Summary
Definition
History and exam
Key diagnostic factors
- estimated blood loss (EBL) ≥500 mL within 24 hours of birth
- uterine atony
- obstetric lacerations and/or expanding haematomas
- signs of hypovolaemia
- retained tissue (placenta, membranes, or placenta accreta spectrum)
- uterine defect on bimanual examination
Other diagnostic factors
- symptoms of hypovolaemia
- uterine tenderness (secondary PPH)
- signs of infection, e.g., fever (secondary PPH)
Risk factors
- placenta previa/low lying placenta
- placenta accreta spectrum
- platelet count <50 × 10⁹/L (<50,000 per microlitre)
- active antepartum bleeding
- inherited coagulopathy
- acquired coagulopathy
- history of PPH in prior delivery
- operative (assisted) vaginal delivery
- current use of therapeutic anticoagulation
- prior caesarean delivery, uterine surgery, or multiple laparotomies
- uterine overdistension (multiple gestation, polyhydramnios, fetal macrosomia with estimated fetal weight >4000 g)
- grand multiparity (>4 prior births)
- large uterine myomas
- class III obesity (BMI >40)
- pre-existing maternal anaemia
- prolonged labour or precipitous delivery
- labour induction or augmentation with prolonged use of oxytocin
- magnesium sulfate use
- caesarean delivery
- placental abruption
- severe pre-eclampsia or HELLP syndrome
- intrauterine fetal demise (IUFD)
- intrapartum infection
- SSRI or SNRI use in the month before delivery
Diagnostic investigations
1st investigations to order
- quantification of blood loss
- blood type and cross-match
- FBC
- coagulation profile (PT, PTT, INR, fibrinogen)
Investigations to consider
- uterine ultrasound
- inherited coagulation assays
- diagnostic laparotomy
- CT abdomen/pelvis
- vaginal microbiology (secondary PPH)
Emerging tests
- thromboelastography (TEG) or rotational thromboelastometry (ROTEM®)
- app-based blood loss quantification technology
Treatment algorithm
primary postpartum haemorrhage: initial presentation
primary postpartum haemorrhage: refractory to initial interventions
secondary postpartum haemorrhage
postpartum haemorrhage resolved
Contributors
Authors
Dena Goffman, MD
Vice Chair for Quality and Patient Safety
Department of Obstetrics and Gynecology
Columbia University Irving Medical Center
New York
NY
Disclosures
DG declares ongoing advisory board roles for Cooper Surgical Obstetrical Safety Council and Organon Jada Scientific Advisory Board; prior PPH educational speaker roles for PRIME, Haymarket, and Laborie; principal investigator for Treating Abnormal Postpartum Uterine Bleeding or Postpartum Hemorrhage with the Jada System-A Postmarket Registry 6/2021 (grant money paid to institution); NIH grant money paid to institution for Effectiveness of Pictographs to Prevent Wrong-Patient Errors in the NICU, and MPI Simulation for Attending Obstetricians to Improve Technical Skills for Managing Postpartum Hemorrhage; none of the above included an obligation to speak on or disseminate product information.
Lilly Liu, MD, MPH
Department of Obstetrics and Gynecology
Columbia University Irving Medical Center
New York
NY
Disclosures
LL declares that she has no competing interests.
Lisa Nathan, MD
Chief of Obstetrics
Department of Obstetrics and Gynecology
Columbia University Irving Medical Center
New York
NY
Disclosures
LN has been paid to speak at an Organon symposium on the Jada System for obstetric hemorrhage management.
Peer reviewers
John C. Smulian, MD, MPH
Chair
Department of Obstetrics and Gynecology
University of Florida College of Medicine
Gainesville
FL
Disclosures
JCS declares that he has no competing interests.
Dilly O. C. Anumba, MBBS, MD, FRCOG, FWACS, LLM
Professor of Obstetrics and Gynaecology
University of Sheffield
Consultant in Obstetrics and Fetomaternal Medicine
Sheffield Teaching Hospitals NHS Foundation Trust
Sheffield
UK
Disclosures
DOCA declares that he has no competing interests.
Guidelines
- Prevention and management of postpartum haemorrhage (green-top guideline no. 52)
- WHO recommendations for the prevention and treatment of postpartum haemorrhage
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