Postpartum Hemorrhage

Basics

Postpartum hemorrhage (PPH) after 20 wk gestation
Primary: Hemorrhage occurring ≤24 hr after delivery:
- Also known as early PPH
Secondary: Hemorrhage occurring 24 hr–12 wk after delivery:
- Also known as delayed PPH
Definitions:
- >500 mL after vaginal delivery
- >1,000 mL after C-section
Occurs in 4% of vaginal deliveries
Occurs in 6% of C-sections
Accounts for 25% of pregnancy-related deaths
∼50% of postpartum deaths are due to PPH
95% of PPH caused by:
- Uterine atony (50–60%)
- Retained placenta (20–30%)
- Cervical/vaginal lacerations (10%)
Complications:
- Hypovolemic shock
- Blood transfusion
- Acute respiratory distress syndrome
- Renal and/or hepatic failure
- Sheehan syndrome (postpartum pituitary necrosis)
- Loss of fertility
- Disseminated intravascular coagulopathy (DIC)

ALERT
Leading cause of death in pregnancy worldwide

4 Ts of primary PPH:
- Tone:
  - Uterine atony
- Tissue
  - Lower genital lacerations
  - Retained placental tissue
- Trauma
  - Placenta accreta
  - Uterine rupture
  - Uterine inversion
  - Ovarian or splenic artery rupture
  - Puerperal hematoma
  - Genital tract trauma
- Thrombin
  - Coagulopathy (ITP, TTP, von Willebrand, DIC)
Causes of secondary PPH:
- Retained products of conception
- Postpartum endometritis
- Withdrawal of exogenous estrogen
- Puerperal hematoma
Associated conditions:
- If bleeding is present at other sites, consider coagulopathy
Risk factors:
- Prior PPH
- Advanced maternal age
- Multiple gestations
- Prolonged labor
- Polyhydramnios
- Instrument-assisted delivery
- Fetal demise
- Anticoagulation therapy
- Placental abruption
- Fibroids
- Prolonged use of oxytocin
- C-section (especially emergent)
- Placenta previa and accreta
- Chorioamnionitis
- General anesthesia
- Large fetus/infant
- Obesity
- Pyrexia

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