• Clinical science

Postpartum hemorrhage (Puerperal hemorrhage)

Summary

Postpartum hemorrhage (PPH) is an obstetric emergency and is defined as a blood loss ≥ 1000 mL or blood loss presenting with signs or symptoms of hypovolemia within 24 hours of delivery. It is the number one cause of maternal morbidity and mortality worldwide. PPH is generally associated with symptoms of hypovolemia. The onset may be within 24 hours (primary PPH) to 12 weeks postpartum (secondary PPH). The most significant causes of postpartum hemorrhage are uterine atony, maternal birth trauma, abnormal placental separation, velamentous cord insertion, and coagulation disorders. Clinical findings are related to the amount of blood loss and can include anemia (e.g., lightheadedness, pallor) or hypovolemic shock (e.g., hypotension, tachycardia). Diagnosis is done through early recognition of clinical findings, systematic evaluation of the most common causes, and, in some cases, confirmed with ultrasound. Treatment depends on the underlying condition and may include general measures to control blood loss and maintain adequate perfusion to vital organs, suturing of bleeding lacerations, active management of the third stage of labor like manual maneuvers to aid in placental separation, and use of uterotonic agents for uterine atony. A hysterectomy is often considered as a last resort in uncontrolled postpartum hemorrhage.

Overview

Definitions [1]

Blood loss ≥ 1000 mL or blood loss presenting with signs or symptoms of hypovolemia within 24 hours of delivery.

  • Primary PPH: (most common) blood loss within 24 hours postpartum
  • Secondary PPH: blood loss from 24 hours to 12 weeks postpartum

Epidemiology [1][2]

  • Leading cause of maternal mortality worldwide
  • Approx. 5% of obstetric patients experience PPH.
  • PPH represents 12% of maternal deaths in the US.

Etiology [1]

Clinical features

Diagnosis

Management

Prevention [1][3]

Complications [2]

The causes of postpartum hemorrhage include the 4 T's: Tone (uterine atony), Trauma (e.g., laceration, uterine inversion), Tissue (retained placenta), Thrombin (bleeding diathesis).

Uterine atony

Definition

  • Failure of the uterus to effectively contract after complete or incomplete delivery of the placenta, which can lead to severe postpartum bleeding from the myometrial vessels

Epidemiology

  • Most common cause of PPH cases (approx. 80%) [1]

Pathophysiology

  • Normally, the myometrium contracts and compresses the spiral arteries, which stops bleeding after delivery.
  • Failure of the myometrium to effectively contract can lead to rapid and severe hemorrhage.

Risk factors [4]

Clinical features [1][5]

Diagnosis

  • Bimanual pelvic exam after emptying the bladder
  • Speculum examination of the vagina and cervix to evaluate possible sources of extrauterine bleeding (e.g., vaginal injury caused during birth)

Treatment [2][4][1][5]

Complications

Uterine inversion

Definition

  • Obstetric emergency in which the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out following vaginal delivery.

Epidemiology

  • Uncommon complication of vaginal birth
  • Morbidity and mortality may occur in approx. 41% of cases [6]

Pathophysiology

  • Partial uterine wall relaxation → prolapse of the uterine wall through the cervical orifice → if simultaneous downward traction of the uterus is performed → inversion of uterus

Types

Depends on the severity of the inversion [7]

  • Partial uterine inversion: uterine fundus collapses into the endometrial cavity, without surpassing the cervix
  • Complete uterine inversion: uterine fundus collapses into the endometrial cavity, coming through the cervix, remaining within the vaginal introitus
  • Uterine prolapse: uterine fundus is coming through the vaginal introitus

Risk factors [1][3][8]

Clinical features

Diagnosis

  • See “Clinical features” above.
  • Ultrasound
    • Confirms diagnosis in uncertain cases
    • Hyperechoic mass in the vagina with central hypoechoic cavity

Treatment

General measures and immediate manual uterine reposition should be done simultaneously. [7]

  • General measures: See “Management” in “Overview” section above.
  • Reposition uterus manually
    • Technique [1][3]
    • Following successful uterine repositioning: oxytocin to induce placental extraction and prevent reinversion
    • If not possible: administer uterine relaxant (e.g., MgSO4, nitroglycerin, or terbutaline)
    • If ineffective: surgical repair

Complications

Abnormal placental separation

Retained placenta [9]

Definition

  • Retention of the placental tissue inside the uterine cavity following the first 30 min postpartum.

Epidemiology

  • Approx. 3% of vaginal deliveries [9]

Etiology

Classification

Risk factors

Clinical features

Diagnosis

Treatment

  • General measures: See “Management” in “Overview” section above.
  • Active management of the third stage of labor: See “Prevention” in “Overview” section above.
  • Manual removal of placenta
    • Consider administering nitroglycerin.
    • Perform under adequate regional or general anesthesia.
    • Administer prophylactic antibiotics.
    • Technique
      • Keep fingers tightly together and use the edge of the hand to make a space between the placenta and the uterine wall to detach the placenta completely.
      • After placenta is detached, withdraw the hand from the uterus, bringing the placenta with it.
      • With the other hand, perform countertraction to the fundus by pushing it in the opposite direction of the hand that is removing the placenta.
  • Surgical management
    • Indicated in cases where manual extraction fails
    • Preferred method: suction curettage (associated with a risk of uterine perforation)
    • Uterine balloon tamponade or packing: if severe bleeding persists

Abnormal placentation [10][11]

Definition

Epidemiology

Classification

Depending on the depth of implantation of the trophoblast in the uterine wall [12]

Pathophysiology [13]

  • The exact pathogenesis is unknown
  • Two main theories include
    • Defective decidua: complete or partial lack of decidua in an area of previous scarring within the endometrial-myometrial interface
    • Excessive trophoblastic invasion: abnormal growth → uncontrolled invasion of villi through the myometrium, including its vascular system

Risk factors [13]

Any prior damage to the endometrium

The types of abnormal placental attachment: Placenta Accreta “Attaches” to the myometrium, placenta Increta “Invades” the myometrium, and placenta Percreta “Perforates” the myometrium.

Clinical features

Diagnosis [15][16]

Treatment [1]

  • Prevention of predelivery
    • Scheduled delivery
    • Avoid pelvic exams
    • Avoid sexual intercourse
    • Preoperative planning for PPH
  • Active management of the third stage of labor: See “Prevention” in “Overview” section above.
  • General measures: See “Management” in “Overview” section above.
  • Surgical procedures

Uterine-preserving measures are relatively contraindicated in placenta accreta spectrum due to high maternal mortality!

Prognosis [10]

Birth trauma

Epidemiology

  • Second most common cause (20% of PPH cases) [2]

Etiology

Clinical features

Treatment [2]

  • Following vaginal delivery
    • Supportive measures (e.g., fundal massage, fluid therapy, uterotonic agents)
    • Immediate repair of visible bleeding lacerations
    • Hemodynamically stable patient: arterial embolization
    • Hemodynamically unstable patient
      • Incision and drainage of hematoma
      • If the cause of bleeding is not identified: immediate laparotomy
  • Following cesarean delivery
    • Supportive measures
    • Uterine artery ligation
    • If the above techniques fail: uterine compression suture technique (e.g., B-Lynch suture)
  • Hysterectomy: as a last resort

Velamentous cord insertion

Definition

  • Abnormal cord insertion into chorioamniotic membranes, resulting in exposed vessels only surrounded by fetal membranes, in the absence of protective Wharton jelly [17]

Epidemiology [18]

  • Occurs in 1% of single pregnancies
  • Up to 15% in twin pregnancies
  • Associated with increased risk of hemorrhage during the third stage of labor

Risk factors

Pathogenesis

The following two mechanisms have been described [19]

  • Trophotropism theory: gradual placental migration towards a well-vascularized uterine section, displacing the cord towards the periphery of the placenta
  • Polarity theory: oblique implantation of the blastocyst leading to an abnormal cord insertion

Clinical features

Diagnosis

Management

Complications

  • 1. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics & Gynecology. 2017; 130(4): pp. e168–e186. doi: 10.1097/aog.0000000000002351.
  • 2. Anderson JM, Etches D. Prevention and Management of Postpartum Hemorrhage. Am Fam Physician. 2007; 75(6): pp. 875–882. pmid: 17390600.
  • 3. Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017; 95(7): pp. 442–449. pmid: 28409600.
  • 4. Marx J, Walls R, Hockberger R. Rosen's Emergency Medicine - Concepts and Clinical Practice E-Book. Elsevier Health Sciences; 2013.
  • 5. Gill P, Patel A, Van Hook MD JW. Uterine Atony. StatPearls. 2020. pmid: 29630290.
  • 6. 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.
  • 7. Bhalla R, Wuntakal R, Odejinmi F, Khan RU. Acute inversion of the uterus. The Obstetrician & Gynaecologist. 2009; 11(1): pp. 13–18. doi: 10.1576/toag.11.1.13.27463.
  • 8. Thakur M, Thakur A. Uterine Inversion. StatPearls. 2020. pmid: 30247846.
  • 9. 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.
  • 10. American College of Obstetricians and Gynecologists. Placenta Accreta Spectrum: Obstetric Care Consensus Number 7. American Journal of Obstetrics and Gynecology. 2018; 132(December 2018): pp. 259–75. url: https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum.
  • 11. 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.
  • 12. Goh WA, Zalud I. Placenta accreta: diagnosis, management and the molecular biology of the morbidly adherent placenta. The Journal of Maternal-Fetal & Neonatal Medicine. 2015: pp. 1–6. doi: 10.3109/14767058.2015.1064103.
  • 13. Jauniaux E, Collins S, Burton GJ. Placenta accreta spectrum: pathophysiology and evidence-based anatomy for prenatal ultrasound imaging. Am J Obstet Gynecol. 2018; 218(1): pp. 75–87. doi: 10.1016/j.ajog.2017.05.067.
  • 14. Konijeti R, Rajfer J, Askari A. Placenta percreta and the urologist. Rev Urol. ; 11(3): pp. 173–6. pmid: 19918343.
  • 15. 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.
  • 16. Doubilet PM, Benson CB. Atlas of Ultrasound in Obstetrics and Gynecology. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: pp. 201–203.
  • 17. 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.
  • 18. 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.
  • 19. Hasegawa J, Iwasaki S, Matsuoka R, Ichizuka K, Sekizawa A, Okai T. Velamentous cord insertion caused by oblique implantation after in vitro fertilization and embryo transfer. J Obstet Gynaecol Res. 2011; 37(11): pp. 1698–1701. doi: 10.1111/j.1447-0756.2011.01555.x.
  • 20. Sinkey RG, Odibo AO, Dashe JS. #37: Diagnosis and management of vasa previa. Am J Obstet Gynecol. 2015; 213(5): pp. 615–619. doi: 10.1016/j.ajog.2015.08.031.
  • 21. 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.
  • Weeks AD. The retained placenta. Best Pract Res Clin Obstet Gynaecol. 2008; 22(6): pp. 1103–17. doi: 10.1016/j.bpobgyn.2008.07.005.
  • American College of Obstetricians and Gynecologists. Postpartum Hemorrhage. Obstetrics & Gynecology. 2017; 130(4): pp. 923–925. doi: 10.1097/aog.0000000000002346.
  • 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.
  • 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.
  • 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.
  • 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.
last updated 09/11/2020
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