Postpartum hemorrhage

Postpartum hemorrhage (PPH) is an obstetric emergency that is a major contributor to maternal morbidity and mortality. Early recognition relies on accurate quantification of blood loss, together with frequent ongoing assessment of patient-specific risk factors, vital signs, and symptoms of hemorrhage.

Meticulous physical examination of the uterus, cervix, vagina, vulva, and perineum can facilitate an accurate diagnosis and prompt treatment of the underlying cause to prevent progression to hemorrhagic shock.

The four Ts mnemonic highlights the most common causes of PPH: tone (uterine atony, by far the most frequent cause); trauma (obstetric lacerations/expanding hematomas/uterine rupture); tissue (retained products of conception or placenta accreta spectrum disorders); and thrombin (acquired or inherited coagulopathy). Steps to address uterine atony form a routine part of the initial management in every patient with PPH.

First-line treatment for PPH comprises immediate resuscitation with intravenous fluids (and blood product transfusion if needed), along with uterine massage, administration of a uterotonic, and consideration of intravenous tranexamic acid. All of these must ideally be initiated within 15 minutes of a diagnosis. Additional management steps are dependent on the underlying cause of bleeding.

In women with refractory PPH, more aggressive interventions may be needed. Options include: temporary compressive measures; uterine tamponade; uterine artery embolization; surgical interventions, with hysterectomy sometimes necessary as a life-saving intervention.

The use of obstetric hemorrhage care bundles has been shown to improve outcomes in patients with PPH.

Active management of the third stage of labor is the single most important intervention to prevent PPH. Identification of high-risk women in the prenatal period is also paramount.

Primary postpartum hemorrhage (PPH) is characterized by a total blood loss ≥1000 mL (including intrapartum loss) or the presence of signs and symptoms of hypovolemia occurring within 24 hours after childbirth, irrespective of the mode of delivery. This standardized definition of PPH was established in 2014 by the reVITALize program and is endorsed by the American College of Obstetricians and Gynecologists.[1]Menard MK, Main EK, Currigan SM. Executive summary of the reVITALize initiative: standardizing obstetric data definitions. Obstet Gynecol. 2014 Jul;124(1):150-3. http://www.ncbi.nlm.nih.gov/pubmed/24901267?tool=bestpractice.com

Primary PPH occurs within the first 24 hours after delivery. Secondary PPH is defined as excessive blood loss that occurs >24 hours and <12 weeks postpartum.[2]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-86. http://www.ncbi.nlm.nih.gov/pubmed/28937571?tool=bestpractice.com

Prior to publication of the reVITALize definition, PPH was traditionally defined as an estimated blood loss (EBL) >500 mL after a vaginal birth or >1000 mL after a cesarean birth.[2]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-86. http://www.ncbi.nlm.nih.gov/pubmed/28937571?tool=bestpractice.com [3]Main EK, Goffman D, Scavone BM, et al. National partnership for maternal safety: consensus bundle on obstetric hemorrhage. Obstet Gynecol. 2015 Jul;126(1):155-62. https://journals.lww.com/anesthesia-analgesia/fulltext/2015/07000/national_partnership_for_maternal_safety_.22.aspx http://www.ncbi.nlm.nih.gov/pubmed/26241269?tool=bestpractice.com International guidelines still vary in their definition of the EBL required for a diagnosis of PPH.[4]Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage: green-top guideline no. 52. BJOG. 2017 Apr;124(5):e106-49. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.14178 http://www.ncbi.nlm.nih.gov/pubmed/27981719?tool=bestpractice.com [5]World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012 [internet publication]. https://www.who.int/publications/i/item/9789241548502 http://www.ncbi.nlm.nih.gov/pubmed/23586122?tool=bestpractice.com