Postpartum Haemorrhage

1. Overview

Postpartum haemorrhage (PPH) is one of the leading causes of maternal mortality worldwide, accounting for approximately 27% of maternal deaths globally. [1] It represents a preventable yet life-threatening obstetric emergency that requires immediate recognition and systematic management. Despite advances in obstetric care, PPH remains a significant contributor to maternal morbidity in both low- and high-resource settings.

PPH is defined as blood loss ≥500ml following vaginal delivery or ≥1000ml following Caesarean section. [2] However, these definitions are based on estimated blood loss, which is notoriously inaccurate—visual estimation frequently underestimates actual blood loss by 30-50%. [3] Pregnant women possess enhanced physiological reserve and can compensate for blood loss up to 1000-1500ml before developing signs of shock, making early recognition challenging.

The clinical importance of PPH extends beyond immediate mortality risk. Survivors may experience long-term sequelae including anaemia requiring transfusion, emergency hysterectomy with loss of fertility, Sheehan syndrome (postpartum pituitary necrosis), acute kidney injury, and psychological trauma including post-traumatic stress disorder. [4]

Classification

PPH is classified temporally and by severity:

Temporal Classification:

1. Primary PPH: Blood loss within 24 hours of delivery

   • Accounts for 90-95% of PPH cases
   • Most commonly due to uterine atony (70.6%), genital tract trauma (16.9%), retained placenta (16.4%), or coagulopathy (2.7%) [5]
   • Multiple concurrent causes occur in approximately 7.8% of cases [5]

2. Secondary PPH: Blood loss from 24 hours to 12 weeks postpartum

   • Less common but often more insidious
   • Usually caused by endometritis, retained products of conception (RPOC), or subinvolution of placental site

Severity Grading:

The distinction between minor and major PPH is critical—major PPH (≥1000ml) carries substantially higher risk of maternal morbidity and mortality, requiring escalation to major haemorrhage protocols. [6]

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2. Epidemiology

Global Burden

Postpartum haemorrhage affects approximately 6-11% of all deliveries worldwide, with significant regional variation. [7] In high-resource countries, the incidence of severe PPH (≥1000ml) is approximately 2-3%, while in low-resource settings, rates may exceed 10%. [8]

Trends

The incidence of PPH has increased in high-resource countries over the past two decades, attributed to:

• Rising Caesarean section rates (increasing risk of placenta accreta spectrum)
• Increasing maternal age and obesity
• Higher rates of multiple pregnancy from assisted reproductive technology
• Improved recognition and documentation [10]

Conversely, maternal mortality from PPH has decreased due to better recognition, implementation of evidence-based protocols (tranexamic acid, active management of third stage), improved access to blood products, and establishment of major haemorrhage protocols. [11]

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3. Aetiology & Pathophysiology

The "4 Ts" Framework

The causes of primary PPH are systematically categorized using the "4 Ts" mnemonic, which facilitates rapid diagnosis and targeted treatment:

Recent meta-analysis data confirm uterine atony as the predominant cause at 70.6% (95% CI 63.9-77.3%), validating the WHO recommendation for universal prophylactic uterotonics. [5] Importantly, 7.8% of PPH cases involve multiple concurrent causes, supporting the use of treatment bundles rather than sequential single interventions. [5]

Exam Detail: ### Detailed Pathophysiology of Uterine Atony

After placental separation, haemostasis is achieved primarily through mechanical compression of spiral arteries by myometrial contraction ("living ligatures"), not through platelet plug formation or coagulation cascade. The placental bed receives 500-800ml/min of blood flow at term; failure of contraction leads to torrential bleeding.

Mechanism of Uterine Contraction:

1. Oxytocin released from posterior pituitary binds to oxytocin receptors on myometrial cells
2. Activates phospholipase C → increases intracellular calcium
3. Calcium binds calmodulin → activates myosin light chain kinase
4. Myosin-actin cross-bridge formation → myometrial contraction
5. Sustained contraction compresses spiral arteries → haemostasis

Prostaglandins (PGE2, PGF2α) supplement oxytocin via direct smooth muscle stimulation and calcium mobilization. Ergometrine causes sustained tetanic contraction via α-adrenergic and serotonergic receptor stimulation.

Risk Factors for Uterine Atony:

• Overdistension: Multiple pregnancy, polyhydramnios, macrosomia (> 4500g)
• Exhaustion: Prolonged labour (> 12 hours), rapid labour, high parity
• Pharmacological: General anaesthesia, halogenated agents, magnesium sulphate, nifedipine
• Infection: Chorioamnionitis causes myometrial inflammation and impaired contractility
• Anatomical: Uterine fibroids (distort architecture), previous uterine surgery

Coagulopathy in Obstetrics

Fibrinogen is the first coagulation factor to fall to critical levels during obstetric haemorrhage. Pregnant women have elevated baseline fibrinogen (4-6 g/L vs. 2-4 g/L non-pregnant), but massive PPH rapidly depletes stores. Fibrinogen less than 2 g/L is associated with progression to severe PPH and need for massive transfusion. [12]

Causes of Obstetric Coagulopathy:

• Dilutional: Massive crystalloid resuscitation
• Consumptive: DIC from placental abruption, HELLP syndrome, amniotic fluid embolism, sepsis, intrauterine fetal death
• Pre-existing: von Willebrand disease (most common inherited bleeding disorder, affects 1-2% of women), haemophilia carriers, thrombocytopenia

Risk Factors

A 2025 systematic review of 327 studies (847 million women) identified risk factors stratified by strength of association: [5]

Strong Association (OR > 2):

• Anaemia (OR 2.8)
• Previous PPH (OR 3.4)
• Caesarean section (OR 2.6)
• Female genital mutilation (OR 2.9)
• Sepsis (OR 3.1)
• No antenatal care (OR 2.4)
• Multiple pregnancy (OR 2.2)
• Placenta praevia (OR 4.8)
• Assisted reproductive technology (OR 2.3)
• Macrosomia > 4500g (OR 2.6)
• Shoulder dystocia (OR 2.7)

Moderate Association (OR 1.5-2):

• Obesity (BMI ≥30 kg/m²) (OR 1.7)
• COVID-19 infection (OR 1.6)
• Gestational diabetes (OR 1.6)
• Polyhydramnios (OR 1.8)
• Pre-eclampsia (OR 1.7)
• Antepartum haemorrhage (OR 1.9)

Weak Association (OR 1-1.5):

• Black/Asian ethnicity (OR 1.2-1.3)
• Overweight (BMI 25-29.9) (OR 1.2)
• Asthma (OR 1.3)
• Thrombocytopenia (OR 1.4)
• Induction of labour (OR 1.3)
• Instrumental delivery (OR 1.4)

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4. Clinical Presentation

Recognition and Assessment

PPH is primarily diagnosed through quantitative blood loss measurement, not subjective visual estimation. Modern obstetric practice mandates objective quantification using:

• Graduated drapes beneath the patient
• Weighing blood-soaked swabs and pads (1g = 1ml blood)
• Calibrated collection devices under operating tables

Visual estimation consistently underestimates blood loss by 30-50%, particularly in major PPH where accuracy is most critical. [3]

Signs and Symptoms

Early Warning Signs:

• Ongoing vaginal bleeding (bright red suggests arterial source/trauma; dark suggests venous/atonic)
• Tachycardia (often first sign due to compensatory mechanisms)
• Maternal anxiety or feeling of impending doom
• Pallor
• Cold, clammy skin

Signs of Haemodynamic Compromise:

Critical Point: Pregnant women can lose 1000-1500ml (15-25% blood volume) before developing hypotension due to physiological pregnancy adaptations:

• 40-50% increase in blood volume
• Increased cardiac output
• Physiological anaemia (haemodilution)

Hypotension is therefore a late sign indicating decompensation and imminent cardiovascular collapse. Tachycardia and rising shock index are earlier markers.

Shock Index

Shock Index (SI) = Heart Rate / Systolic BP

Modified Shock Index (MSI = HR / MAP) and Shock Index x Age may provide additional sensitivity, particularly in older mothers. [13]

Physical Examination: Identifying the "T"

Systematic examination to determine which of the "4 Ts" is responsible:

1. Palpate the Uterine Fundus:

• Boggy, soft, enlarged uterus → TONE (uterine atony)
• Firm, well-contracted uterus → Trauma, Tissue, or Thrombin

2. Inspect the Placenta:

• Incomplete placenta (missing cotyledons, torn membranes) → TISSUE
• Placenta retained in uterus beyond 30 minutes → TISSUE

3. Speculum/Visual Examination:

• Cervical, vaginal, or perineal lacerations → TRAUMA
• Expanding haematoma (vulval, vaginal, broad ligament) → TRAUMA
• Uterine inversion (rare, catastrophic) → TRAUMA

4. Assess Clotting:

• Oozing from IV sites, venepuncture sites → THROMBIN
• Failure to form clot in test tube after 7 minutes (bedside clotting test) → THROMBIN
• Bleeding from multiple sites (gums, nose) → THROMBIN

Multiple causes may coexist in 7.8% of cases. [5]

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5. Differential Diagnosis

When confronted with excessive postpartum bleeding, consider:

Must-Not-Miss Diagnoses:

• Uterine rupture: Obstetric emergency; maternal and fetal mortality
• Uterine inversion: Extreme pain, profound shock (vagal response)
• Placenta accreta/percreta: Attempting placental removal causes torrential haemorrhage; requires immediate hysterectomy

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6. Investigations

PPH is a clinical diagnosis requiring immediate management. Investigations run concurrently with resuscitation, not sequentially.

Immediate Investigations (Within 5 Minutes)

Bedside:

• Bedside clot test: Place 5ml venous blood in plain tube; failure to clot within 7 minutes suggests coagulopathy/hypofibrinogenaemia
• Point-of-care haemoglobin (if available)
• Blood glucose (if diabetic)

Laboratory - Urgent (STAT/Code Red):

Exam Detail: ### Fibrinogen in Obstetric Haemorrhage

Fibrinogen is the first coagulation factor to reach critically low levels during PPH, falling before other factors or platelets. [12] Pregnant women have physiologically elevated fibrinogen (4-6 g/L), but massive haemorrhage and haemodilution from crystalloid resuscitation rapidly deplete levels.

Critical Fibrinogen Thresholds:

• less than 2 g/L: Associated with ongoing PPH, failure of haemostasis, need for massive transfusion
• less than 1 g/L: Severe risk of uncontrolled bleeding; requires immediate cryoprecipitate

Replacement:

• Cryoprecipitate: Contains concentrated fibrinogen, factor VIII, vWF, factor XIII
• Dose: 2 pools (10 units) raises fibrinogen by ~1 g/L
• Target: Maintain fibrinogen > 2 g/L during active bleeding

Fibrinogen concentrate (RiaSTAP) is an alternative but less widely available and expensive.

Second-Line Investigations

Imaging:

• Bedside ultrasound: Assess for retained placental tissue (sensitivity 60-90% for RPOC)
• CT pelvis: If concern for retroperitoneal/broad ligament haematoma, arterial bleeding requiring embolization

Point-of-Care Coagulation Testing:

• Rotational thromboelastometry (ROTEM) or Thromboelastography (TEG): Provides real-time assessment of clot formation, strength, and fibrinolysis; guides targeted blood product replacement
• Not universally available but increasingly used in major obstetric units

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7. Classification / Risk Stratification

Clinical Severity Classification

PPH severity guides escalation of management:

Obstetric Early Warning Scores

Many units use Modified Early Obstetric Warning Systems (MEOWS) incorporating:

• Heart rate
• Systolic BP
• Respiratory rate
• Temperature
• Oxygen saturation
• Consciousness level

Elevated MEOWS scores trigger escalation to senior obstetricians and anaesthetists.

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8. Management

PPH management follows a systematic, stepwise escalation approach. Speed is critical—delays in escalation are associated with worse outcomes.

IMMEDIATE ACTIONS (The "Golden Minute")

┌────────────────────────────────────────────────────────────────┐
│              PPH IMMEDIATE RESPONSE (0-5 MINUTES)              │
├────────────────────────────────────────────────────────────────┤
│  1. CALL FOR HELP                                              │
│     - Activate emergency buzzer (2222 / obstetric emergency)   │
│     - Call senior obstetrician, senior anaesthetist            │
│     - Call theatre team, blood bank                            │
│                                                                │
│  2. RESUSCITATION (ABC Approach)                               │
│     - Lie flat (head-down if shocked)                          │
│     - High-flow oxygen (15L via non-rebreathe mask)            │
│     - Two large-bore IV cannulas (14G/16G)                     │
│     - Rapid IV access (consider intraosseous if difficult)     │
│                                                                │
│  3. BLOODS                                                     │
│     - FBC, coagulation screen, fibrinogen, Group & Save        │
│     - Cross-match 4-6 units red cells (STAT request)           │
│     - Arterial blood gas (lactate, base excess)                │
│                                                                │
│  4. FLUIDS & MEDICATIONS                                       │
│     - Warmed crystalloid (up to 2L rapidly)                    │
│     - **TRANEXAMIC ACID 1g IV over 10 minutes**                │
│       (Evidence: WOMAN trial - give within 3 hours) [14]       │
│     - Then BLOOD (once available; don't wait for cross-match)  │
│                                                                │
│  5. MONITORING                                                 │
│     - Continuous pulse oximetry, BP, ECG                       │
│     - Urinary catheter (monitor urine output - target > 0.5ml/kg│
│     - Quantify blood loss (weigh swabs, graduated drapes)      │
└────────────────────────────────────────────────────────────────┘

Exam Detail: ### Tranexamic Acid: The WOMAN Trial

The WOMAN Trial (2017) was a landmark randomised controlled trial involving 20,060 women with PPH in 21 countries. [14]

Key Findings:

• Tranexamic acid reduced death due to bleeding by 31% (RR 0.69, 95% CI 0.52-0.91)
• Effect was time-dependent:
  • "If given within 3 hours: RR 0.69 (significant benefit)"
  • "If given after 3 hours: RR 1.15 (potential harm)"
• No increase in thromboembolic events
• Cost-effective intervention

Mechanism: Tranexamic acid is an antifibrinolytic that competitively inhibits plasminogen activation, preventing clot breakdown. Pregnancy is a hyperfibrinolytic state; PPH exacerbates fibrinolysis.

Current Practice: Tranexamic acid 1g IV should be administered to all women with diagnosed PPH as early as possible, ideally within 3 hours of delivery. [15]

Prophylactic TXA: Recent Cochrane review (2024) found prophylactic TXA during Caesarean section results in little to no difference in estimated blood loss ≥1000ml (RR 0.94, 95% CI 0.79-1.11), but may slightly reduce calculated blood loss. [16] Prophylactic use is not currently standard practice.

STEP 1: MECHANICAL MEASURES (Immediate)

Stop the Tap - Physical Manoeuvres:

1. Uterine Massage ("Rub the Fundus")

   • Bimanual compression: One fist in anterior vaginal fornix, other hand on abdomen compressing uterus between hands
   • Massages and stimulates uterine contraction
   • Provides immediate tamponade effect
   • Continue until uterus firms

2. Empty the Bladder

   • Indwelling urinary catheter (Foley 14-16F)
   • Full bladder mechanically prevents uterine contraction and descent
   • Monitor urine output (target > 30ml/hr or > 0.5ml/kg/hr)

3. Controlled Cord Traction

   • If placenta undelivered, attempt controlled cord traction with suprapubic counter-pressure (Brandt-Andrews manoeuvre)
   • DO NOT apply excessive force (risk of uterine inversion, cord avulsion)
   • If placenta does not deliver within 30 minutes with gentle traction → retained placenta → manual removal in theatre

4. Repair Genital Tract Trauma

   • Identify and suture lacerations (cervical, vaginal, perineal)
   • May require examination under anaesthesia (EUA) for adequate visualization
   • Episiotomy must be repaired anatomically in layers

STEP 2: MEDICAL MANAGEMENT (Uterotonics)

Uterotonics are the cornerstone of PPH management. Combination therapy is more effective than oxytocin alone. [17]

First-Line: Oxytocin

Administration: Slow IV bolus (over 1-2 minutes) to avoid hypotension, followed by infusion. Most effective uterotonic.

Second-Line: Ergometrine

CRITICAL CONTRAINDICATION: DO NOT use in pre-eclampsia or hypertension (risk of stroke, myocardial infarction, cerebral haemorrhage from severe vasoconstriction).

Second-Line: Carboprost (Prostaglandin F2α)

Dosing: Can repeat every 15 minutes; maximum 8 doses (2mg total).

CRITICAL CONTRAINDICATION: DO NOT use in asthma (risk of severe bronchospasm and respiratory failure).

Second-Line: Misoprostol (Prostaglandin E1)

Advantages: Heat-stable, inexpensive, no contraindications; ideal for low-resource settings or when other uterotonics fail/contraindicated.

Disadvantages: Slower onset; less potent than oxytocin or carboprost.

Exam Detail: ### Combination Uterotonic Therapy

Evidence supports combination therapy (oxytocin + second-line uterotonic) over oxytocin monotherapy for both prevention and treatment of PPH. [17]

Network Meta-Analysis Findings:

• Oxytocin + ergometrine: 34% reduction in PPH > 500ml vs. oxytocin alone
• Oxytocin + misoprostol: 24% reduction in PPH > 500ml vs. oxytocin alone
• Carboprost: Most effective treatment for established PPH

Current Practice:

1. All women: Oxytocin 10 units IM at delivery (active management of third stage)
2. PPH occurs: Add second-line agent (ergometrine if normotensive; carboprost if no asthma; misoprostol if contraindications exist)
3. Sequential administration if PPH persists despite first second-line agent

STEP 3: MASSIVE HAEMORRHAGE PROTOCOL

Activate if:

• Blood loss ≥1500ml
• Shock Index > 1.2
• Ongoing bleeding requiring surgical intervention

Massive Haemorrhage Protocol Principles:

1. Early Activation

   • Contact blood bank: "Obstetric Code Red" or "Major Haemorrhage Protocol"
   • Blood bank delivers pre-prepared packs (6 units PRBC + 4 units FFP + 1 pool platelets)

2. Balanced Transfusion (1:1:1 Ratio)

Rationale for 1:1:1: Massive haemorrhage with crystalloid resuscitation causes dilutional coagulopathy. Early balanced transfusion prevents DIC and "trauma triad of death" (hypothermia, acidosis, coagulopathy). [18]

3. Avoid Crystalloid Overload

   • Limit crystalloid to 2-3L total
   • Warmed fluids (prevent hypothermia)
   • Transition to blood products as soon as available

4. O-Negative Blood

   • If life-threatening haemorrhage and cross-matched blood unavailable, use O-negative PRBC
   • Switch to type-specific or cross-matched blood when available

5. Monitoring

   • Repeat coagulation screen, fibrinogen, FBC every 30-60 minutes
   • Arterial blood gas: Monitor lactate (tissue perfusion), base excess (acidosis), ionised calcium (depleted by citrate in blood products)
   • Temperature: Hypothermia (less than 35°C) impairs coagulation; use warming devices

STEP 4: SURGICAL INTERVENTIONS

If PPH continues despite medical management (uterotonics, tranexamic acid, massage), proceed to theatre.

Indications for Theatre:

• Blood loss > 1500ml despite uterotonics
• Bleeding continues > 30 minutes
• Suspected retained placental tissue requiring manual removal
• Genital tract trauma requiring repair under anaesthesia
• Consideration of surgical haemostatic procedures

Surgical Options (Escalating Hierarchy):

1. Examination Under Anaesthesia (EUA)

• Purpose: Identify and treat correctable causes
• Assess:
  • Retained placental tissue (manual removal)
  • Cervical/vaginal lacerations (suture repair)
  • Uterine inversion (manual replacement)

2. Intrauterine Balloon Tamponade

Mechanism: Balloon tamponade applies direct pressure to placental bed, reducing blood flow and promoting coagulation.

Contraindications: Uterine rupture, genital tract trauma (must repair first).

Monitoring: Continuous monitoring for balloon displacement; record drainage volume via channel.

3. Uterine Compression Sutures

B-Lynch Suture:

• Technique: Compression suture encircling uterus longitudinally, compressing anterior and posterior walls
• Efficacy: 75-90% in case series [20]
• Requires: Laparotomy, experienced surgeon
• Preserves: Uterus (fertility-sparing)
• Complications: Uterine ischaemia, infection, synechiae (Asherman syndrome)

Alternatives: Cho suture, Hayman suture (multiple variations exist).

4. Uterine Artery Ligation

• Technique: Bilateral ligation of uterine arteries at level of lower uterine segment
• Efficacy: 80-90% in atony; less effective in trauma/accreta
• Preserves: Uterus (collateral blood supply via ovarian arteries maintains uterine perfusion)

Internal Iliac Artery Ligation:

• Technically challenging, high failure rate (50-60%), risk of ureteric injury
• Rarely performed in modern practice (superseded by embolization)

5. Uterine Artery Embolization (UAE)

• Technique: Interventional radiology procedure; selective catheterization of uterine arteries via femoral artery, embolization with gelfoam/coils
• Efficacy: 85-95% success rate [21]
• Advantages: Uterus-sparing, minimally invasive, no general anaesthesia
• Disadvantages: Requires interventional radiology availability (not universal), time delay, patient must be haemodynamically stable

Indications:

• Persistent bleeding after conservative surgical measures in stable patient
• Arterial bleeding from placental bed or surgical sites
• Broad ligament haematoma

6. Hysterectomy (Last Resort)

Indications:

• Uncontrollable bleeding despite all other measures
• Uterine rupture
• Placenta percreta with bladder invasion
• Life-saving procedure

Procedure:

• Subtotal (supracervical) hysterectomy: Faster, lower morbidity; preferred in emergency
• Total hysterectomy: Required if cervical involvement or placenta praevia/accreta

Mortality: 0.5-1% (high-risk due to coagulopathy, massive haemorrhage, emergency setting)

Counselling: Permanent loss of fertility; psychological impact significant

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9. Special Scenarios

Placenta Accreta Spectrum (PAS)

Placenta accreta spectrum represents abnormal placental adherence due to defective decidualization. Incidence has increased 10-fold over 50 years due to rising Caesarean section rates. [22]

Classification:

• Accreta (75%): Placental villi adhere to myometrium (no decidua)
• Increta (18%): Villi invade into myometrium
• Percreta (7%): Villi penetrate through serosa ± into bladder/bowel

Risk Factors:

• Previous Caesarean section (strongest risk factor; 0.3% after 1 CS → 6.7% after ≥5 CS)
• Placenta praevia + previous CS (50-67% risk of PAS)
• Maternal age > 35 years
• Previous uterine surgery (myomectomy, D&C)

Diagnosis:

• Antenatal ultrasound: Loss of retroplacental clear space, placental lacunae, bladder wall interruption
• MRI: If posterior/lateral placenta or suspected percreta

Management:

• DO NOT attempt manual removal (causes torrential haemorrhage)
• Caesarean hysterectomy by experienced team (MDT approach: senior obstetrician, urologist, vascular surgeon, interventional radiologist)
• Prophylactic UAE/balloon occlusion in selected cases
• Conservative management (leave placenta in situ, methotrexate) rarely attempted; high morbidity

Maternal Morbidity: 40-50% require massive transfusion; 5-7% maternal mortality in severe cases. [22]

Secondary Postpartum Haemorrhage

Definition: Abnormal bleeding from 24 hours to 12 weeks postpartum.

Causes:

1. Endometritis (most common): Infection of endometrium/myometrium
2. Retained Products of Conception (RPOC): Placental fragments prevent involution
3. Subinvolution of Placental Site: Failure of spiral artery thrombosis
4. Gestational Trophoblastic Disease (rare): Choriocarcinoma

Clinical Features:

• Prolonged, heavy vaginal bleeding (often malodorous if infected)
• Fever, abdominal pain, uterine tenderness (endometritis)
• Enlarged, soft uterus on bimanual examination

Investigations:

• Pelvic ultrasound: Assess for RPOC (echogenic material in endometrial cavity > 10mm)
  • Sensitivity 60-90%, specificity 50-70% (blood clots mimic RPOC)
• Bloods: FBC (anaemia, leucocytosis), CRP (infection), blood cultures (if septic)

Management:

1. Antibiotics: Co-amoxiclav 1.2g IV TDS + Metronidazole 500mg IV TDS (cover anaerobes, streptococci, E. coli)

   • Alternative: Clindamycin 900mg IV TDS + Gentamicin 5-7mg/kg IV OD

2. Surgical Management of Miscarriage (SMM) / Evacuation of Retained Products of Conception (ERPC):

   • Indications: Heavy bleeding, haemodynamic instability, large RPOC (> 15mm), failed medical management
   • Technique: Gentle suction curettage under ultrasound guidance
   • Risks: Uterine perforation (1-2%), intrauterine adhesions (Asherman syndrome), infection
   • Avoid if bleeding minimal and patient stable (high perforation risk; many cases resolve spontaneously)

3. Expectant/Medical Management:

   • If minimal bleeding, small RPOC, stable haemodynamics
   • Misoprostol 800mcg PV (off-label use)
   • Repeat USS at 2 weeks

Sheehan Syndrome (Postpartum Pituitary Necrosis):

Severe PPH causes hypovolaemic shock → pituitary ischaemia/infarction (pituitary is vulnerable due to increased metabolic demand in pregnancy). [4]

Clinical Features:

• Failure to lactate (first sign; prolactin deficiency)
• Failure to resume menses (GnRH deficiency)
• Fatigue, weakness (ACTH/TSH deficiency)
• Hypotension (cortisol deficiency)

Diagnosis:

• MRI pituitary (empty sella)
• Hormonal assessment: Low TSH, ACTH, prolactin, GnRH; low free T4, cortisol, oestrogen

Management:

• Lifelong hormone replacement (levothyroxine, hydrocortisone, oestrogen)
• Rare in modern practice due to improved PPH management

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10. Complications

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11. Prognosis

Short-Term Outcomes

Prognosis depends on rapidity of recognition and intervention:

• Maternal mortality: 0.1-0.5% in high-resource settings with established protocols [9]
• Maternal mortality: 1-2% in low-resource settings [9]
• Hysterectomy rate: 0.5-1% of major PPH
• ICU admission: 5-10% of major PPH

Factors Associated with Worse Outcomes:

• Delay in diagnosis (> 30 minutes to recognition)
• Delay in activating massive haemorrhage protocol
• Excessive crystalloid without blood products (dilutional coagulopathy)
• Lack of experienced personnel/team coordination

Long-Term Outcomes

Physical:

• Anaemia (60-70% if major PPH; may persist for months)
• Pelvic pain (if surgical interventions)
• Loss of fertility (if hysterectomy)
• Asherman syndrome (intrauterine adhesions) if aggressive curettage for RPOC

Psychological:

• Post-traumatic stress disorder (PTSD): 10-15% [4]
• Postnatal depression: increased risk
• Fear of future pregnancy
• Bonding difficulties with infant

Subsequent Pregnancies:

• Recurrence risk: 10-15% in subsequent pregnancy (higher if severe PPH requiring transfusion)
• Risk mitigation:
  • Active management of third stage (prophylactic oxytocin)
  • Delivery in consultant-led unit with immediate access to theatre, blood bank
  • Early IV access, group & save
  • Consider prophylactic tranexamic acid (emerging evidence)

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12. Prevention & Risk Reduction

Primary Prevention

Active Management of Third Stage of Labour (AMTSL):

Universal prophylaxis reduces PPH risk by 60% compared to expectant management. [23]

Components:

1. Prophylactic uterotonic (oxytocin 10 units IM) immediately after delivery of baby
2. Controlled cord traction (Brandt-Andrews manoeuvre) to deliver placenta
3. Uterine massage after placental delivery to ensure contraction

Evidence: Cochrane review (2018) confirmed oxytocin 10 units IM/IV as optimal prophylactic uterotonic. [24]

High-Risk Patients:

• Consider higher-dose oxytocin (e.g., infusion 40 units in 500ml) or combination prophylaxis (oxytocin + misoprostol)
• Early senior involvement
• Cross-match blood in advance
• Delivery in obstetric unit with immediate access to theatre

Modifiable Risk Factors

Training and Drills

Regular multidisciplinary PPH drills improve team performance, reduce delay to intervention, and improve maternal outcomes. [25] Best practice includes:

• Quarterly simulated PPH scenarios
• Clear escalation pathways
• Role allocation (team leader, IV access, drug administration, scribe, blood runner)
• Debrief after real events

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13. Key Guidelines

International Guidelines

Evidence Summary

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14. Examination Focus

Common MRCOG / OSCE Scenarios

Scenario 1: Immediate PPH Management

"You are the registrar called to the labour ward. A 32-year-old G2P1 woman has just delivered vaginally. The midwife reports ongoing heavy bleeding, estimated at 700ml. How would you manage this situation?"

Model Answer:

"This is postpartum haemorrhage. I would approach this systematically using an ABCDE framework and activate the PPH protocol.

Immediate Actions (within 2 minutes):

• Call for senior help (consultant obstetrician, anaesthetist)
• Ensure patient is lying flat, apply oxygen 15L via non-rebreathe mask
• Establish IV access (two large-bore cannulas 14-16G)
• Send urgent bloods: FBC, coagulation screen including fibrinogen, group & save, cross-match 4 units
• Quantify ongoing blood loss using graduated drapes and weighing swabs
• Insert urinary catheter to empty bladder and monitor output

Identify the Cause (4 Ts):

• Palpate uterine fundus: if boggy and soft → uterine atony (most likely)
• Inspect placenta for completeness
• Examine for genital tract trauma (may require speculum)
• Assess for coagulopathy (bedside clotting test, oozing from IV sites)

Medical Management:

• Administer tranexamic acid 1g IV immediately (WOMAN trial evidence)
• Uterine massage (bimanual compression if fundus atonic)
• Oxytocin: 5-10 units IV slow bolus, then infusion 40 units in 500ml at 125ml/hr
• If bleeding continues after 5-10 minutes, add second-line uterotonic:
  • Ergometrine 0.5mg IM/IV (check BP first—avoid if hypertensive)
  • Carboprost 250mcg IM (avoid if asthmatic)
  • Misoprostol 800mcg PR (if contraindications to above)

Fluid Resuscitation:

• Warmed crystalloid initially (up to 2L)
• Transition to blood products if blood loss > 1500ml or shock index > 0.9
• Activate massive haemorrhage protocol if ongoing bleeding

Escalation:

• If bleeding continues despite medical management, proceed to theatre for:
  • Examination under anaesthesia
  • Intrauterine balloon tamponade (Bakri balloon)
  • Surgical interventions (B-Lynch suture, uterine artery ligation, hysterectomy if life-threatening)

Monitoring:

• Continuous pulse oximetry, BP, HR, urine output
• Repeat FBC, coag screen every 30-60 min during active bleeding
• Document all interventions and blood loss"

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Scenario 2: Drug Contraindications

"A 28-year-old woman with known asthma has PPH. Which uterotonic should you avoid and why?"

Answer: "Carboprost (Hemabate, prostaglandin F2α) is absolutely contraindicated in asthma because it causes bronchospasm and can precipitate severe respiratory failure. This is due to prostaglandin-mediated bronchoconstriction. Alternative second-line uterotonics in this patient would be ergometrine (if normotensive) or misoprostol."

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Scenario 3: Tranexamic Acid

"What is the evidence for tranexamic acid in PPH? When should it be given?"

Answer: "The WOMAN trial (2017) was a large randomized controlled trial of 20,060 women in 21 countries. It demonstrated that tranexamic acid reduces death due to bleeding by 31% (RR 0.69, 95% CI 0.52-0.91) when given within 3 hours of delivery. Crucially, the effect is time-dependent—if given after 3 hours, there was potential harm (RR 1.15). There was no increase in thromboembolic events. Current guidelines recommend tranexamic acid 1g IV for all women with diagnosed PPH, administered as early as possible within 3 hours. The dose can be repeated after 30 minutes if bleeding continues."

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High-Yield Viva Points

Viva Point: Opening Statement:

"Postpartum haemorrhage is defined as blood loss ≥500ml after vaginal delivery or ≥1000ml after Caesarean section. It is a leading cause of maternal mortality worldwide, affecting 6-11% of deliveries. Major PPH (≥1000ml) is a life-threatening emergency requiring immediate, systematic management."

Key Facts to Mention:

1. Four Ts: Uterine atony accounts for 70.6% of cases, followed by genital trauma (16.9%), retained tissue (16.4%), and coagulopathy (2.7%). [5]

2. WOMAN Trial: Tranexamic acid 1g IV within 3 hours reduces death from bleeding by 31%. [14]

3. Active Management Third Stage: Prophylactic oxytocin 10 units IM reduces PPH risk by 60%. [23]

4. Fibrinogen: First clotting factor to reach critically low levels (less than 2 g/L) in obstetric haemorrhage; requires cryoprecipitate replacement. [12]

5. Contraindications:

   • Ergometrine: Hypertension/pre-eclampsia (risk of stroke)
   • Carboprost: Asthma (risk of bronchospasm)

6. Escalation: If medical management fails → intrauterine balloon (85-90% success) → surgical interventions (B-Lynch, UAE, hysterectomy).

7. Recurrence: 10-15% risk in subsequent pregnancy; requires active management and senior involvement.

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Common Exam Mistakes

❌ Mistakes that fail candidates:

1. Forgetting tranexamic acid — Universal recommendation; must give within 3 hours
2. Using ergometrine in pre-eclampsia — Causes hypertensive crisis, stroke
3. Using carboprost in asthma — Causes severe bronchospasm
4. Excessive crystalloid without blood products — Causes dilutional coagulopathy, worsens outcome
5. Delaying escalation to theatre — "Medical management has failed" = proceed to surgery
6. Attempting forceful placental removal in accreta — Causes torrential haemorrhage; requires hysterectomy
7. Not checking fibrinogen levels — Most sensitive marker in obstetric haemorrhage
8. Visual estimation of blood loss — Underestimates by 30-50%; must quantify (weigh swabs, graduated drapes)
9. Not activating massive haemorrhage protocol early enough — Should activate at 1500ml or shock index > 1.2
10. Forgetting urinary catheter — Full bladder prevents uterine contraction

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15. Patient Explanation (Layperson)

What is Postpartum Haemorrhage?

"Postpartum haemorrhage—or PPH—means losing more blood than normal after having your baby. After your baby is born, the placenta (afterbirth) separates from your womb. This leaves an area about the size of a dinner plate where blood vessels are open. Normally, your womb contracts strongly—like squeezing a fist—to clamp down these blood vessels and stop the bleeding. If your womb doesn't contract properly, or if there's a tear, or a piece of placenta is still inside, you can lose a lot of blood quickly."

Why did this happen to me?

"There are several reasons PPH can happen. The most common reason is that the womb muscle was 'tired' after labour—especially if you had a long labour, twins, or a big baby. Sometimes there's a small tear that needs stitching, or a small piece of placenta left behind. It's important to know that PPH can happen to anyone, even with perfect pregnancies and deliveries. It's not something you did wrong."

How did the doctors stop the bleeding?

"We acted quickly using several steps. First, we gave you an injection of a drug called oxytocin to help your womb contract. We also gave you a drug called tranexamic acid, which helps your blood clot better. We massaged your womb through your tummy to stimulate it to contract. We put a catheter (tube) in your bladder because a full bladder can stop the womb from contracting properly. If these measures didn't work, we may have used other medications or taken you to the operating theatre to explore further options, such as placing a special balloon inside your womb to apply pressure and stop the bleeding."

Will I need a blood transfusion?

"If you lost a significant amount of blood, you may need a blood transfusion to replace what you lost. Blood transfusions are very safe and can help you recover faster by restoring your red blood cells, which carry oxygen around your body. You might feel tired, weak, or dizzy after losing blood—this is normal and will improve as your body makes new blood cells or receives transfused blood."

Will this happen again if I have another baby?

"There is a slightly higher chance (about 10-15%) that PPH could happen in your next pregnancy, but the vast majority of women who have PPH once do not have it again. If you plan another pregnancy, we will plan ahead: you'll deliver in a hospital with immediate access to an operating theatre and blood bank; we'll give you preventive medication as soon as your baby is born; and senior doctors will be involved in your care. Many women go on to have perfectly normal deliveries after experiencing PPH."

How can I recover?

"Rest is very important. Your body has been through a lot. You may feel tired and weak for several weeks—this is normal. Make sure you:

• Take iron supplements if prescribed (these help rebuild your red blood cells)
• Eat a healthy, balanced diet with plenty of iron-rich foods (red meat, spinach, beans)
• Accept help from family and friends
• Attend all follow-up appointments

If you feel breathless, very dizzy, have chest pain, or notice heavy bleeding starting again, seek medical help immediately."

What about emotional recovery?

"Experiencing a serious complication like PPH can be frightening and upsetting. Some women experience anxiety, flashbacks, or feel traumatized by the experience. This is a normal reaction to a scary event. Please talk to your midwife, health visitor, or GP if you're struggling emotionally. There are specialist services that can help with birth trauma, and talking therapies like counselling can be very effective. You are not alone, and support is available."

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16. References

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