Postpartum hemorrhage

Laima Maleckienė, Romualdas Juršėnas

 

Postpartum hemorrhage (PPH) is defined as a blood loss of 500 mL or more after vaginal delivery, or more than 1000 mL after cesarean delivery that results in symptoms of hemodynamic instability.

Bleeding during the first 24 hours after delivery is early PPH.

Bleeding between 24 hours and 6 weeks after delivery is late PPH.

The incidence of PPH for all deliveries is up to 3-6%.

Causes of early PPH:

Causes of late PPH:

Predisposing factors for uterine atony:

Prevention of PPH

·        Antepartum or early intrapartum assessment of risk factors for PPH should be performed.

·        Patients identified as being at risk for PPH should have blood typed and cross-matched immediately.

·        Active management of the third stage of labor. Uterotonic agents should be administered as soon as the newborn’s anterior shoulder is delivered: oxytocin 10-20 U/L of normal saline by intravenous infusion or 5-10 U I/M.

 

Management Scheme for Postpartum Hemorrhage

 

Diagnostic maneuver

Etiology

Therapeutic Maneuver

Uterine palpation

Uterine atony

Blood for typing and cross-maching

Establishment I/V infusion system (1 or 2)

Uterotonic agents

Indwelling urinary catheter

Oxygen through mask

Massage of the uterus

Bimanual compression of the uterus

Monitoring of maternal vital signs

Fluid and blood replacement

Inspection of the lower genital tract

 

Lacerations

 

Uterine inversion

 

 

Repairment of lacerations

 

Manual or surgical repositioning of the uterus

Uterotonics for at least 24 hours

Antibioticoprophylaxis

Manual exploration of uterine cavity

Retained products

 

 

Uterine rupture

Manual removal of placenta

Instrumental currettage (if needed)

 

Laparotomy (repair or hysterectomy)

Coagulation studies

Coagulopathy

Specific factor replacement

 

If bleeding severe and/or continuous - laparotomy.

Conservative surgery:

Radical surgery:

·        Hysterectomy (total or subtotal)

Embolization of uterine vessels can be considered.

Uterotonic agents

·      Oxytocin 20-80 U/L of crystalloid I/V infusion (continuously if effective).

·      If oxytocine is not effective, one or all drugs:

-         methylergometrine 0.2 mg I/M, next dose after 15 min., then every 4 hours.

-         PGE1 analogue (misoprostol) 600-1000 μg  rectally.

-         15-methyl PGF2a (Enzaprost) 0.25 mg I/M, I/V or intramyometrial injection (during laparotomy) every 15-90 min. (max. 2 mg)

Fluid and blood replacement

Prognozis

Prognosis of PPH depends mostly on the cause, but the underestimation of blood loss, delaying diagnosis and treatment may lead to a life threatening situation.

References

 

1.      American College of Obstetricians and Gynecologists. Postpartum hemorrhage. ACOG Technical Bulletin No 243. Washington, DC: American College of Obstetricians and Gynecologists; 1998.

2.      Lorentzen B, Bjerknes T, Borstad E. Post-partum haemorrhage. In: Dalaker K, Berle EJ, editors. Clinical guidelines in obstetrics 1999. Oslo: The Norwegian Medical Association; 1999. p. 155-8.

3.      Alexander J, Thomas P, Sanghera J. Treatments for secondary postpartum haemorrhage (Cochrane Review). In: The Cochrane Library, 1, 2002. Oxford: Update Software.

4.      Sleep J, Roberts J, Chalmers I. Care during the second stage of labour. In: Enkin M, Keirse MJ,  Renfrew M, Neilson J, editors. Effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press; 1989. p. 1136.

5.      AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of
uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 1994;171(3):694—700.

6.      B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum hemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 1997;104:372-5.