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Postpartum Hemorrhage

Postpartum hemorrhage is a life-threatening condition that is defined as blood loss of more than 500 milliliters after vaginal delivery or more than 1000 milliliters after cesarean section. It occurs in approximately 5% to 18% of births and is most likely to occur after cesarean delivery. The most common cause of postpartum hemorrhage is uterine atony.


Presentation

The first indication of postpartum hemorrhage (PPH) may be blood-drenched pads and bed sheets. There may also be copious amounts of vaginal bleeding or symptoms of significant blood loss or hypovolemic shock (e.g., palpitations, dizziness, hypotension, tachycardia, weakness, pallor) [1] [2]. Symptoms may onset quickly, such as in the case of uterine atony, or they may appear more gradually [3] [4]. Anemia, fatigue and orthtostatic hypostension may present as complications due to PPH. Postpartum hemorrhage is also associated with increased morbidity and mortality.

Pallor
  • ., palpitations, dizziness, hypotension, tachycardia, weakness, pallor). Symptoms may onset quickly, such as in the case of uterine atony, or they may appear more gradually.[symptoma.com]
  • CASE REPORT: We describe a 28-year-old woman who presented with secondary PPH accompanied by bleeding from gums, marked pallor, hematemesis, ecchymotic and purpuric spots all over the body, 8 days post-partum.[ncbi.nlm.nih.gov]
  • Blood loss of this volume will usually bring significant cardiovascular changes, such as hypotension, tachycardia, restlessness, pallor, oliguria, and cardiovascular collapse from hemorrhagic shock. this degree of blood loss means that the patient has[mdedge.com]
  • […] infusion or 10 Units IM Vigorous fundal massage for 15 seconds minimum Stage 1 Blood Loss 500ml Vaginal delivery; 1000 ml cesarean section 15% Vital Sign change -or-HR equal to or greater than 110, BP equal to or less than 85/45 O2 Sat less than 95%, pallor[perinatology.com]
  • […] delivered soon after with 2rd degree tear  Placenta delivered: appears intact with no missing or extra lobes  Bleeding estimated at 400 mL, with a slow trickle from tear  During suturing of her tear you note vitals deteriorating to  HR 120, BP 90/60, pallor[slideshare.net]
Abdominal Pain
  • Ten days after delivery, the woman experienced high fever and low abdominal pain. Histologic findings after hysterectomy were consistent with uterine necrosis and acute suppurative myometritis.[ncbi.nlm.nih.gov]
  • These include fever, abdominal pain, painful urination, general weakness, abdominal tenderness over the suprapubic area and adnexae. 3 Go to the hospital if you see these warning signs.[wikihow.com]
  • Figures and Tables - Analysis 3.17 Comparison 3 Oxytocin solution versus saline solution, Outcome 17 Abdominal pain.[doi.org]
  • Figures and Tables - Analysis 2.12 Comparison 2 Carbetocin versus syntometrine, Outcome 12 Uterine or abdominal pain. Figures and Tables - Analysis 2.13 Comparison 2 Carbetocin versus syntometrine, Outcome 13 Facial flushing.[doi.org]
Intestinal Perforation
  • perforation due to paratyphoid 27·1 (20·9 to 34·5) 17·6 ( 33·0 to 1·4) 23·7 ( 37·8 to 6·1) * 3·1 (1·9–4·6) 17·5 ( 32·8 to 1·6) 23·6 ( 37·7 to 5·9) * Other intestinal infectious diseases .. .. .. 1·8 (0·6–4·1) 67·0 ( 78·8 to 45·8) * 69·3 ( 80·2 to 50·[ncbi.nlm.nih.gov]
Hypotension
  • ., palpitations, dizziness, hypotension, tachycardia, weakness, pallor). Symptoms may onset quickly, such as in the case of uterine atony, or they may appear more gradually.[symptoma.com]
  • Hypotension, dizziness, tachycardia or palpitations, and decreasing urine output will typically occur when more than 10% of maternal blood volume has been lost.[mdedge.com]
  • Introduction Defined as the loss of 1000mL of blood loss within the first 24 hours after delivery regardless of the route of delivery physiologic stress can cause hypotension and increased cortisol demand (problematic in primary adrenal insufficiency)[step2.medbullets.com]
  • If bleeding continues, tachycardia and hypotension worsen. As a protective effect to maintain cardiac output, peripheral vasoconstriction occurs, leading to decreased tissue perfusion.[clinicaladvisor.com]
  • Oxytocin should not be given as an IV bolus because severe hypotension may occur. In addition, the uterus is explored for lacerations and retained placental tissues. The cervix and vagina are also examined; lacerations are repaired.[merckmanuals.com]
Tachycardia
  • ., palpitations, dizziness, hypotension, tachycardia, weakness, pallor). Symptoms may onset quickly, such as in the case of uterine atony, or they may appear more gradually.[symptoma.com]
  • Tachycardia and disseminated intravascular coagulation were significant risk factors for intractable PPH. All of the women with intractable PPH underwent TAE, and 89 (72.3%) were transferred by ground transport to receive treatment in this system.[ncbi.nlm.nih.gov]
  • Hypotension, dizziness, tachycardia or palpitations, and decreasing urine output will typically occur when more than 10% of maternal blood volume has been lost.[mdedge.com]
  • Usual signs of tachycardia and hypotension associated with severe bleeding may be masked or occur late because of the relative hypervolemic state of pregnancy. Concealed pelvic hematomas with ongoing blood loss may also be masked initially.[clinicaladvisor.com]
  • […] connective tissue - common areas are the vagina, vulvar, and retroperitoneal areas What would the pt feel if they are suffering from postpartum hematoma - produces deep and sever pain which goes unreliieved S/S of hemorrhage as postpartum hemorrhage - tachycardia[quizlet.com]
Encephalopathy
  • We also found PRES had many features similar with contrast-induced encephalopathy.[ncbi.nlm.nih.gov]
  • The most important cause of neonatal death in 2013 was neonatal encephalopathy, followed by neonatal sepsis, congenital anomalies, and lower respiratory infections ( table 3 ).[ncbi.nlm.nih.gov]
  • Data from case reports reported severe adverse effects (cerebral ischaemia, vasospasm and hypertensive encephalopathy) ( Dua 1994 ; Taylor 1985 ), indicating that the drug should be used with caution.[doi.org]
  • A second category of diseases includes those in which YLDs are increasing but YLLs are decreasing, including disorders such as thyroid cancer, cirrhosis, and neonatal encephalopathy.[ncbi.nlm.nih.gov]
Vaginal Bleeding
  • A 35-year-old woman presented with severe vaginal bleeding on the 47th day after a cesarean section. She had received endometrial curettage due to postpartum hemorrhage a few days earlier in another local hospital.[ncbi.nlm.nih.gov]
  • A 36-year-old pregnant woman with placenta previa and percreta at 35 weeks' gestation complicated with massive vaginal bleeding. An emergency cesarean section was performed, and placenta previa with percreta and uterine atony were noted.[ncbi.nlm.nih.gov]
  • There may also be copious amounts of vaginal bleeding or symptoms of significant blood loss or hypovolemic shock (e.g., palpitations, dizziness, hypotension, tachycardia, weakness, pallor).[symptoma.com]
  • Excessive vaginal bleeding occurred 10, 9, and 31 days after delivery, respectively. Ultrasonogram and pelvic angiography revealed the UAP in each case and uterine artery embolization was performed. UAP may be a complication of precipitous delivery.[ncbi.nlm.nih.gov]
  • Vaginal balloon tamponade can be a solution in difficult cases of intractable vaginal hemorrhage or occult vaginal bleeding causing vaginal hematoma.[ncbi.nlm.nih.gov]
Pelvic Pain
  • Pain: The mother will be experiencing deep, severe pelvic pain or rectal pain. This can be indicative of internal bleeding. External vaginal orifice: there will be bulging masses and skin discoloration (usually purplish to bluish black hue).[wikihow.com]

Workup

The diagnosis of postpartum hemorrhage begins with recognition of excessive bleeding by either visual confirmation (e.g., copious vaginal bleeding) or recognition of symptoms associated with significant blood loss (e.g., tachycardia, pallor, fatigue, hypotension) [5] [6]. Subsequent steps in the workup of postpartum hemorrhage are to determine the cause of the blood loss, amount of blood lost, and treatment.

In patients with postpartum hemorrhage, a physical exam of the lower abdomen and uterine area may reveal a uterine atony. Uterine atony is one of the most common causes of postpartum hemorrhage; it is characterized by a boggy uterus and swollen or expanded uterine size [1] [7] [8]. The patient's risk factors for uterine atony should be assessed (e.g, uterine overdistention, prolonged labor, rapid labor and delivery, chorioamnioitis, delivery of 5 or more live infants) [5] [9].

On examination, blood may be seen at the introitus if the placenta has delivered. If the placenta is retained, then blood may be retained in the uterus behind the remaining placenta and/or the membranes. Hematomas seen on the retroperitoneum or lower genital tract may also be indicative of bleeding [2] [10].

The onset of postpartum hemorrhage is rapid in most cases, with little to no time for laboratory or imaging work up. However, laboratory tests and ultrasound may aid in diagnosis and determination of an etiology.

  • A complete blood count (CBC), which consists of hemoglobin and hematocrit levels, is usually performed prior to delivery and a couple of times after delivery. A significant drop in the hematocrit and hemoglobin values of the CBC performed shortly after delivery and the subsequent one (usually 24 hours after delivery) is an indication for possible bleeding [11].
  • Coagulation studies can be performed to rule out various coagulopathies.
  • A pelvic ultrasound may support the diagnosis of postpartum hemorrhage by showing blood within the uterus, invasive placenta, remaining placental tissues or fragments, uterine rupture, and/or blood clots [4] [12]. In cases where there is massive blood loss, continued bleeding, or rapid bleeding, surgical exploration is needed to determine the etiology of bleeding and for the necessary treatment.

Treatment

  • Objective: To investigate the risk factors that impact the efficacy of interventional treatment of intractable postpartum hemorrhage (IPH).[ncbi.nlm.nih.gov]
  • CONCLUSION: This is the first controlled study assessing the efficacy of PAE for the treatment of PPH. Our data suggest that PAE is effective for the treatment of severe PPH.[ncbi.nlm.nih.gov]
  • Treatment with uterotonic drugs like oxytocin and prostaglandins and conservative procedures like transfusion of packed red cells and fresh frozen plasma failed to control the diffuse bleeding.[ncbi.nlm.nih.gov]
  • Selective arterial embolization may be considered as a primary means of treatment.[ncbi.nlm.nih.gov]
  • Primary suturation was the first-line treatment in all patients. In two of the patients, hysterectomy was performed after the defined surgical procedures were not successful in controling the bleeding.[ncbi.nlm.nih.gov]

Prognosis

  • […] massive fluid resuscitation and/or massive transfusion requirements of 10 units of PRBC renal (acute tubular necrosis) hepatic failure acute respiratory distress syndrome multisystem organ failure pituitary avascular necrosis (Sheehan's syndrome) The prognosis[clinicaladvisor.com]
  • Standard of Care and Prognosis Close monitoring is the best route for PPH. The mother's condition, skin color, blood pressure, blood loss, uterine size and tone are closely assessed.[defranciscolaw.com]
  • Prognosis 90% of cases of postpartum endometritis treated with antibiotics improve within 48-72 hours. [ 16 ] If this is not the case, the patient should be re-evaluated.[patient.co.uk]

Etiology

  • Use of uterine angiography and embolization at an early stage in the search for the etiology of postpartum hemorrhage helps to decrease morbidity and mortality.[ncbi.nlm.nih.gov]
  • However, laboratory tests and ultrasound may aid in diagnosis and determination of an etiology.[symptoma.com]
  • BACKGROUND: Postpartum hemorrhage has many well-established etiologies. It may also be secondary to an inner myometrial laceration, a less frequent and more difficult entity to diagnose.[ncbi.nlm.nih.gov]
  • Gestational thrombocytopenia is a rare event, and the etiology is unknown. Generally, there is no need for intervention because of the absence of coagulopathy.[ncbi.nlm.nih.gov]
  • The most common etiologies for severe PPH were uterine atony (60%) and placental complications (36%).[ncbi.nlm.nih.gov]

Epidemiology

  • Center, Leiden, The Netherlands. 4 National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom. 5 Leiden University Medical Center, Leiden, The Netherlands. 6 Department of Obstetrics and Gynecology, Deventer Hospital, Deventer[ncbi.nlm.nih.gov]
  • This review will examine the epidemiology of PPH as well as current recommendations for key elements in obstetric hemorrhage protocols.[ncbi.nlm.nih.gov]
  • Epidemiology Resources, 1991. Schneeweiss S. Sensitivity analysis and external adjustment for unmeasured confounders in epidemiologic database studies of therapeutics. Pharmacoepidemiol Drug Safety 2006 ; 15 : 291 -303. Blomberg M.[bmj.com]
  • (The objective of this epidemiologic study was to evaluate the trends of risk factors and causes for maternal mortality in the United States and to identify patients at high risk for death.[clinicaladvisor.com]
Sex distribution
Age distribution

Pathophysiology

  • Postpartum Hemorrhage Today Chapter 9: Blood Loss Chapter 10: Assessing and Replenishing Lost Volume Chapter 11: Pitfalls in Assessing Blood Loss and Decision to Transfer Chapter 12: Doppler Evaluation of Hemodynamic Changes in Uterine Blood Flow Chapter 13: Pathophysiology[glowm.com]
  • Pathophysiology Most frequent cause of PPH is uterine atony.[clinicaladvisor.com]
  • , fibroids, hypertensive disorders, obesity, chorioamnionitis, placenta previa, prolonged or augmented labour, and macrosomia, 3 4 5 6 7 8 9 10 11 12 13 14 many cases of postpartum haemorrhage occur in the absence of recognised risk factors, and the pathophysiology[bmj.com]

Prevention

  • Yet 87% who received advance misoprostol and delivered at home used it for PPH prevention. Among FCHVs, 96% were providing advance misoprostol for PPH prevention; however 81% had experienced at least one misoprostol stock out within the past year.[ncbi.nlm.nih.gov]
  • The main outcome measures were lives saved, surgeries averted, and severe anemia prevented.[ncbi.nlm.nih.gov]
  • Therefore, preventive measures must be offered to all pregnant women. This study investigated the effects of multi-professional, scenario-based training on the prevention and management of PPH at a Tanzanian zonal consultant hospital.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: There is not enough evidence to determine if uterine massage prevents postpartum hemorrhage at cesarean delivery. Copyright 2018 Elsevier B.V. All rights reserved.[ncbi.nlm.nih.gov]
  • Every birthing hospital should have a protocol in place for the prevention and management of postpartum hemorrhage. Prevention of PPH: There are few known risk factors for postpartum hemorrhage.[perinatalweb.org]

References

Article

  1. WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. Geneva: World Health Organization; 2012. Available from: http://www.ncbi.nlm.nih.gov/books/NBK131942/
  2. Clinical Practice Obstetrics Committee. Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage: No. 235 October 2009 (Replaces No. 88, April 2000). Int J Gynaecol Obstet. 2010;108:258–67.
  3. McLintock C, James AH. Obstetric hemorrhage. J Thromb Haemost. 2011;9:1441–51.
  4. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol. 2006;108 (4):1039–47.
  5. Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. RCOG Green-top Guideline No. 52. London: Royal College of O, Gynaecologists; 2009. Available at http://www .rcog.org.uk /womens-health/clinical-guidance /prevention-and-management-postpartum-haemorrhage-green-top-52.
  6. Bais JM, Eskes M, Pel M, Bonsel GJ, Bleker OP. Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 mL) and severe (> or = 1000 mL) postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol. 2004;115:166–72.
  7. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol. 1991;77:69–76.
  8. Stones RW, Paterson CM, Saunders NJ. Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol. 1993;48:15–8.
  9. Sherman SJ, Greenspoon JS, Nelson JM, Paul RH. Identifying the obstetric patient at high risk of multiple-unit blood transfusions. J Reprod Med. 1992;37:649–52.
  10. Baskett TF. Complications of the third stage of labour. Essential Management of Obstetrical Emergencies. 3rd ed. Bristol, England: Clinical Press; 1999: 196-201.
  11. Ekeroma AJ, Ansari A, Stirrat GM. Blood transfusion in obstetrics and gynaecology. Br J Obstet Gynaecol. 1997;104:278–84.
  12. Oba T, Hasegawa J, Sekizawa A. Postpartum ultrasound: postpartum assessment using ultrasonography.J Matern Fetal Neonatal Med. 2016;30:1-4.

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Last updated: 2019-06-28 10:47