Overview
Postpartum Haemorrhage
1. Overview
Postpartum Haemorrhage (PPH) is a leading cause of maternal mortality worldwide. It is defined as blood loss >500ml after vaginal delivery or >1000ml after Caesarean section.
Classification
- Primary PPH: Occurs within 24 hours of birth. (Most common/severe).
- Secondary PPH: Occurs between 24 hours and 12 weeks postpartum. (Usually infection/retained tissue).
Severity Grading:
- Minor: 500-1000ml.
- Major: >1000ml.
- Moderate: 1000-2000ml.
- Severe: >2000ml.
2. Pathophysiology: The 4 Ts
Almost all causes of PPH fall into the "4 Ts".
| The "T" | Cause | Frequency | Mechanism |
|---|---|---|---|
| TONE | Uterine Atony | 70% (Most common) | The uterus fails to contract after delivery. Muscle fibres don't compress the spiral arteries. Risk factors: Twins, Macrosomia, Prolonged labor, Polyhydramnios. |
| TRAUMA | Lacerations | 20% | Tears of cervix, vagina, or perineum. Hematomas. Uterine Rupture (Rare, catastrophic). |
| TISSUE | Retained Placenta | 10% | Piece of placenta/membrane left inside prevents contraction. |
| THROMBIN | Coagulopathy | <1% | Pre-existing (Von Willebrand's) or Acquired (DIC from HELLP/Sepsis). |
3. Clinical Features
Assessment
Quantifying Blood Loss:
- Visual estimation is notoriously inaccurate (underestimated by 30-50%).
- Weighing swabs/pads is Gold Standard.
Signs of Shock (Physiological changes):
- Pregnant women can compensate well (lose 1000-1500ml) before BP drops.
- Tachycardia: Often the first sign.
- Hypotension: Late sign.
- Agitation/Confusion: Hypoxia.
4. Diagnosis
PPH is a clinical diagnosis based on volume. The "Diagnostic" step is identifying the Cause (4 Ts).
- Feel the Fundus:
- Boggy/Soft = Atony (Tone).
- Firm/Central but bleeding = Trauma (Tear) or Coagulopathy.
- Check Placenta: Is it complete? (Tissue).
- Speculum Exam: Inspect for tears (Trauma).
- Clotting Screen: Fibrinogen is the most sensitive marker for obstetrics (Thrombin).
5. Management Algorithm
CALL FOR HELP - 2222 (Obstetric Emergency)
┌─────────────────────────────────────────────────────────────────────────────┐
│ PPH MANAGEMENT: STEPWISE APPROACH │
├─────────────────────────────────────────────────────────────────────────────┤
│ │
│ STEP 0: IMMEDIATE ACTIONS (The "Golden Minute") │
│ • Lie flat. │
│ • **ABC**: High flow Oxygen (15L). │
│ • Two large bore cannulas (14G/16G). │
│ • **Bloods**: FBC, Coag, Fibrinogen, Cross-match (4-6 units). │
│ • **Tranexamic Acid 1g IV** (WOMAN Trial - Give within 3 hrs). │
│ • **Fluid**: Warmed crystalloid (up to 2-3L) -> then BLOOD. │
│ └─────────────────────────────────────────────────────────────────────┘ │
│ ↓ │
│ ┌─────────────────────────────────────────────────────────────────────┐ │
│ │ STEP 1: MECHANICAL (Stop the Tap) │ │
│ │ • **Rub the Fundus**: Bimanual compression (Fist in vagina, hand │ │
│ │ on abdomen). Squeeze the uterus. │ │
│ │ • Empty the Bladder (Catheter). Full bladder prevents contraction. │ │
│ │ • Repair tears (Suture). │ │
│ └─────────────────────────────────────────────────────────────────────┘ │
│ ↓ │
│ ┌─────────────────────────────────────────────────────────────────────┐ │
│ │ STEP 2: MEDICAL (Uterotonics) │ │
│ │ 1. **Oxytocin (Syntocinon)**: 5-10 units IV/IM bolus + Infusion │ │
│ │ (40u in 500ml). │ │
│ │ 2. **Ergometrine**: 0.5mg IM/IV (Strong vasoconstrictor). │ │
│ │ *Avoid in Hypertension/Pre-eclampsia*. │ │
│ │ 3. **Carboprost**: 250mcg IM (Deep muscle). Repeat q15m (max 8). │ │
│ │ *Avoid in Asthma* (Bronchospasm). │ │
│ │ 4. **Misoprostol**: 800-1000mcg PR (Rectal). Sublingual option. │ │
│ └─────────────────────────────────────────────────────────────────────┘ │
│ ↓ Bleeding Continues │
│ ┌─────────────────────────────────────────────────────────────────────┐ │
│ │ STEP 3: SURGICAL (Theatres) │ │
│ │ • Examination Under Anaesthetic (EUA) to check for tissue/tears. │ │
│ │ • **Intrauterine Balloon (Bakri)**: Tamponade effect. │ │
│ │ • **B-Lynch Suture**: Compression suture (requires laparotomy). │ │
│ │ • Uterine Artery Embolization (Interventional Radiology). │ │
│ │ • **Hysterectomy**: Life-saving last resort. │ │
│ └─────────────────────────────────────────────────────────────────────┘ │
│ │
└─────────────────────────────────────────────────────────────────────────────┘
The "O Neg" Protocol
In massive hemorrhage (>1.5-2L or collapse):
- Activate Massive Transfusion Protocol.
- Give O Negative Blood immediately (don't wait for cross-match).
- Give FFP/Platelets/Cryoprecipitate early (prevent DIC). Ratio 1:1:1.
6. Secondary PPH
- Time: >24h to 12 weeks.
- Cause: Usually Endometritis (Infection) or Retained Products of Conception (RPOC).
- Features: Fever, smelly lochia, tender uterus, ongoing bleeding.
- Management:
- Ultrasound (check for RPOC).
- Antibiotics (Co-amoxiclav + Metronidazole).
- Surgical Evacuation (SMM) only if heavy bleeding or large tissue (risk of perforation).
7. Prognosis
- Depends on speed of resuscitation.
- Sheehan's Syndrome: Severe PPH causes pituitary infarction -> Pan-hypopituitarism (failure to lactate, amenorrhea).
8. Complications
- DIC: Disseminated Intravascular Coagulation. Consumption of clotting factors.
- Renal Failure: Acute Tubular Necrosis from hypovolemia.
- Hysterectomy: Loss of fertility.
- PTSD: Traumatic birth experience.
9. Special Considerations
Tranexamic Acid (TXA)
- Evidence: The WOMAN Trial (2017).
- Finding: TXA reduced death due to bleeding by ~30% if given within 3 hours.
- Rule: Give 1g IV immediately for ALL cases of PPH. Report-grade evidence.
Placenta Accreta
- If placenta won't come out, DO NOT PULL.
- Acreta (morbid adhesion) requires surgical resection/hysterectomy. Pulling leads to inversion or massive hemorrhage.
10. Key Clinical Pearls
Exam-Focused Points
- Definitions: >500ml vaginal, >1000ml C-section.
- 4 Ts: Tone, Trauma, Tissue, Thrombin.
- First Step: Call for Help + Rub the Fundus (Mechanical before Medical).
- Contraindications:
- Ergometrine: Avoid in Hypertension/Pre-eclampsia (causes stroke).
- Carboprost: Avoid in Asthma (causes bronchospasm).
- TXA: 1g IV immediately (WOMAN trial).
- Shock Index: Pulse / BP. If >1, significant blood loss.
- Fibrinogen: The first clotting factor to deplete in pregnancy coagulopathy. Replace with Cryoprecipitate.
Common Exam Scenarios
- Patient with PPH, history of asthma. Which drug to avoid? (Carboprost).
- Patient with PPH, BP 160/100. Which drug to avoid? (Ergometrine).
- Bleeding despite contracted (firm) uterus. Cause? (Trauma/Tear - Tone is fine).
11. Patient Explanation
What happened?
"You lost a significant amount of blood after the birth. This is usually because the womb was tired and didn't clamp down strongly enough to seal the blood vessels where the placenta was attached."
Why did you press on my tummy?
"We needed to act fast. Pressing on the tummy (massaging the womb) is the quickest way to stimulate the muscle to clamp down and stop the bleeding while the medication takes effect."
Will it happen again?
"There is a slightly higher risk in future pregnancies, but now we know, we will manage the next birth carefully (delivering the placenta with injection quickly) to minimize the risk."
12. Evidence & Guidelines
Key Guidelines
| Guideline | Organization | Year | Key Points |
|---|---|---|---|
| PPH (GTG 52) | RCOG | 2016 | The 4 Ts algorithm. |
| PPH Prevention | WHO | 2018 | Active management of 3rd stage. |
Landmark Trials
WOMAN Trial (2017):
- 20,000 women global trial.
- Result: Tranexamic acid reduces death from bleeding by 1/3.
- Crucial: Must be given early (<3 hours).
- Practice Change: Now first-line universal protocol.
Evidence-Based Recommendations
| Recommendation | Evidence Level |
|---|---|
| Active Management of 3rd Stage | High (Reduces PPH risk by 60%) |
| Tranexamic Acid | High |
| Oxytocin First Line | High |
| Intrauterine Balloon | Moderate |
13. References
- Shakur H, et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116.
- Mavrides E, et al. Prevention and Management of Postpartum Haemorrhage (Green-top Guideline No. 52). BJOG. 2016;124(5):e106-e149.
- Gallos ID, et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev. 2018;(12):CD011689.