Postpartum Hemorrhage

Postpartum hemorrhage is the blood loss of approximately >500ml with normal spontaneous vertex delivery or blood loss >1000ml with cesarian section, before, during, or after delivery. It is a major cause of maternal mortality. It can be primary or secondary.

Primary postpartum hemorrhage– within 24 hours

Secondary postpartum hemorrhage– between 24 hours and six weeks postnatally

Etiology

Indirect causes– delays at;

• Home
• Way-transportation
• Hospital

Direct causes

• Atonic uterus due to;
• Infections
• Leiomyomas- it causes mechanical obstruction to retraction of the uterus
• Overdistension, as in multiple gestations, leads to imperfect uterine retraction hence bleeding
• Intrinsic dysfunction
• Multiparity- it causes inadequate retraction of the uterus
• Prolonged labor-second stage- it predisposes to poor retraction and infections such as amnionitis, all of which lead to bleeding
• Drugs- drugs such as tocolytic cause prolonged distension of the uterus
• Lacerations
• Cervical, vaginal, or vulval
• Surgical procedures such as episiotomy and cesarean section can cause iatrogenic trauma to the genital tract leading to blood loss
• Retained placental tissues
• This is seen in the placenta accreta-percreta spectrum and manual rupture of membranes
• The retained tissues cause mechanical obstruction to uterine retraction
• Coagulation abnormalities
• Disseminated intravascular coagulation, hypofibrinogenemia, etc
• The coagulopathy may be due to diminished procoagulants or increased fibrinolytic activity. As a result, maternal hemorrhage would otherwise be absent if coagulopathy were absent.

Diagnosis

• Clinical evaluation is integral in determining the amount of blood loss
• Complete blood count
• Check for the red blood cell indices for anemia diagnosis
• Check platelet levels
• A full coagulation profile- to check for any coagulation factor deficiencies
• Pelvic ultrasound- to check for any retained placental tissues or foreign objects in the uterine cavity

Treatment and management

The goals of treatment are

• To empty the uterus to facilitate contraction
• Replace the blood loss
• Ensure effective hemostasis in active bleeding
• Intravenous fluid resuscitation
• Blood transfusion-depending on the severity of symptoms
• Uterine massage- check not to over-massage the uterus to avoid uncoordinated uterine contractions
• Repair if the lacerations
• Use of uterotonic eg oxytocin, misoprostol etc
• Removal of retained placental tissues

Prevention

Postpartum hemorrhage is difficult to prevent. However, some measures can be taken to reduce the occurrence and mitigate the effects. They include;

1. Improvement of maternal health status to keep hemoglobin levels above 10 g/dl
2. Blood grouping and crossmatching before the estimated date of delivery
3. Placental localization using MRI or ultrasound
4. Active management of the third stage of labor
5. Exploration of the uterovaginal canal after delivery to check for any obstetric lacerations
6. Observation for about two hours post-delivery before discharge