Postpartum Hemorrhage Overview

Postpartum Hemorrhage (PPH)

• PPH is defined as excessive bleeding after childbirth, occurring within 24 hours or up to 12 weeks later.
• Classified by blood loss exceeding 500ml after vaginal delivery or 1000ml after a Cesarean section.

Types of Postpartum Hemorrhage

• Primary Hemorrhage: Blood loss of more than or equal to 500ml from the genital tract within 24 hours of delivery.
• Secondary Hemorrhage: Blood loss of more than or equal to 500ml from the genital tract between 24 hours of delivery and 12 weeks post-delivery.

Symptoms of Postpartum Hemorrhage

• Excessive bleeding (soaking through one or more pads per hour).
• Weakness or dizziness.
• Rapid heart rate.
• Low blood pressure.
• Pale skin.

Aetiology (Causes) of Postpartum Hemorrhage

• Tone: Uterine atony (failure of the uterus to contract properly after delivery), treated by bimanual uterine massage and oxytocin. Retained products of conception (parts of the placenta) needing uterine evacuation and antibiotics if endometritis (infection).
• Trauma: Lacerations (tears) or hematomas (blood clots) in the genital tract, repaired if necessary,. Uterine rupture managed surgically.
• Thrombin: Problems with blood clotting (DIC - Disseminated intravascular coagulation), requiring replacement of clotting factors.

Causes of Postpartum Hemorrhage

• Uterine atony.
• Retained placenta.
• Genital tract laceration.
• Coagulopathy (blood clotting disorder).
• Acute inversion of the uterus (uterus turns inside out).

Uterine Atony

• Uterus fails to contract after delivery of the placenta.
• Risk factors include:
  • Multiparity (multiple pregnancies).
  • Over-distension of the uterus (e.g., macrosomia, polyhydramnios).
  • Prolonged labour.
  • Fibroids.
  • Placenta previa.
  • Oxytocin-induced labour.

Retained Placenta

• Placenta remains attached or partially attached after delivery.
• Conditions include:
  • Placenta separated but undelivered.
  • Placenta partly or wholly attached (e.g. accreta, increta, percreta).

Genital Tract Laceration

• Tears in the perineum or vagina, often from instrumental delivery or episiotomy.
• Can extend upward causing uterine rupture.

Coagulopathy

• Clotting disorder affecting blood clotting.
• Examples include von Willebrand's disease and platelet disorders.
  • Unidentified dead foetus.
  • Amniotic fluid embolus (amniotic fluid entering the maternal circulation).

Acute Inversion of the Uterus

• The uterus turns inside out.
• Caused by traction on the umbilical cord before the placenta separates.

Risk Factors for Postpartum Hemorrhage

• Previous history of PPH.
• Prolonged labor.
• Use of medications during delivery (e.g., magnesium sulphate).
• Multiple pregnancies.
• Uterine overdistension.

Complications of Postpartum Hemorrhage

• Circulatory collapse (shock).
• Organ failure.
• Stroke.
• Death.
• Sheehan's syndrome (damage to the pituitary gland)
• Pituitary necrosis (death of the pituitary gland)
• Puerperal anaemia (postpartum anemia).
• Fear of future pregnancies.

Management of Postpartum Hemorrhage

• Uterine massage to stimulate contraction.
• Medications to promote uterine contractions (e.g., oxytocin).
• Intravenous fluids and blood transfusions.
• Hysterectomy (removal of the uterus) in severe cases.

Prevention of Postpartum Hemorrhage

• Monitoring during labor and delivery for signs of PPH.
• Immediate administration of uterotonics after delivery.
• Ensuring complete delivery of the placenta.

Conclusion

• PPH is a medical emergency requiring prompt recognition and treatment.
• Careful monitoring and treatment help prevent severe complications such as shock and death.
• Healthcare providers must be well-prepared to manage PPH.

References

• World Health Organization (WHO)
• Mayo Clinic, including websites provided in the document's references.