fluid therapy, uterotonic agents)
      • Immediate repair of obvious bleeding lacerations
      • Consider arterial embolization if the patient is hemodynamically stable or immediate laparotomy if hemodynamically unstable.
    • Following cesarean section
      • Supportive measures
      • Uterine artery ligation
      • Uterine compression suture technique (e.g., B-Lynch suture which compresses the uterus), if the above techniques fail
  • Hysterectomy as a last resort

References:[2]

  • 1. Anderson JM, Etches D. Prevention and Management of Postpartum Hemorrhage. Am Fam Physician. 2007; 75(6): pp. 875–882. pmid: 17390600.
  • 2. Belfort MA. Overview of postpartum hemorrhage. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/overview-of-postpartum-hemorrhage. Last updated March 29, 2017. Accessed May 2, 2017.
  • 3. Smith JR. Postpartum Hemorrhage. In: Postpartum Hemorrhage. New York, NY: WebMD. http://emedicine.medscape.com/article/275038-overview. Updated March 1, 2016. Accessed May 2, 2017.
  • 4. Marx J, Walls R, Hockberger R. Rosen's Emergency Medicine - Concepts and Clinical Practice E-Book. Elsevier Health Sciences; 2013.
  • 5. Repke JT, Berghella V, Barss VA. Puerperal Uterine Inversion. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/puerperal-uterine-inversion. Last updated August 8, 2017. Accessed September 14, 2017.
  • 6. Resnik R, Silver RM. Clinical features and diagnosis of the morbidly adherent placenta (placenta accreta, increta, and percreta). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-the-morbidly-adherent-placenta-placenta-accreta-increta-and-percreta. Last updated January 13, 2017. Accessed May 2, 2017.
  • 7. Weeks A. Retained placenta after vaginal birth. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. http://www.uptodate.com/contents/retained-placenta-after-vaginal-birth. Last updated October 5, 2016. Accessed May 2, 2017.
  • 8. Carusi DA. Retained products of conception. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/retained-products-of-conception. Last updated January 26, 2016. Accessed May 2, 2017.
  • 9. Kainer F, Hasbargen U. Emergencies associated with pregnancy and delivery: Peripartum hemorrhage. Dtsch Arztebl Int. 2008; 105(37): pp. 629–638. doi: 10.3238/arztebl.2008.0629.
  • Lockwood CJ, Russo-Stieglitz K. Velamentous umbilical cord insertion and vasa previa. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/velamentous-umbilical-cord-insertion-and-vasa-previa. Last updated November 22, 2016. Accessed April 25, 2017.
  • Perlman NC, Carusi DA.

    Retained placenta after vaginal delivery: risk factors and management

    . International Journal of Women's Health. 2019; Volume 11: pp. 527–534. doi: 10.2147/ijwh.s218933.
  • Bohîlțea RE, Cîrstoiu MM, Ciuvica AI, et al. Velamentous insertion of umbilical cord with vasa praevia: case series and literature review. Journal of medicine and life. ; 9(2): pp. 126–9. pmid: 27453740.
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  • Doubilet PM, Benson CB. Atlas of Ultrasound in Obstetrics and Gynecology. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: pp. 201–203.
  • Kumar S, Satija B, Wadhwa L, et al. Utility of ultrasound and magnetic resonance imaging in prenatal diagnosis of placenta accreta: A prospective study. Indian Journal of Radiology and Imaging. 2015; 25(4): p. 464. doi: 10.4103/0971-3026.169456.
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  • Wendel MP, Shnaekel KL, Magann EF. Uterine Inversion: A Review of a Life-Threatening Obstetrical Emergency. Obstet Gynecol Surv. 2018; 73(7): pp. 411–417. doi: 10.1097/OGX.0000000000000580.
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  • American College of Obstetricians and Gynecologists. Postpartum Hemorrhage. Obstetrics & Gynecology. 2017; 130(4): pp. 923–925. doi: 10.1097/aog.0000000000002346.
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last updated 07/07/2020
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