Post partum haemorrhage
Reading File
Finding Sources
Searching PubMed
"postpartum hemorrhage" management
Searching Images
postpartum haemorrhage uterine atony management
Reading File
Finding Sources
Finding Sources
Reading File
Reading File
Finding Sources
Finding Sources
Finding Sources
Reading File
Finding Sources
Searching Images
B-Lynch compression suture uterine tamponade PPH
Finding Sources
I now have comprehensive information from multiple authoritative sources. Here is a detailed, structured overview of Postpartum Haemorrhage:
Postpartum Haemorrhage (PPH)
Definition
PPH is classified by timing and volume of blood loss:
- Primary PPH: Blood loss ≥500 mL within the first 24 hours of delivery
- Secondary PPH: Abnormal bleeding occurring after 24 hours up to 12 weeks postpartum - usually linked to retained products of conception and/or infection
- Some guidelines define severe PPH as loss ≥1000 mL, particularly after caesarean section
Causes - The "4 Ts"
| Cause | Examples | Frequency |
|---|---|---|
| Tone (uterine atony) | Failure of uterus to contract | >50-80% |
| Trauma | Genital tract lacerations, uterine rupture, post-CS | Common |
| Tissue | Retained placenta or placental fragments | Common |
| Thrombin | Coagulopathy, DIC, placental abruption | Less common |
Additional causes include abnormal placentation (placenta accreta, increta, percreta) and rare causes such as uterine arteriovenous malformation (AVM).
Risk Factors for Uterine Atony (most common cause)
- Chorioamnionitis
- Oxytocin use during labour (receptor downregulation)
- High parity (grand multiparity)
- Fetal macrosomia
- Multiple gestation
- Prolonged labour
- Retained products of conception
- Use of volatile anaesthetics, magnesium sulfate, or terbutaline
Clinical Assessment
- Vital signs: tachycardia, hypotension (often late signs due to physiological adaptation in pregnancy)
- Uterine palpation: boggy/atonic uterus vs. well-contracted
- Inspection of the lower genital tract for lacerations
- Check for placental completeness after delivery
- Labs: FBC, coagulation screen (PT, APTT, fibrinogen), crossmatch, point-of-care viscoelastic tests (TEG/ROTEM)
Management - Step-by-Step Algorithm
Step 1: Immediate Resuscitation (simultaneous with cause identification)
- Call for help - multidisciplinary team (obstetricians, anaesthesiologists, nurses, blood bank)
- 2 large-bore IV cannulae, aggressive IV fluid resuscitation
- Send bloods (FBC, coagulation, group & crossmatch)
- Monitor urine output via catheter
Step 2: Uterotonic Drugs (for atony)
| Drug | Dose/Route | Notes |
|---|---|---|
| Oxytocin (1st line) | 3-10 IU slow IV bolus; 20 IU in 1L crystalloid infusion | WHO recommends 20 IU/L after uncomplicated CS. Bolus >10 IU can cause haemodynamic compromise, nausea, headache |
| Methylergonovine (ergometrine) | 0.2 mg IM | Contraindicated in hypertension and cardiac disease; can cause systemic/pulmonary hypertension, coronary spasm |
| Carboprost (PGF2α) | 0.25 mg IM every 15-90 min (max 8 doses) | Contraindicated in asthma; causes bronchospasm, pulmonary hypertension, tachycardia |
| Misoprostol (PGE1) | 600-800 mcg orally/sublingually/vaginally | Useful when oxytocin unavailable or patient desensitised; fewer contraindications |
Step 3: Physical Tamponade
- Bimanual uterine compression - initial, immediate
- Intrauterine balloon tamponade - (e.g. Bakri balloon) simple, effective next step with success rates up to 91%
- Jada System (vacuum-induced device) - definitive control in >90% of patients at a median of 3 minutes
Step 4: Tranexamic Acid
- Lysine analogue - inhibits plasmin-mediated fibrin degradation (antifibrinolytic)
- The WOMAN trial (20,060 women, RCT) demonstrated: tranexamic acid reduces death from bleeding when given within 3 hours (RR 0.69; 95% CI 0.52-0.91; p=0.008) - PMID: 28456509
- ACOG recommends it when initial medical therapy fails
- Administer after cord clamping (crosses placenta)
- Prophylactic use does NOT reduce PPH risk in vaginal delivery
Step 5: Blood Product Transfusion (Massive Transfusion Protocol)
- Do NOT wait for lab results before transfusing clinically if patient is deteriorating
- Early administration using massive transfusion protocols (MTP)
- Packed red blood cells (PRBCs) + Fresh frozen plasma (FFP) in fixed ratios
- Fibrinogen / Cryoprecipitate early - fibrinogen is likely to be low in PPH
- Viscoelastic tests (TEG/ROTEM) help guide product selection and detect coagulopathy
- Recombinant factor VIIa - not universally recommended; multiple adverse events reported
Step 6: Surgical/Interventional Options (if medical management fails)
All have ~85-90% success rates:
- B-Lynch compression suture - placed if abdomen is open; brace suture compressing the uterus
- Uterine vessel ligation (internal iliac artery ligation)
- Uterine artery embolisation (UAE) - interventional radiology; bilateral approach via common femoral arteries; uses Gelfoam; particularly useful to preserve uterus; negative angiogram doesn't preclude empirical embolisation
- Peripartum hysterectomy - last resort when all else fails; effectiveness of PPH algorithm can be measured by auditing hysterectomy rate
Abnormal Placentation (Special Consideration)
Abnormal placentation (placenta accreta spectrum) occurs due to defect in the decidua basalis:
| Type | Depth | Prevalence |
|---|---|---|
| Accreta | Into myometrium | 84% |
| Increta | To serosa | 13% |
| Percreta | Beyond serosa (e.g. bladder) | 3% |
- Incidence has increased 10-fold over 50 years, driven by rising caesarean section rates
- Most important risk factors: prior CS + placenta praevia combined
- UAe has lower success rates in this group; hysterectomy often unavoidable
- Prenatal diagnosis via US/MRI (sensitivity 33-95%)
Prevention - Active Management of the Third Stage (AMTSL)
- Prophylactic oxytocin immediately after delivery of the baby (before/after placenta delivery)
- Controlled cord traction
- Uterine massage after placenta delivery
- AMTSL reduces PPH incidence by ~60%
Maternal Outcomes
- PPH is the leading cause of maternal death worldwide and is increasing in incidence
- Successful management requires early recognition, multidisciplinary coordination, and a pre-agreed institutional algorithm
- Units should audit peripartum hysterectomy rates as a quality indicator for PPH management
Sources: Miller's Anesthesia 10e (pp. 8905-8909); Grainger & Allison's Diagnostic Radiology; Effectiveness of care bundles for PPH prevention (Vogel et al., 2024); Vacuum-induced tamponade systematic review (Card et al., 2024)
This is a shared conversation. Sign in to Orris to start your own chat.