Postpartum Hemorrhage

Basics

Description

  • 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
    • >1000 mL after C-section
    • >Cumulative blood loss greater than or equal to 1000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hr after the delivery, including intrapartum loss regardless of route of delivery
  • 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

Etiology

  • 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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