Post-partum haemorrhage

• Postpartum haemorrhage (PPH) is defined as blood loss of 500ml or more following childbirth

  Is one of the leading direct causes of maternal mortality in the UK
• PPH can be categorised according to the volume of blood loss and timing of the haemorrhage:

  • Minor PPH: 500-1000ml blood loss without clinical signs of shock.
  • Major PPH: >1000ml blood loss, or <1000ml visible blood loss with clinical signs of shock.
  • Primary PPH: PPH occurring within 24 hours of delivery.
  • Secondary PPH: PPH occurring from 24 hours up to 12 weeks post-delivery.
• Causes of primary PPH - the four Ts

  • Tone - atonic uterus - most common cause
  • Trauma - injury as a result of childbirth - perineal tears, lacerations, episiotomy
  • Tissue - retained products of conception e.g. retained placenta
  • Thrombin - underlying disorders of clotting or use of LMWH
• Secondary PPH is usually due to:

  • Endometritis - infection of the endometrium
  • Retained products of conception
• Atonic uterus:

  • Most common cause of primary PPH
  • Normally there is contraction of the uterus which compresses intramyometrial blood vessels which stops bleeding from the placental bed
  • In bladder atony, this compression does not occur
• Risk factors:

  • Previous PPH (particularly when the cause was atony)
  • Grand multiparity
  • Overdistension of the uterus - polyhydramnios, macrosomia, multiple pregnancy
  • Clotting disorders
  • Antepartum haemorrhage
  • Placenta praevia
  • Prolonged labour
  • Operative birth of caesarean section
  • Induction of labour
• Clinical features:

  • Heavy bleeding from the vagina
  • May be signs of haemodynamic instability
  • Primary PPH:
  • Tone - uterus may feel enlarged, soft or boggy
  • Trauma - visible lacerations or tears
  • Tissue - placental tissue may be incomplete
  • Secondary (endometritis)
  • Signs of sepsis
  • Uterus may be tender or bulky
  • Speculum - os may be open and foul smelling discharge
• Investigations:

  • FBC, U&Es, LFTs
  • Coagulation screen - cause of heavy bleeding or secondary to heavy bleeding
  • Group and save and crossmatch
  • Sepsis screening - cultures
  • High vaginal swabs
  • Pelvic ultrasound scan - products of retained products of conception
• Minimising risk:

  • Identify anaemia with FBC at booking and 28 weeks - treat with iron supplementation
  • Active management of third stage - all women should be offered prophylactic uterotonics (e.g. oxytocin) to reduce risk of PPH
• Immediate management:

  • Obstetric emergency which should be managed by senior obstetrician, anaesthetics and midwifery teams
  • ABCDE approach
  • Estimating blood loss - weigh swabs
  • Major obstetric haemorrhage protocol if >1000ml blood loss with ongoing bleeding
• Atony management:

  • Pharmacological - uterotonic drugs e.g. oxytocin, ergometrine
  • Mechanical - rub the uterus fundus to stimulate contractions and/or bimanual compression
  • Surgical - intra-uterine balloon tamponade, haemostatic sutures (compression sutures)
  • Hysterectomy is rare but should be considered in life-threatening haemorrhage where other measures have failed
• Trauma management:

  • Any perineal tears should be repaired by an experienced obstetrician or midwife
• Tissue management:

  • If the placenta is retained and there is ongoing bleeding
  • Theatre for manual removal of the placenta/retained tissues
• Thrombin management:

  • Consider tranexamic acid
  • Consider vitamin K after discussion with haematology
  • Liaise with haematology with regards to blood products
• Secondary PPH management:

  • Usually caused by endometritis and/or retained products of conception
  • Treatment of sepsis
  • Pelvic ultrasound if retained products are suspected
  • Surgical evacuation of retained products of conception may be necessary
• Complications:

  • Anaemia possibly requiring blood transfusion
  • Hypovolaemic shock leading to organ dysfunction
  • PTSD
  • Hysterectomy
  • DIC
  • Sheehan's syndrome (postpartum pituitary gland necrosis)
  • Death