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Postpartum hemorrhage

Last updated: October 5, 2021

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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.

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]

Overview of common causes of postpartum hemorrhage
Risk factors/Etiology Clinical features Diagnostics Treatment
Uterine atony
  • Bimanual pelvic examination
Uterine inversion
  • Brisk postpartum hemorrhage
  • Lower abdominal pain
  • Round mass (inverted uterus) protruding from the cervix or vagina
  • Absent fundus (top of the uterus) at the periumbilical position during transabdominal palpation
  • Based on clinical features
  • Ultrasound (confirms diagnosis in uncertain cases)
Abnormal placental separation Retained placenta
  • Severe bleeding before placental delivery
  • Inability to completely separate the placenta during the third stage of labor
Abnormal placentation
Birth trauma
  • Based on clinical features
Velamentous cord insertion

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).

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]

AEIOU are risk factors for uterine atony: Anatomic Abnormalities, Exhausted myometrium, Infections, Overdistended Uterus

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

Complications

Definition

Epidemiology

Classification [7]

Degree of inversion

Time of onset

  • Acute uterine inversion: uterine inversion occurring immediately after or within 24 hours of delivery
  • Chronic uterine inversion: uterine inversion that has gone unnoticed or uncorrected, usually seen weeks or months after delivery

Etiology

Risk factors [1][3][8]

Pathophysiology

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

Clinical features

Diagnosis

Treatment

  • General measures and immediate manual uterine repositioning should be performed. [7]
  • In case of chronic uterine inversion, surgical intervention is usually necessary.

General measures

  • See “Management” in the “Overview” section above.
  • Stop all uterotonic agents (e.g., oxytocin) in order to relax the uterus.
  • If the placenta is still in situ, remove it only after successful repositioning of the uterus.

Manual uterine repositioning

  • Technique [1][3]
    • Grasp the protruding uterus at the fundus with the thumb on the anterior surface and the four other fingers on the posterior surface.
    • Carefully push the uterus back towards the posterior fornix through the pelvic cavity until it is in the correct position.
  • If repositioning is unsuccessful
    • Hemodynamically stable patients
    • Hemodynamically unstable patients: surgical repair
  • Following successful repositioning: oxytocin to induce placental extraction and prevent atony and reinversion

Complications

Retained placenta [9]

Definition

Epidemiology

  • Approx. 3% of vaginal deliveries [9]

Etiology

Classification

  • Adherent placenta: a placenta that is not detached because of insufficient uterine contractions (e.g., uterine atony)
  • Trapped placenta: a detached placenta that cannot be delivered spontaneously or with light cord traction because of cervical closure

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]

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

Prognosis [10]

Epidemiology

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

Etiology

Clinical features

Treatment [2]

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

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  14. 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. undefined; 9 (2): p.126-9.
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