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Postpartum Hemorrhage (PPH) - Postgraduate Level Review

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1. DEFINITION

Tintinalli's: "Excessive blood loss is also defined as a 10% drop in hematocrit, a need for transfusion of packed red blood cells, or volume loss generating symptoms of hypovolemia."

• PPH accounts for up to 11% of obstetric deaths globally
• The maternal cardiovascular adaptations of pregnancy (40% plasma volume expansion, 25% RBC volume increase) can mask signs of hemorrhage - blood pressure may not drop until >30% of total blood volume (approx. 1500 mL) is lost
• Prevalence in the US increased from 2.9% to 3.2% between 2010-2014 (Creasy & Resnik)

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2. ETIOLOGY - THE "4 Ts" (MNEMONIC)

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3. UTERINE ATONY (Most Common Cause)

Pathophysiology

Risk Factors for Atony (TORC-PUMMEL)

• Tocolytics / halogenated anesthetic agents
• Overdistension (polyhydramnios, macrosomia, multiple gestation)
• Retained placenta/products
• Chorioamnionitis
• Prolonged / precipitate labor
• Uterine abnormalities
• Multiparity
• Magnesium sulfate use
• Eclampsia / preeclampsia
• Labor augmentation (paradoxically)

Examination Finding

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4. TRAUMA - GENITAL TRACT LACERATIONS

Perineal Tear Classification

• Hematomas can form without frank hemorrhage and may go undetected for hours, leading to hemorrhagic shock
• Risk factors: nulliparity, macrosomia, operative delivery, episiotomy, prolonged 2nd stage, malpresentation

Uterine Rupture

• Previous cesarean section is the primary risk factor
• Single-layer closure, fetal weight >3500g, and labor augmentation increase risk during TOLAC

Uterine Inversion (rare: 1 in 2000 deliveries)

• Usually due to excessive fundal pressure, vigorous cord traction, or fundal placentation
• Presentation: beefy-red mass at introitus (complete inversion) or inability to palpate fundus abdominally (incomplete inversion)
• Management: immediate manual reinversion, tocolysis (MgSO4, β-mimetics, nitroglycerin), general anesthesia if required
• Do NOT remove attached placenta before reinversion

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5. TISSUE - RETAINED PLACENTA & ACCRETA SPECTRUM

Retained Products of Conception

• ~10% of PPH cases
• Aggressive cord traction during 3rd stage can cause retained cotyledons
• Ultrasound: expanded endometrium or echogenic mass within uterus
• Treatment: digital uterine exploration and blunt dissection; curettage if needed

Placenta Accreta Spectrum (PAS)

• Current incidence: ~3/1000 deliveries (rising with cesarean rates)
• Risk factors: multiparity, prior cesarean sections (the most potent combination is placenta previa + prior cesarean), previous curettage, uterine anomalies
• Antepartum ultrasound diagnosis allows planned delivery in tertiary centers, reducing blood loss

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6. THROMBIN - COAGULOPATHY

• DIC triggered by: placental abruption, eclampsia, amniotic fluid embolism, sepsis, retained dead fetus, dilution from aggressive resuscitation
• Lab findings: hypofibrinogenemia, thrombocytopenia, elevated fibrin split products and D-dimer
• All women with PPH should receive tranexamic acid (TXA) 1 g IV and be evaluated for DIC (Rosen's)

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7. MANAGEMENT - STEPWISE APPROACH

Step 1: Initial Resuscitation (simultaneous with assessment)

• Frequent vital signs monitoring
• Establish 2 large-bore IV lines
• Aggressive fluid replacement with Lactated Ringer's solution
• Type and cross-match blood; use O-negative unmatched blood in emergencies
• Apply non-pneumatic anti-shock garment (NASG) in resource-limited or transport settings
• Foley catheter - decompress bladder, monitor urine output
• Real-time ultrasound to identify retained placenta or blood clots

Step 2: Identify the Cause (4 Ts assessment)

Step 3: Uterotonic Pharmacotherapy

2025 Cochrane Network Meta-Analysis (Gallos et al., PMID 40237648): Carbetocin (heat-stable formulation) and oxytocin-ergometrine combination ranked highest for PPH prevention after vaginal delivery. Carbetocin is preferred over oxytocin in high-income settings for cesarean sections.

Step 4: Bimanual Uterine Massage / Compression

Step 5: Uterine Tamponade (before surgery)

• Bakri balloon / Foley catheter: tamponade effective for low placental implantation site bleeding; success rates up to 91% (Grainger & Allison)
• Uterine packing with sterile gauze: retrospective evidence of efficacy in atony

Step 6: Tranexamic Acid (TXA)

• WOMAN Trial (20,060 women, 21 countries): TXA 1 g IV reduces death from bleeding by 19% overall, 31% if given within 3 hours of delivery
• Second dose (1 g IV) if bleeding continues after 30 min or restarts within 24 hours
• No increase in thrombotic events in the WOMAN Trial
• 2024 Lancet individual patient meta-analysis (PMID 39461793) confirmed: TXA reduces PPH-related mortality; early administration is critical
• TXA is now recommended by WHO for all PPH (vaginal and cesarean delivery)

Step 7: Surgical Interventions (escalating)

• "Brace" suture compresses uterus longitudinally, obliterating the blood supply
• Described by B-Lynch et al. (1997); Hayman technique is a simpler variant
• Indicated when abdomen is already open and medical management has failed

• Uterine artery ligation (O'Leary suture): first surgical step at laparotomy
• Internal iliac (hypogastric) artery ligation: reduces pulse pressure by 85%; collateral circulation preserves uterine viability; fertility preserved in subsequent pregnancies

• Selective angiographic embolization - fertility-preserving
• Requires hemodynamic stability and available IR suite
• Prophylactic internal iliac balloon catheters for PAS: retrospective data shows no clear reduction in blood loss, with complications (vascular injury to leg)

• Last resort for life-threatening hemorrhage
• Emergency hysterectomy has greater blood loss than elective (planned) hysterectomy
• In PAS: antepartum planning with multidisciplinary conference (MFM, anesthesia, urology, vascular surgery, gyn-oncology, IR) before 34 weeks

Step 8: Massive Transfusion Protocol (MTP)

• Activation when >10 units pRBC anticipated
• Ratio-based transfusion: pRBC:FFP:platelets = 1:1:1 (damage control resuscitation)
• Target fibrinogen >200 mg/dL; cryoprecipitate if fibrinogen <150 mg/dL
• Cell salvage: safe in obstetrics (no increase in AFE); useful in Jehovah's Witness patients if kept in closed circuit
• Recombinant Factor VIIa (rFVIIa): 60 µg/kg; reduces need for second-line therapies but fails in 50% and carries risk of nonfatal thrombotic events (Creasy & Resnik)

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8. PREVENTION - ACTIVE MANAGEMENT OF THIRD STAGE OF LABOR (AMTSL)

1. Uterotonic administration (oxytocin 10 U IM within 1 minute of delivery of anterior shoulder) - most important step
2. Controlled cord traction (Brandt-Andrews maneuver)
3. Uterine massage after placental delivery

AMTSL reduces duration of 3rd stage, blood loss, need for blood transfusion, and maternal mortality compared to expectant management.

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9. SECONDARY PPH (24 hours - 6 weeks)

Causes

• Failure of uterine subinvolution at former placental site
• Retained placental tissue (most common cause)
• Genital tract wound breakdown
• Uterogenital infection (endometritis)
• Arteriovenous malformation (rare)

Management

• Ultrasound to identify retained products
• Surgical evacuation if retained tissue confirmed
• Antibiotics if infection suspected
• Uterine artery embolization for AVM or persistent bleeding

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10. SPECIAL SITUATIONS

Placenta Accreta Spectrum - Planned Management

• Elective delivery at 34-36 weeks with planned cesarean hysterectomy
• Multidisciplinary team required
• Large-bore IV access + arterial line + massive transfusion protocol
• Combined spinal-epidural preferred; convert to GA early if massive hemorrhage occurs
• Neuraxial anesthesia associated with reduced blood loss vs general anesthesia (Creasy & Resnik)

DIC in PPH (2026 Comprehensive Review - PMID 40680793)

• Pathophysiology: massive tissue factor release → consumptive coagulopathy
• Treatment: correct the underlying cause + component therapy (FFP, cryoprecipitate, platelets)
• Fresh frozen plasma: replaces all clotting factors
• Goal fibrinogen >200 mg/dL in obstetric hemorrhage (higher threshold than non-pregnant)

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11. HIGH-YIELD EXAM POINTS

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Recent Evidence Summary (2023-2026)

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