History

Fact Explanation
Excess per-vaginal bleeding after delivery Post partum hemorrhage (PPH) is defined as bleeding from the female genital tract in excess of 500ml following delivery of the fetus.[1] If occurring within the first 24h it is classified as primary PPH and after 24h up to 6weeks postpartum as secondary PPH.[2] PPH complicates 5% of pregnancies and is responsible for a majority of maternal deaths.[3] PPH is an important complication of the third stage of labor which may be fatal if massive and poorly managed. Estimation of the actual blood volume lost is often inaccurate and requires vigilant assessment to avoid delayed treatment.
Syncope Massive blood loss would result in reduced blood supply to the brain.
Sudden maternal collapse Due to massive loss of blood
Features of multi-organ failure Massive postpartum obstetric hemorrhage may progress to hypovolaemic shock and multi-organ failure. The patient may present with acute renal failure, hepatic failure, disseminated intravascular hemorrhage and adult respiratory distress syndrome.
Abdominal pain, PV discharge, fever Secondary PPH due to endometritis may present with PV bleeding, abdominal pain, PV discharge and fever.
Assessment of aetiology/risk factors Cases of primary PPH are uterine atony, retained placental products, trauma and coagulation disorders. Uterine atony is the cause in a majority of patients (80%) and risk factors for uterine atony are over distended uterus (multiple pregnancy, polyhydramnios, macrosomia), prolonged labor, augmentation of labor, antepartum hemorrhage, anemia etc. Causes of secondary PPH – retained products of conception, infection (endometritis), chronic subinvolution of the uterus and rarely trophoblastic disease.[4] [5] The importance of identifying risk factors is that the medical team could anticipate and be prepared for management of PPH.
History of coagulopathy Check for a family history of bleeding disorders. A personal history of bleeding as suggested by superficial bruises, menorrhagia, haemarthrosis etc may indicated inherited or acquired causes of coagulation defects. Check for features of liver failure.
References
  1. EL-REFAEY H.. Post-partum haemorrhage: definitions, medical and surgical management. A time for change. British Medical Bulletin [online] 2003 December, 67(1):205-217 [viewed 24 July 2014] Available from: doi:10.1093/bmb/ldg016
  2. Postpartum Haemorrhage, Prevention and Management (Green-top 52). Royal College of Obstetricians and Gynaecologists, 2009 [Viewed on 24 July 2014]. Available from : http://www.rcog.org.uk/womens-health/clinical-guidance/prevention-and-management-postpartum-haemorrhage-green-top-52
  3. REYNDERS FC, SENTEN L, TJALMA W, JACQUEMYN Y. Postpartum hemorrhage: practical approach to a life-threatening complication. Clin Exp Obstet Gynecol [online] 2006, 33(2):81-4 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16903242
  4. EDHI MUHAMMAD MUZZAMMIL, ASLAM HAFIZ MUHAMMAD, NAQVI ZEHRA, HASHMI HALEEMA. "Post partum hemorrhage: causes and management". Array [online] 2013 December [viewed 24 July 2014] Available from: doi:10.1186/1756-0500-6-236
  5. SOSA CLAUDIO G., ALTHABE FERNANDO, BELIZáN JOSé M., BUEKENS PIERRE. Risk Factors for Postpartum Hemorrhage in Vaginal Deliveries in a Latin-American Population. Obstetrics & Gynecology [online] 2009 June, 113(6):1313-1319 [viewed 24 July 2014] Available from: doi:10.1097/AOG.0b013e3181a66b05

Examination

Fact Explanation
General examination : Unconsciousness Primary PPH may cause maternal collapse resulting from massive hemorrhage.
Cardiovascular examination : Tachycardia and hypotension Due to hypovolaemic shock.
Abdominal examination : Relaxed uterus with a high fundus Due to uterine atony. Failure of the uterus to contract results in lack of occlusion of placental blood vessels. This leads to excessive bleeding from the placental bed.
Vaginal examination : Estimate blood volume A rough estimate of the blood volume lost can be made using the number of soaked gauze and towels. Research has shown that blood volume lost is often under-estimated.[1]
Vaginal examination : Inspect for genital tract trauma Inspect for perineal, vaginal and cervical tears. Inspect the episiotomy site as in some instances a large episiotomy may lead to continuous bleeding. Examination under anesthesia may be required to visualize tears higher up in the genital tract.[2]
Examine the placenta and membranes Inspect the placenta and verify whether it is complete. Examine for retained parts of placental cotyledons and membranes within the genital tract. Evacuate any remaining clots from the cervix since clots inhibit uterine contraction.
Assess airway, breathing and circulation in patients who present in a collapsed state Prompt resuscitation is required in patients who present in a collapsed state. Inspect the airway, clear any secretions and verify its patency. Inspect for chest movements, listen and feel for breathing. Measure the pulse rate, blood pressure, capillary refill time and urine output to assess the status of circulation.
Secondary PPH The lower abdomen may be tender due to endometritis. Uterine tenderness may be present on vaginal examination. Speculum examination may show bleeding and purulent discharge from the cervical os.
References
  1. BOSE P, REGAN F, PATERSON-BROWN S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG, 2006, 113, 919–24.
  2. Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage. SOGC CLINICAL PRACTICE GUIDELINE, 2009 [Viewed on 21 July 2014]. Available from : http://sogc.org/wp-content/uploads/2013/01/gui235CPG0910.pdf

Differential Diagnoses

Fact Explanation
Uterine atony The placental bed comprises of numerous spiral arteries which provide blood supply to the placenta. At term the blood flow through these vessels may be as high as >500ml/min. Following placental separation the uterus contract and retracts resulting in occlusion of these vessels. In uterine atony the uterus fails to contract adequately leading to postpartum hemorrhage. Over-distension of the uterus as in multiple pregnancy, macrosomia predisposes to uterine atony. Exhaustion of the myometrium also results in poor uterine contractions – prolonged labor, augmentation of labor. Uterine fibroids obstruct tight retraction of the uterus. Uterine atony can be diagnosed clinically. The uterus is relaxed when palpated and the fundus will be at a higher level.[1]
Retained tissue products Retained tissue products – membranes, cotyledons interfere with uterine contraction. Failure to remove the placenta as whole, risks parts of it being left within the uterus. This risk is increased with morbidly adherent placenta (placenta accreta, placenta percreta) and placenta succenturiata. The patient will present with PPH with the uterus well contracted. Diagnosis can be made clinically. Ultrasound scan may be required in secondary PPH.
Genital tract trauma Trauma to the uterus, cervix, vagina and introitus may cause profuse bleeding. Consider the possibility of endocervical canal tears.[2] Risk factors for genital tract tears are macrosomic babies, precipitate labor, instrumental delivery etc. The patient may also bleed form a large episiotomy or ruptured vulval varicosities. Suspect trauma if bleeding persists in spite of a well contract uterus. Diagnosis is usually made on clinical examination. Tears situated higher up in the cervix, uterus may require examination in the theater.
Coagulation disorders Primary PPH caused by coagulation abnormalities is rare. Risk factors for coagulation abnormalities – Placental abruption, sepsis, massive blood loss, amniotic fluid embolism, chorioamnionitis etc. Suspect coagulation disorders in patients who have a family history of bleeding disorders and who have a past history of heavy menstrual bleeding.[3] On clinical examination the uterus will be hard and there will be no evidence of trauma or retained products of conception. Diagnosis can be arrived at by coagulation studies.
References
  1. DRIESSEN MARINE, BOUVIER-COLLE MARIE-HèLèNE, DUPONT CORINNE, KHOSHNOOD BABAK, RUDIGOZ RENè-CHARLES, DENEUX-THARAUX CATHERINE. Postpartum Hemorrhage Resulting From Uterine Atony After Vaginal Delivery. Obstetrics & Gynecology [online] 2011 January, 117(1):21-31 [viewed 24 July 2014] Available from: doi:10.1097/AOG.0b013e318202c845
  2. SCHUITEMAKER NW, MACKENZIE MR. Postpartum haemorrhage due to a laceration in the endocervical canal; three case reports. Eur J Obstet Gynecol Reprod Biol [online] 1989 Feb, 30(2):183-5 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2784772
  3. SILVER RM, MAJOR H. Maternal coagulation disorders and postpartum hemorrhage. Clin Obstet Gynecol [online] 2010 Mar, 53(1):252-64 [viewed 24 July 2014] Available from: doi:10.1097/GRF.0b013e3181cef930

Investigations - for Diagnosis

Fact Explanation
Diagnosis of primary PPH is clinical Postpartum hemorrhage is an obstetric emergency. Rapid diagnosis requires a high index of suspicion and alertness. Findings in physical examination help in differentiating uterine atony, retained tissue products and genital tract trauma.
Coagulation studies : PT and APTT May be rarely required to exclude coagulation disorders. Serum fibrinogen is considered a good marker for diagnosis and prediction of severity of PPH. Dilution caused by fluid resuscitation should be considered when interpreting the results of these tests.[1]
Full blood count Neutrophil leucocytosis may be present in endometritis, causing secondary PPH.
ESR/ CRP Markers of acute phase response will be elevated in endometritis.
High vaginal swab To identify the causative organism in endometritis.
Ultrasound scan To visualize the uterus for presence of retained products.
References
  1. DE LANGE NM, LANCé MD, DE GROOT R, BECKERS EA, HENSKENS YM, SCHEEPERS HC. Obstetric hemorrhage and coagulation: an update. Thromboelastography, thromboelastometry, and conventional coagulation tests in the diagnosis and prediction of postpartum hemorrhage. Obstet Gynecol Surv [online] 2012 Jul, 67(7):426-35 [viewed 24 July 2014] Available from: doi:10.1097/OGX.0b013e3182605861

Investigations - Fitness for Management

Fact Explanation
Full blood count To assess hemoglobin level, in hemorrhage.
Blood cross matching and saving Save about 4 units of blood for use in a massive hemorrhage.[1]
Blood urea Monitor renal function in acute blood loss as it lead to a prerenal acute kidney injury.
Serum electrolytes Electrolyte disturbance can occur due to acute kidney injury.
References
  1. Postpartum Haemorrhage, Prevention and Management (Green-top 52). Royal College of Obstetricians and Gynaecologists, 2009 [Viewed on 24 July 2014]. Available from : http://www.rcog.org.uk/womens-health/clinical-guidance/prevention-and-management-postpartum-haemorrhage-green-top-52

Management - General Measures

Fact Explanation
Call for help Postpartum hemorrhage is an obstetric emergency. Inform the obstetric team, nursing staff and neonatologists. The anesthetic staff and theater staff should be informed about the possibility of emergency admission.
Prevention of primary PPH The primary aim is to prevent atonic PPH. In high risk patients correct anemia during the antenatal period.[1] Manage the delivery of such patients in facilities with adequate expertise and emergency facilities.[2] Be prepared for PPH during labor : Reserve cross matched blood, establish IV access prior to 2nd stage, actively manage the 3rd stage of labor and prophylactic IV oxytocin after delivery.[3]
Monitoring of patient Monitor the pulse rate, blood pressure, oxygen saturation, level of consciousness and urine output regularly. Continue monitoring for PV bleeding.
Care of the neonate Assess the neonate at birth and provide continued care during the period of postpartum hemorrhage.
Patient education and counseling Provide information about the condition, risks and management to the patient and partner. Counsel the patient and partner regarding risks to the patient and need for operative intervention if necessary.
References
  1. CHELMOW D. Postpartum haemorrhage: prevention Clin Evid (Online) [online] :1410 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907937
  2. FORD JB, ROBERTS CL, BELL JC, ALGERT CS, MORRIS JM. Postpartum haemorrhage occurrence and recurrence: a population-based study. Med J Aust [online] 2007 Oct 1, 187(7):391-3 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17908001
  3. PRENDIVILLE WJ, ELBOURNE D, MCDONALD S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev [online] 2000:CD000007 [viewed 24 July 2014] Available from: doi:10.1002/14651858.CD000007

Management - Specific Treatments

Fact Explanation
Resuscitation Postpartum hemorrhage is an obstetric emergency. Assess the airway, breathing and circulation. Maintain airway patency by head tilt and chin lift, use an oropharyngeal airway if necessary. Administer oxygen via a mask. Establish intravenous access by two large bore cannulae. Initiate fluid resuscitation to maintain the circulation. Transfuse blood if necessary.[1]
Management of uterine atony Both medical and surgical methods are available to manage atonic PPH which are instituted in stepwise manner.[2] Perform uterine fundal massage to encourage uterine contraction. Catheterize the bladder if necessary. Administer uterotonics (oxytocin bolus + infusion, IM ergometrine, IM carboprost/hemabate, PR misoprostol) to improve contractions of the uterus.[3] Prostaglandin F2α agents may be administered via inta-myometrial route.[4] Both external and internal bimanual compression of the uterus and aortic compression may aid in temporary arrest of massive bleeding. This measure can be used gain important time to transfer the patient to theater and carry out surgical treatments.
Management of uterine atony : Surgical measures Surgical measures are usually reserved for refractory bleeding. Intra-uterine balloon insertion may be tried initially.[5] The tamponade effect of the inflated balloon and the warm saline used to inflate the balloon may arrest the bleeding. This is less invasive procedure and can be administered quickly. A bakri ballon, condom catheter or Sengstaken-Blakemore tube may be used for this purpose. Patients who fail to respond to the tamponade test require laparotomy. Uterine compression sutures can be used to occlude the bleeding sites – B-Lynch sutures and modification, multiple square sutures and plication of uterine wall.[6] Devascularization procedures are another option for persistent bleeding. Ligation of bilateral uterine or internal iliac arteries reduce blood flow to the uterus. Uterine artery embolization gives similar results to ligation of the artery. This is achieved by inserting a catheter via the femoral vessels which embolizes thrombogenic material into the uterine artery. This method avoids the risks of emergency surgery and preserves fertility.[7] Hysterectomy is the last resort if all other interventions fail. Both total and partial hysterectomy may be carried out, total hysterectomy is preferred over subtotal hysterectomy due to the risk of bleeding from the lower segment.[8]
Management of genital tract trauma Suspect a genital tract tear if bleeding persists despite having achieving a well contracted tonic uterus. Identify the location of the tear. This may require examination under anesthesia under a good light source. The patient is placed in the lithotomy position and systematic exploration of the genital tract is carried out. Vaginal retractors, forceps to pull down the cervix and speculums may be required for visualization of higher level tears. Bleeding may obscure visualization. Use vaginal packs or suction to remove the blood. Vaginal tears are sutured and it is important start suturing above the apex of the tear. Both interrupted and continuous suturing may be used. Cervical laceration, commonly occur in the 3 o’clock and 9 o’clock positions. Lacerations which are bleeding need suturing as above. Broad-spectrum antibiotics are used to reduce the risk of infection. Tears extending into the uterus require emergency laparotomy. Minor tears may be sutured in two layers. Major tears which bleed uncontrollably may require hysterectomy.
Management of retained products If on abdominal palpation the uterus is hard and contracted, consider the possibility of retained tissue products within the uterus. Re-examine the placenta to check whether it has being completely removed. Retained products should be removed digitally or by sponge forceps. Ideally this is performed in the theater. Perform manual exploration of the uterine cavity and evacuate any remaining parts. Curettage is best avoided due to the risk of uterine perforation.
Management of coagulopathy Correct with fresh frozen plasma, cryoprecipitate or platelets.
Management of secondary PPH The major causes of secondary PPH are endometritis and retained products of conception. Resuscitate the patient if necessary. Intravenous antibiotics should be started promptly. Evacuation of retained products of conception (ERPC) may be required in certain patients. ERPC should be carried out with care to avoid rupturing the soft postpartum uterus. The current knowledge and evidence about treatment measures in secondary PPH is limited and requires further research.[9]
References
  1. AHONEN J, STEFANOVIC V, LASSILA R. Management of post-partum haemorrhage. Acta Anaesthesiol Scand [online] 2010 Nov, 54(10):1164-78 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21069897
  2. WHO recommendations for the prevention and treatment of postpartum haemorrhage. World health organization, 2012 [Viewed on 23 July 2014]. Available from : http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf
  3. SHELDON WR, BLUM J, DUROCHER J, WINIKOFF B. Misoprostol for the prevention and treatment of postpartum hemorrhage. Expert Opin Investig Drugs [online] 2012 Feb, 21(2):235-50 [viewed 24 July 2014] Available from: doi:10.1517/13543784.2012.647405
  4. BRUCE SL, PAUL RH, VAN DORSTEN JP. Control of postpartum uterine atony by intramyometrial prostaglandin. Obstet Gynecol [online] 1982 Jun, 59(6 Suppl):47S-50S [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/6979727
  5. DOUMOUCHTSIS SK, PAPAGEORGHIOU AT, ARULKUMARAN S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv [online] 2007 Aug, 62(8):540-7 [viewed 24 July 2014] Available from: doi:10.1097/01.ogx.0000271137.81361.93
  6. HAYMAN RG, ARULKUMARAN S, STEER PJ. Uterine compression sutures: surgical management of postpartum hemorrhage. Obstet Gynecol [online] 2002 Mar, 99(3):502-6 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11864681
  7. PELAGE JP, LE DREF O, JACOB D, SOYER P, HERBRETEAU D, RYMER R. Selective arterial embolization of the uterine arteries in the management of intractable post-partum hemorrhage. Acta Obstet Gynecol Scand [online] 1999 Sep, 78(8):698-703 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10468062
  8. TAMIZIAN O, ARULKUMARAN S. The surgical management of postpartum haemorrhage. Curr Opin Obstet Gynecol [online] 2001 Apr, 13(2):127-31 [viewed 24 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11315865
  9. ALEXANDER J, THOMAS P, SANGHERA J. Treatments for secondary postpartum haemorrhage. Cochrane Database Syst Rev [online] 2002:CD002867 [viewed 24 July 2014] Available from: doi:10.1002/14651858.CD002867