Postpartum Hemorrhage

Postpartum Hemorrhage is a topic covered in the 5-Minute Emergency Consult.

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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 after delivery (but <12 wk):
    • 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
  • Leading cause of death in pregnancy worldwide
    • 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
    • Loss of fertility
    • Disseminated intravascular coagulopathy (DIC)

Etiology

  • 4 Ts:
    • Tone
    • Tissue
    • Trauma
    • Thrombin
  • Immediate:
    • Uterine atony
    • Lower genital lacerations
    • Retained placental tissue
    • Placenta accreta
    • Uterine rupture
    • Uterine inversion
    • Puerperal hematoma
    • Coagulopathies
  • Delayed:
    • Retained products of conception
    • Postpartum endometritis
    • Withdrawal of exogenous estrogen
    • Puerperal hematoma
  • Coagulopathies:
    • Pre-existing idiopathic thrombocytopenic purpura
    • Thrombotic thrombocytopenic purpura
    • Von Willebrand disease
    • DIC
  • Associated conditions:
    • If bleeding is present at other sites, consider coagulopathy
  • Risk factors:
    • Prior PPH
    • Advanced maternal age
    • Multiple gestations
    • Prolonged labor
    • Polyhydramnios
    • Instrumental delivery
    • Fetal demise
    • Anticoagulation therapy
    • Placental abruption
    • Fibroids
    • Prolonged use of oxytocin
    • C-section
    • Placenta previa and accreta
    • Chorioamnionitis
    • General anesthesia

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Citation

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TY - ELEC T1 - Postpartum Hemorrhage ID - 307420 Y1 - 2016 PB - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307420/all/Postpartum_Hemorrhage ER -