Postpartum Hemorrhage (PPH)

Definition

• Primary (early) PPH: within the first 24 hours of delivery
• Secondary (late) PPH: 24 hours to 6 weeks postpartum

• ROSEN's Emergency Medicine, p. 3420

Causes - The "Four Ts"

• ROSEN's Emergency Medicine, p. 3420; Tintinalli's Emergency Medicine

Uterine Atony (Tone)

• Overdistension (polyhydramnios, multiple gestation, fetal macrosomia)
• Prolonged or rapid labor
• High parity, chorioamnionitis
• Oxytocin or tocolytic use, halogenated anesthetic agents

Trauma

• Lacerations graded 1st-4th degree; 3rd/4th degree involve the anal sphincter and rectal mucosa (require OR repair)
• Concealed hematomas can cause hemorrhagic shock without visible bleeding; hematomas <4 cm may be observed with ice packs, larger ones require incision and packing
• Uterine rupture: rare (~1 in 2000 deliveries), highest risk with prior uterine surgery; presents with persistent abdominal pain, severe bleeding, loss of fetal station

Tissue

• Retained cotyledons prevent uterine contraction
• Placenta accreta spectrum: accreta (adherent to myometrium), increta (invades myometrium), percreta (penetrates full thickness); incidence ~3/1000 deliveries, rising with repeat cesareans and placenta previa

Thrombin (Coagulopathy)

• DIC triggered by placental abruption, eclampsia, amniotic fluid embolism, postpartum infection, dilutional coagulopathy from aggressive resuscitation, or retained dead fetal tissue (thromboplastin release)

Secondary (Late) PPH Causes

• Failure of the former placental site to sub-involute
• Retained placental tissue
• Genital tract wounds / infection
• Hereditary coagulopathy

Risk Factors Summary

Initial Assessment & Stabilization

1. Frequent vital sign monitoring (early sign may be a mild tachycardia only)
2. Establish 2 large-bore IV lines immediately
3. IV fluid resuscitation - lactated Ringer's solution
4. Supplemental oxygen
5. Labs: CBC with platelets, blood type and crossmatch, fibrinogen, fibrin split products, PT/PTT
6. Real-time ultrasound to identify retained placenta or blood clots
7. Prepare for blood transfusion; use O-negative unmatched blood in true emergencies
8. Foley catheter to monitor urine output

• Creasy & Resnik's Maternal-Fetal Medicine, p. 948; Textbook of Family Medicine 9e, p. 519

Management - Step-by-Step

Step 1: Bimanual Uterine Massage

Step 2: Uterotonic Agents (first-line for atony)

Step 3: Tranexamic Acid

• 1 g IV for all women with PPH
• WOMAN Trial data: reduces death from bleeding if given within 3 hours (RR 0.69; 95% CI 0.52-0.91)
• ACOG recommends TXA when initial medical therapy fails
• Prophylactic TXA does not reduce PPH incidence over oxytocin alone (per RCT evidence)
• Wait until cord is clamped before giving (crosses placenta)
• Miller's Anesthesia 10e, p. 8908; ROSEN's Emergency Medicine

Step 4: Identify and Treat the Specific Cause

• Firm uterus + continuing bleeding → inspect for lacerations, explore for retained products, consider uterine inversion
• Inspect cervix, vagina, perineum with good lighting and assistance
• Manual uterine exploration; curettage for retained cotyledons
• Evaluate and treat coagulopathy (FFP, cryoprecipitate, platelets as needed)

Escalation - Invasive Options

• Miller's Anesthesia 10e, p. 8909; Creasy & Resnik, p. 948

Cell Salvage

Uterine Inversion

• More common with fundal placental implantation (thins the myometrium)
• Fundal pressure and excessive cord traction are contributing factors
• Complete inversion: inverted fundus appears as a beefy-red mass at the introitus
• Incomplete inversion: fundus not palpable abdominally - suspect if uterus cannot be felt

1. Urgent IV fluid resuscitation
2. Tocolysis to relax the uterus: MgSO4, β-mimetics, nitroglycerin, or terbutaline
3. Johnson maneuver: grasp the uterus, push fundus firmly back up through the cervix into the abdomen; hold in place for several minutes
4. If Johnson fails: laparotomy (Huntington procedure - traction on round ligaments; or Haultain procedure - posterior longitudinal incision through inverted fundus)
5. After reinversion: administer uterotonic agents immediately

• Creasy & Resnik, p. 949; Textbook of Family Medicine 9e

Monitoring in Severe PPH

• Central venous pressure or Swan-Ganz catheter in extensive hemorrhage to guide fluid resuscitation and prevent pulmonary edema
• Pulse oximetry if using prostaglandin F2α (oxygen desaturation reported)

Prevention

• Active management of third stage of labor (AMTSL): early oxytocin administration + early cord clamping + controlled cord traction reduces PPH by ~two-thirds
• Identify and prepare patients with risk factors for PPH before delivery (adequate IV access, blood products available)

Recent Evidence (2025)

Severe Pre-eclampsia: Signs, Symptoms, and Management at 36 Weeks

Definition

PART 1: Signs and Symptoms of Severe Pre-eclampsia

Diagnostic Criteria (ACOG) for Severe Features

• Tintinalli's Emergency Medicine; Creasy & Resnik's MFM, p. 1070

Clinical Signs

• Severe, persistent headache (83% of women preceding eclampsia)
• Hyperreflexia (80%) - brisk deep tendon reflexes
• Clonus (present in 46%)
• Visual disturbances - blurred vision, scotomata, photopsia (45%)
• Altered consciousness, confusion (heralding impending eclampsia)

• BP persistently ≥160/110 mmHg
• Pulmonary edema - dyspnoea, orthopnoea, basal crepitations
• Peripheral oedema (60% - though non-specific)

• Right upper quadrant (RUQ) or epigastric pain (20%) - due to hepatic capsular distension/subcapsular haematoma
• Nausea and vomiting

• Oliguria (<500 mL/24h or <20-30 mL/hour)
• Proteinuria (significant, though not required if other end-organ damage present)

• Fetal growth restriction
• Oligohydramnios
• Non-reassuring fetal heart rate patterns

Frequency of Symptoms Preceding Eclampsia

HELLP Syndrome (severe variant)

• H - Haemolysis (microangiopathic haemolytic anaemia, elevated LDH)
• EL - Elevated Liver enzymes (ALT/AST >70 U/L)
• LP - Low Platelets (<100,000/mL)

PART 2: Management of Severe Pre-eclampsia at 36 Weeks

Step 1: Immediate Stabilisation

1. Hospitalise immediately on the labour and delivery unit
2. Establish IV access (2 large-bore lines)
3. Continuous maternal monitoring: BP every 15-30 minutes initially, pulse, O₂ saturation, respiratory rate
4. Continuous electronic fetal heart rate monitoring
5. Foley catheter - strict hourly urine output monitoring (target ≥30 mL/hr)
6. Restrict IV fluids to 80-100 mL/hr to avoid pulmonary oedema (these patients are plasma volume-depleted but at high risk of fluid overload)
7. Do not use diuretics or hyperosmotic agents routinely

• ROSEN's Emergency Medicine, Box 173.4; Creasy & Resnik's MFM, p. 1071

Step 2: Investigations

Maternal Blood Tests

Urine

Imaging

• ROSEN's Emergency Medicine, p. 3357; Tintinalli's Emergency Medicine

Step 3: Seizure Prophylaxis - Magnesium Sulphate

• Loading dose: 4-6 g IV over 15-30 minutes
• Maintenance: 1-2 g/hour as continuous IV infusion (mechanically controlled - never bolus)

• Creasy & Resnik's MFM, pp. 1071-1072; Morgan & Mikhail's Clinical Anaesthesiology

Step 4: Antihypertensive Therapy

• Creasy & Resnik's MFM, pp. 1072-1073 (Tables 45.6 and 45.7)

Step 5: Delivery Decision at 36 Weeks

• Vaginal delivery is preferred - the diagnosis of severe pre-eclampsia does not mandate caesarean section
• Caesarean reserved for standard obstetric indications (non-reassuring fetal status, malpresentation, unfavourable cervix unresponsive to induction, imminent hepatic rupture)
• Cervical ripening agents (prostaglandins, balloon) may be used if cervix is not favourable
• Continuous fetal monitoring is mandatory throughout labour (MgSO₄ can reduce fetal heart rate variability)

• Eclampsia
• Pulmonary oedema
• DIC
• Uncontrollable severe hypertension
• Non-reassuring fetal testing / placental abruption
• Marked hepatic capsular distension (liver rupture risk - do not delay even hours)
• Creasy & Resnik's MFM, pp. 1069-1072

Step 6: Intrapartum and Postpartum Monitoring

Special Situations

Oliguria

• Defined as <20-30 mL/hr for 2 hours
• If no signs of heart failure: cautious trial of 1000 mL isotonic crystalloid over 1 hour
• If no response: guided by central venous or pulmonary wedge pressure
• Avoid hypotonic fluids (worsen dilutional hyponatraemia)
• Furosemide use is controversial; avoid unless pulmonary oedema is confirmed

If Eclamptic Seizure Occurs (despite MgSO₄)

1. Protect airway, lateral decubitus position, suction
2. Additional anticonvulsant: diazepam 5-10 mg IV, or lorazepam 4 mg IV, or pentobarbital 125 mg IV
3. If seizures persist: general anaesthesia
4. CT head to exclude intracranial haemorrhage
5. Expedite delivery

Regional Anaesthesia

• Epidural/spinal is the preferred technique for labour and caesarean
• Volume expansion needed to prevent sympatholysis-induced hypotension and impaired uteroplacental perfusion
• Regional anaesthesia should NOT be used as a means of lowering blood pressure (reduces cardiac output, not vascular resistance)

Summary Flowchart

36 weeks + Severe Pre-eclampsia
         ↓
1. ADMIT to L&D · 2 IVs · Foley · Fetal monitoring
         ↓
2. LABS: CBC, LFTs, creatinine, coag, uric acid, crossmatch
   IMAGING: Obstetric USS, CT head if altered consciousness
         ↓
3. MgSO₄ 4–6 g IV loading → 1–2 g/hr infusion (24-48h postpartum)
         ↓
4. BP ≥160/105 mmHg? → Labetalol IV / Hydralazine IV / Nifedipine oral
   Target: Systolic 135–145, Diastolic 95–100 mmHg
         ↓
5. DELIVER (vaginal preferred)
   Consider antenatal corticosteroids if >12h before delivery
         ↓
6. Continue MgSO₄ 24-48h postpartum · Monitor closely for 48h