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.

• Sepsis

  The RCOG guideline for sepsis following pregnancy recommends IV piperacillin/tazobactim. [ 18 ] For severe sepsis, carbapenem plus clindamycin. Other options, for less severe infections include co-amoxiclav, metronidazole and gentamicin. [patient.info]

  The images obtained for the first case were corroborated by histologic analysis from a hysterectomy done for sepsis. [ncbi.nlm.nih.gov]

  […] uterus, often following precipitous delivery epistiotomy uterine rupture uterine inversion forceps/operative delivery cesarean section hematoma (vaginal, vulvar, retroperitoneal) Thrombin : coagulopathy hemophilia Von Willebrand's disease ITP, TTP DIC (sepsis [sharinginhealth.ca]

• Fatigue

  Anemia, fatigue and orthtostatic hypostension may present as complications due to PPH. Postpartum hemorrhage is also associated with increased morbidity and mortality. [symptoma.com]

  So an amount of blood loss that makes the woman feel fatigued, or light-headed, or confused and sweaty, or perhaps makes her look pale, or a significant amount of blood loss that results in signs of low blood volumes. [khanacademy.org]

  The woman has symptoms of significant blood loss, such as low blood pressure, a rapid heart rate, dizziness, light-headedness, fatigue, and weakness. Excessive blood loss usually occurs soon after delivery but may occur as late as 1 month afterward. [msdmanuals.com]

  This can be caused from a long labor, or a precipitous labor, either of which can induce uterine fatigue and facilitate possible partial separation of the placenta. Try to anticipate this if she has had either of these labor patterns. [midwiferytoday.com]

• Falling

  Medium: 1,000 to 1,500 mL Blood loss of this volume is usually accompanied by cardiovascular signs, such as a fall in blood pressure, diaphoresis, and tachycardia. Women with this level of hemorrhage exhibit mild signs of shock. [mdedge.com]

  With continuous bleeding, the pulse rate increases, blood pressure falls and the patient goes into shock. It may even lead to her death. [momjunction.com]

  During pregnancy both factor VIII and von Willebrand factor (vWF) levels increase, with peaks at 29 to 32 weeks gestation and at 35 weeks gestation, respectively. 2 Following delivery, vWF levels may fall precipitously within the first few weeks resulting [hematology.org]

  (80-100 mm Hg) Weakness, tachycardia, sweating Mild 1500-2000 mL (25-35%) Moderate fall (70-80 mm Hg) Restlessness, pallor, oliguria Moderate 2000-3000 mL (35-50%) Marked fall (50-70 mm Hg) Collapse, air hunger, anuria Severe Two important facts are [emedicine.medscape.com]

• Shivering

  Misoprostol use is associated with significant increases in shivering and a temperature of 38º Celsius compared with both placebo and other uterotonics. [ncbi.nlm.nih.gov]

  It may also have harmful side effects, in particular raised body temperature (pyrexia) and shivering. [doi.org]

  Several studies that were not included in this review evaluated medications in developing countries and generally reported positive outcomes for oxytocin and misoprostol at appropriate doses; however, adverse effects, particularly fever and shivering, [effectivehealthcare.ahrq.gov]

• Pallor

  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]

  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]

• Vomiting

  • Side effects are very rare, but occasional causes nausea & vomiting. • The only serious side effect is dilutional hyponatremia, which may happen with prolonged use. • Rapid IV infusion is associated with hypotension & tachycardia. • Oxytocin is dosed [slideshare.net]

  Vomiting and nausea (vomiting and nausea considered as separate outcomes ‐ any dose of oxytocin and 10 iu oxytocin: three trials, 5458 women; 5 iu oxytocin: no data available; vomiting and nausea considered as a combined outcome ‐ any dose of oxytocin [doi.org]

  four trials, 1030 women); vomiting (RR 0.21; 95% CI 0.11 to 0.39; four trials, 1030 women). [ncbi.nlm.nih.gov]

• Nausea

  • Side effects are very rare, but occasional causes nausea & vomiting. • The only serious side effect is dilutional hyponatremia, which may happen with prolonged use. • Rapid IV infusion is associated with hypotension & tachycardia. • Oxytocin is dosed [slideshare.net]

  […] to 6.00; nausea: OR 4.07, 95% CI 3.43 to 4.84; vomiting and nausea combined: OR 5.71, 95% CI 4.97 to 6.57). [doi.org]

  There was no statistically significant difference in terms of the need for therapeutic uterotonic agents, but the risk of adverse effects such as nausea and vomiting were significantly lower in the carbetocin group: nausea (RR 0.24; 95% CI 0.15 to 0.40 [ncbi.nlm.nih.gov]

• 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]

  Figures and Tables - Analysis 3.17 Comparison 3 Oxytocin solution versus saline solution, Outcome 17 Abdominal pain. [doi.org]

  Most women present with abdominal pain, postpartum hemorrhage, a visible vaginal mass or palpable mass at bimanual exam. [emergencymedicinecases.com]

  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]

• Hypotension

  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]

  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]

  The OR may be needed to definitively identify source of bleeding. history physical exam History Interview the patient for signs and symptoms of hypotension. [sharinginhealth.ca]

  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

  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]

  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]

  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]

  Tachycardia. Tenderness of the suprapubic area and adnexae. Elevated fundus which feels boggy in RPOC. Investigation FBC. Blood cultures. Check MSU. High vaginal swab; also gonorrhoea/chlamydia. [patient.info]

• Stroke

  Mutations in ACTA2 are the most common genetic cause of thoracic aortic aneurysm, and are also the cause of other disorders, including Moyamoya disease, coronary artery disease and stroke as well as Multisystemic Smooth Muscle Dysfunction Syndrome. [ncbi.nlm.nih.gov]

  […] involving the postpartum care of the mother, including failure to recognize and treat: Anesthesia-related illness Infection/sepsis Life-threatening bowel obstructions after C-section Hemorrhage (uncontrolled bleeding) Pulmonary embolism (that can cause a stroke [birthinjuryjustice.org]

  […] may complain of visual disturbances, ringing in the ears, or extreme weakness. capillary hemorrhage oozing of blood from minute vessels. cerebral hemorrhage a hemorrhage into the cerebrum; one of the three main causes of cerebral vascular accident ( stroke [medical-dictionary.thefreedictionary.com]

• Vaginal Bleeding

  However, recurrent vaginal bleeding and hypovolemic shock occurred 2 days later. Active bleeding from a debris-full diverticulum in the lateral wall of the uterine isthmus was found during an emergent hysterotomy. [ncbi.nlm.nih.gov]

  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, [symptoma.com]

• Oliguria

  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]

  These include: oliguria headache pre-syncope Physical Exam Assess fundus for firmness, or lack thereof (bogginess). Perform prompt and firm uterine massage, removing clots by bimanual exam. [sharinginhealth.ca]

  A nivel clínico la HPP se ha definido como el sangrado excesivo que se torna al paciente sintomático y la presencia de signos de hipovolemia como la hipotensión, taquicardia, oliguria, y disminución de la saturación de oxígeno por debajo de 95%. [medigraphic.com]

  […] oxygen to tissues due to decreased intravascular (blood) volume (< 95%) ( 5 ) Drop in blood pressure (≤ 85/45 (> 15% drop)), which may lead to shock or death if not treated on time Restlessness Pallor Weakness Lightheadedness Hypotension Tachycardia Oliguria [momjunction.com]

• Uterine Hemorrhage

  This novel indication for a cervical cerclage may be a useful adjunct to intrauterine balloon catheter in management of postpartum uterine hemorrhage. [ncbi.nlm.nih.gov]

  Respiratory Aspiration Postpartum Hemorrhage Pathologic Processes Respiration Disorders Respiratory Tract Diseases Obstetric Labor Complications Pregnancy Complications Puerperal Disorders Uterine Hemorrhage [clinicaltrials.gov]

• Pelvic Pain

  In assessing for trauma, pain and external color of the vagina have to be considered. Pain: The mother will be experiencing deep, severe pelvic pain or rectal pain. This can be indicative of internal bleeding. [wikihow.com]

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.

Any other medical or surgical intervention used for treatment of primary PPH versus other treatment or versus control or placebo. [doi.org]

Compared with misoprostol, oxytocin infusion is more effective and causes fewer side effects when used as first-line therapy for the treatment of primary PPH. [ncbi.nlm.nih.gov]

• Safe & Effective treatment option in management of PPH. • Oxytocin is a gold standard treatment in PPH. • Increasing clinical evidences suggest Misoprostol as an alternative to Oxytocin. 26. [slideshare.net]

However, the treatment for invasive placenta is a hysterectomy. 6. [momjunction.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.info]

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]

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. [doi.org]

[…] of Medical and Health Sciences, Gynecology & Obstetrics, Medical case reports, Maternal and Child Health Journal, Obstetrical and Gynecological Journal, Maturitus, Journal of Birth, Reproductive Science, Journal of Pregnancy, International Journal of Epidemiology [imedpub.com]

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]

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]

Pathophysiology Over the course of a pregnancy, maternal blood volume increases by approximately 50% (from 4 L to 6 L). [emedicine.medscape.com]

High: 1,500 to 2,000 mL, or greater This is a medical emergency that must be managed aggressively to prevent morbidity and death. [mdedge.com]

The benefit of prophylactic oxytocin to prevent PPH greater than 500 mL was seen in all subgroups. [ncbi.nlm.nih.gov]

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3. McLintock C, James AH. Obstetric hemorrhage. J Thromb Haemost. 2011;9:1441–51.
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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.
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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.
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12. Oba T, Hasegawa J, Sekizawa A. Postpartum ultrasound: postpartum assessment using ultrasonography.J Matern Fetal Neonatal Med. 2016;30:1-4.