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–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

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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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
    • >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

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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