Introduction

Postpartum haemorrhage (PPH) refers to abnormal bleeding after pregnancy. It is typically defined as primary (typically with 24 hours of delivery) or secondary (usually after discharge home). Primary postpartum haemorrhage is the most common type.

It is normal for some bleeding to occur after giving birth. Typically this blood comes from the uterine wall at the location of attachment of the placenta. Bleeding may continue for up to 12 weeks, and is typically small amounts, and becomes more borne coloured as time progresses.

Postpartum bleeding is considered abnormal when:

  • Estimated to be >500mls within 24 hours of delivery (primary)
  • Bleeding increases after discharge from hospital, or continues longer than 12 weeks (secondary)

Causes

Primary – “The four T’s”

  • Tone –¬†uterine atony, distended bladder
  • Trauma –¬†lacerations of uterus, cervix or vagina
  • Tissue –¬†retained placenta
  • Thrombin –¬†coagulopathy – either pre-existing condition, or acquired

Uterine atony and retained products are the most common causes

Secondary

Primary postpartum haemorrhage

Obstetric haemorrhage was in the past a major cause of maternal death at the time of childbirth. However, modern medicine has greatly reduced its mortality risk, and it is now only the 6th most common cause of maternal death.

Severe PPH is defined as blood loss >1000mls in the first 24 hours after delivery

Epidemiology and Aetiology

  • Incidence of 5-10%
    • Severe PPH – around 1%
  • Risk of death from PPH is about 1 in 100 000 in the UK
    • 9 deaths were reported between 2006-2008 in the UK

Risk factors:

  • Antepartum haemorrhage in current pregnancy
  • Placenta praevia – 12x risk
    • This is where the placenta is located in the lower segment of the uterus, and may cover the cervical os. A common cause of antepartum haemorrhage
  • Placental abruption
    • This is where the placenta separates from the uterus prior to delivery. Also a common cause of antepartum haemorrhage
  • Multiple pregnancy – 5x risk
  • Pre-eclampsia¬†– 4x risk
  • Previous PPH
  • Asian ethnic origin
  • Maternal obesity
  • Maternal age >40
  • Maternal anaemia
  • Factors in delivery
    • Emergency Caesarian section¬†– 4x risk
    • Elective Caesarian section – 2x risk
    • Retained placenta
    • Induction of labour
    • Labour >12 hours
    • >4kg baby
    • Assisted vaginal delivery
  • Pre-existing maternal factors
    • Known haemorrhage disorders
      • Haemophilia A
      • Haemophilia B
      • Von Willebrand’s disease

Presentation

General presents with continuous bleeding after delivery which fails to stop after the third stage.

Signs of shock may be apparent – especially if >1000mls blood los

  • Tachycardia
  • Hypotension
  • Syncope / loss of consciousness
    • Or, drowsiness / confusion

Management

Primary PPH is an emergency. Often staff on postnatal wards receive particular training in how to manage a PPH emergency. The Royal College of Obstetricians and Gynaecologists recommends a 4-component, simultaneous approach:

  • Communication
    • Alert the members of team responsible for care of PPH. In minor cases, this may just mean the lead midwife and the obstetrics team. In severe cases, this may also involve a haematologist, anaesthetist, and institute the mass transfusion policy
  • Resuscitation
    • IV access – large bore (14-gauge) cannula – ideally x2
    • Minor cases – start IV fluids
    • Major cases – start transfusion as soon as possible – IV fluids may be used as a stop-gap whilst waiting for blood to arrive
    • Assess ABC
    • Consider¬†recombinant factor VIIa¬†(rFVIIa) to stop the bleeding
  • Monitoring and investigations
    • FBC, coagulation screen, U+E, LFTs
    • Crossmatch 4 units of blood
    • Monitor – pulse, PB, urine output, respiratory rate, temperature
    • Consider arterial line and ICU transfer
  • Stop the bleeding
    • Examination – to find the cause. If no obvious cause – consider uterine atony
    • If uterine atony
      • Bimanual massage of the uterus will stimulate contraction
      • Empty the bladder
      • Oxytocin 5U IV
        • Repeat if ineffective
        • Cosnider setting up oxytocin infusion
      • Ergometrine 0.5mg IV or IM
      • Carboprost 0.25mg IM – max 8 doses
        • Contraindicated in asthma
      • Misoprostol 1000 mcg rectally
        • Usually only if oxytocin is not available
      • If unsuccessful – consider surgical options
        • Ballon tamponade
        • Haemostatic suturing
        • Bilateral ignition of uterine arteries
        • Bilateral ligation of internal iliac arteries
        • Arterial emoblisation
        • Hysterectomy

Complications

  • Hypovolaemic shock
  • DIC –¬†disseminated intravascular coagulation
  • AKI –¬†acute kidney injury
  • Liver failure
  • ARDS –¬†acute respiratory distress syndrome
  • Death

Secondary postpartum haemorrhage

Most cases are due to endometritis are retained products of conception (RPOC)

Endometritis occurs in 1-3% of pregnancies. It is a postpartum infection of the endometrium, and has its own endometritis article.

Presentation

  • Fevers
  • Abdominal pain
  • Offensive vaginal discharge
  • Abnormal vaginal bleeding
  • Dyspareunia
  • Dysuria
  • On examination
    • Tachycardia
    • Fever
    • Tender suprapubically
    • Boggy, palpable fungus in RPOC

Investigations

  • FBC
  • Blood cultures
  • MSU
  • High vaginal swab for chlamydia / gonorrhoea
  • Speculum examination
    • Can detect lacerations
    • Can detect and remove clot covering the os, which if removed, can allow the os to close
  • Ultrasound – if suspected RPOC (not useful in endometritis)

Management

  • If signs of sepsis – refer immediately to hospital
    • Fever >38 degrees
    • Tachycardia
    • Increased respiratory rate
    • Diarrhoea or vomiting
    • Generally unwell
  • If endometritis is suspected:
    • Antibiotics. Oral in mild cases, IV in severe cases
    • Typically treated with Tazocin (piperacillin + tazobactam) IV, or co-amoxiclav (oral)
    • 90% of cases improve with antibiotics within 72 hours
    • If treating in primary care – review the patient after 48-72 hours to assess efficacy of treatment
  • If RPOC suspected:
    • Typically requires surgical management – e.g. D&C
    • Risk of uterine perforation
  • In all cases:
    • Assess for anaemia and consider iron supplementation to correct this if present

References

  • Murtagh‚Äôs General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
  • Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
  • Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
  • Postpartum haemorrhage - patient.info

Read more about our sources

Related Articles