Hemorragia postparto: causas, síntomas, diagnóstico y tratamiento

Postpartum hemorrhage (PPH) is a serious complication during the immediate postdelivery phase. It is characterized by excessive bleeding, typically more than 500 milliliters, which can lead to life-threatening complications such as hypovolemic shock and death. According to the American Academy of Family Physicians (AAFP), PPH occurs in up to 18% of all births, and 3% of those cases are severe enough to require medical intervention.

Causes

The four main causes of PPH are:

1. Uterine atony: This refers to a weakened uterus unable to contract properly after giving birth. It is the most common cause of PPH, accounting for about 70% of cases.
2. Retained placental tissue: Part of the placenta may remain attached to the uterus, leading to ongoing bleeding.
3. Genital tract trauma: Damage to the surrounding tissues and organs from a difficult delivery can cause hemorrhaging.
4. Coagulopathy: Disorders affecting blood clotting, such as disseminated intravascular coagulation (DIC), von Willebrand disease, and others, can intensify bleeding.

Other factors contributing to PPH include placental previa, placenta accreta, chorioamnionitis, and preeclampsia. Additionally, certain patient characteristics may increase the likelihood of developing PPH, including primipara status, a prolonged second stage of labor, and cervical lacerations.

Symptoms

Symptoms of PPH vary depending on the severity of the bleeding. They include:

• Severe vaginal bleeding
• Dizziness or feeling faint
• Rapid pulse
• Low blood pressure
• Shortness of breath
• Fatigue
• Depressed mood
• Shortage of red blood cells (anemia)

These symptoms can indicate blood loss and potential danger to both mother and baby.

Diagnosis

Diagnosing PPH usually involves identifying symptoms and risk factors, as well as conducting physical examinations to assess blood loss. Bedside estimates of blood loss may be unreliable, so healthcare professionals rely on vital signs, urine output, and hemoglobin levels to determine the degree of blood loss. Laboratory tests can confirm blood loss and identify any underlying coagulopathies that may be contributing to the bleeding.

Treatment

Initial treatments include fluid resuscitation, transfusions of blood and blood products, and uterine tamponades using balloons or other devices to halt bleeding while specialists prepare for possible hysterectomy. Pharmaceutical therapies may involve oxytocin or ergotamine derivative drugs to promote contractions, misoprostol or methylergonovine for mild to moderate bleeding, and potentially tranexamic acid within the first few hours after childbirth.

Prevention

To minimize PPH, several strategies can be employed:

• Active management of the third stage of labor by administering uterotonic drugs and applying controlled cord traction, which has been shown to decrease postpartum blood loss and shorten the third stage of labor.
• Early cord clamping is no longer recommended, but oxytocin (Pitocin) remains an effective choice for preventing postpartum hemorrhage in at-risk patients when given within 30 minutes after delivery.
• Strategies for minimizing blood loss include avoiding routine episiotomy and using perineal warm compresses during delivery.
• Every unit should have a hemorrhage cart with medications, supplies, checklists, and instruction cards readily available.
• Emergency management plans should be established, including protocols for massive transfusions and team training with realistic simulation exercises to improve perinatal safety.

In conclusion, postpartum hemorrhage is a significant concern during childbirth and requires prompt recognition and treatment. Early intervention can prevent severe complications and save lives. Healthcare providers must remain vigilant and prepared to manage potential bleeding risks associated with pregnancy and delivery.