• 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]

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's jelly
  • Etiology: unknown
  • Clinical findings
    • Features of fetal hypoxia, especially following rupture of membranes (ROM)
    • Besides abnormal vaginal bleeding, the mother's condition is unaffected as blood loss occurs only in the fetus.
  • Diagnosis
  • Treatment
    • Normal delivery of the fetus (consider elective cesarean section if the first stage is not complete and the cord is in the lower segment of the uterus)
    • Regular fetal assessment (e.g., fetal growth and heart rate tracing)
    • Deliver ≤ 40 weeks gestation
  • Complications

References:[10][11]