Postpartum Hemorrhage

Postpartum hemorrhage is one of the most common and deadly obstetric complications. Since 2017, postpartum hemorrhage has been defined as blood loss greater than 1,000 mL for both cesarean and vaginal deliveries, or excessive blood loss with signs of hemodynamic instability. Blood loss of more than 500 mL following a vaginal delivery is considered abnormal, though no longer classified as postpartum hemorrhage. The most common cause of postpartum hemorrhage is uterine atony. Retained products of conception, trauma, and coagulopathies may also cause postpartum hemorrhage. Appropriate management requires rapid identification of the cause of the hemorrhage, medical and/or surgical correction, and patient resuscitation.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Definition and Epidemiology

Definition

Postpartum hemorrhage is defined as excessive blood loss following the delivery of an infant > 20 weeks gestational age.

  • The classic definition of postpartum hemorrhage was based on mode of delivery:
    • Blood loss > 500 mL following a vaginal delivery 
    • Blood loss > 1,000 mL following a cesarean section
  • The newer meaning of postpartum hemorrhage was defined by the American College of Obstetricians and Gynecologists in 2017:
    • Postpartum hemorrhage:
      • Cumulative blood loss ≥ 1,000 mL regardless of delivery route, OR
      • Bleeding associated with signs/symptoms of hypovolemia within 24 hours of delivery
    • While reducing cases labeled as postpartum hemorrhage, blood loss of > 500 mL following a vaginal delivery is still considered abnormal and should prompt investigation.
  • Postpartum hemorrhage can be primary or secondary:
    • Primary postpartum hemorrhage: occurs within 24 hours of delivery
    • Secondary postpartum hemorrhage: occurs between 24 hours and 12 weeks after delivery

Epidemiology

  • Incidence: 
    • 1%–10% of deliveries
    • Higher in sites using quantitative (compared to estimated) blood loss measurements
  • Leading cause of maternal mortality:
    • Approximately 11% of pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care-related mortality in developed countries
    • Up to 60% of maternal deaths in developing countries
  • Uterine atony accounts for 70%–80% of all postpartum hemorrhage

Etiology

Primary postpartum hemorrhage

The primary etiologies can be remembered as “the 4 Ts” (tone, tissue, trauma, and thrombin).

  • Tone (uterine atony):
    • Inability of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall to contract effectively following delivery
    • The most common cause of postpartum hemorrhage
    • Risk factors:
      • Prolonged labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor (uterine muscle fatigue)
      • Intraamniotic infections (e.g., chorioamnionitis Chorioamnionitis Chorioamnionitis, commonly referred to as intraamniotic infection (IAI), is a common obstetric complication involving infection and inflammation of the fetal membranes, amniotic fluid, placenta, or the fetus itself. Chorioamnionitis is typically caused by a polymicrobial infection that ascends from the lower genitourinary tract. Chorioamnionitis)
      • Uterine overdistension: a multiple pregnancy Multiple pregnancy Multiple pregnancy, or multifetal gestation, is a pregnancy with more than 1 fetus. Multiple pregnancy with more than 2 fetuses is referred to as a higher-order multiple pregnancy and the most common type of multiple pregnancy is a twin pregnancy. Due to advanced maternal age and evolving assisted reproductive technology, the rates of multiple pregnancies have steadily increased over the past 3 decades. Multiple Pregnancy (e.g., twins), polyhydramnios Polyhydramnios Polyhydramnios is a pathological excess of amniotic fluid. Common causes of polyhydramnios include fetal anomalies, gestational diabetes, multiple gestations, and congenital infections. Patients are often asymptomatic but may present with dyspnea, extremity swelling, or abdominal distention. Polyhydramnios, large for gestational age infants
      • Grand multiparity
      • Uterine inversion
      • General anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts
  • Tissue (retained products of conception):
    • Placenta tear during the 3rd stage of labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor
    • Abnormal placentation:
      • Placenta accreta
      • Placenta previa
  • Trauma: 
    • Lacerations:
      • Vagina
      • Perineum
      • Cervix
    • Lateral extension of the uterine incision into the uterine arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries during cesarean section
    • Uterine rupture (during a vaginal birth after cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery through a prior uterine incision)
    • Hematomas
    • Risk factors:
      • Operative vaginal delivery
      • Precipitous delivery
      • Emergent cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery
  • Thrombin disorders (coagulopathies):
    • DIC DIC Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage. Disseminated Intravascular Coagulation, which is more likely to occur with:
      • Intrauterine fetal demise (IUFD)
      • Placental abruption
      • Amniotic fluid embolism
      • Sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock
    • Hemolysis, elevated liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes, and low platelet count (HELLP) syndrome
    • Gestational thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia
    • Idiopathic thrombocytopenic purpura
    • Von Willebrand disease Von Willebrand disease Von Willebrand disease (vWD) is a bleeding disorder characterized by a qualitative or quantitative deficiency of von Willebrand factor (vWF). Von Willebrand factor is a multimeric protein involved in the plate adhesion phase of hemostasis by forming a bridge between platelets and damaged portions of the vessel wall. Von Willebrand Disease (von Willebrand factor rapidly decreases in delivery)
Postpartum hemrrhage placenta

Different types of placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity accreta

Image: “A diagram illustrating the different types of placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity accreta” by TheNewMessiah. License: Public Domain, edited by Lecturio.

Secondary postpartum hemorrhage

  • Uterine infection (postpartum endometritis Endometritis Endometritis is an inflammation of the endometrium, the inner layer of the uterus. The most common subtype is postpartum endometritis, resulting from the ascension of normal vaginal flora to the previously aseptic uterus. Endometritis)
  • Retained products of conception
  • Subinvolution of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall
  • Inherited coagulation defects

Pathophysiology

Postpartum hemorrhage due to a nontraumatic etiology results when 1 or both of the primary mechanisms required for normal postpartum hemostasis Hemostasis Hemostasis refers to the innate, stepwise body processes that occur following vessel injury, resulting in clot formation and cessation of bleeding. Hemostasis occurs in 2 phases, namely, primary and secondary. Primary hemostasis involves forming a plug that stops the bleeding temporarily. Secondary hemostasis involves the activation of the coagulation cascade. Hemostasis are disrupted. The 2 primary mechanisms are mechanical hemostasis Hemostasis Hemostasis refers to the innate, stepwise body processes that occur following vessel injury, resulting in clot formation and cessation of bleeding. Hemostasis occurs in 2 phases, namely, primary and secondary. Primary hemostasis involves forming a plug that stops the bleeding temporarily. Secondary hemostasis involves the activation of the coagulation cascade. Hemostasis and hemostatic factors.

Mechanical hemostasis Hemostasis Hemostasis refers to the innate, stepwise body processes that occur following vessel injury, resulting in clot formation and cessation of bleeding. Hemostasis occurs in 2 phases, namely, primary and secondary. Primary hemostasis involves forming a plug that stops the bleeding temporarily. Secondary hemostasis involves the activation of the coagulation cascade. Hemostasis

  • Normal contraction of the myometrium → compression of myometrial vasculature in the crisscross latticework of the smooth muscle fibers of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall
  • Disrupted in:
    • Uterine atony:
      • Failure of myometrial contraction → continued uterine blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure → hemorrhage from the exposed vessels supplying the placental bed
      • Anything impairing postpartum contraction of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall leads to postpartum hemorrhage.
    • Retained products of conception:
      • Blood flows into the maternal side of the placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity and out through the placental fragment
      • Retained products prevent the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall from fully contracting → uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall fills up with blood → uterine atony

Hemostatic factors

  • Clotting is facilitated by:
    • Factors released from the uterine decidua (i.e., tissue factor)
    • Systemic, circulating coagulation factors and platelets Platelets Platelets are small cell fragments involved in hemostasis. Thrombopoiesis takes place primarily in the bone marrow through a series of cell differentiation and is influenced by several cytokines. Platelets are formed after fragmentation of the megakaryocyte cytoplasm. Platelets
  • Disrupted in coagulopathies (inadequate hemostatic factors to stop the bleeding of the placental bed)

Clinical Presentation and Diagnosis

Most patients present with heavy bleeding and/or signs of hemodynamic instability. Diagnosis is usually clinical.

Clinical presentation

  • Heavy vaginal bleeding (often dramatic)
  • Hemodynamic instability:
    • Tachycardia
    • Tachypnea
    • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
    • ↓ Urine output 
    • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin findings: 
      • Cool and clammy
      • Delayed capillary refill
      • Pale
    • Mental status changes

Diagnosis

  • On exam look for:
    • Uterine atony: soft, boggy uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall
    • Uterine inversion: firm, round mass in the vagina Vagina The vagina is the female genital canal, extending from the vulva externally to the cervix uteri internally. The structures have sexual, reproductive, and urinary functions and a rich blood supply, mainly arising from the internal iliac artery. Vagina, Vulva, and Pelvic Floor
    • Retained products of conception: 
      • Visible trailing membranes
      • Palpable irregularities within the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall
    • Lacerations/trauma
  • Monitor vital signs for signs of hemodynamic instability.
  • Measure blood loss:
    • Clinical estimate of blood loss by visual assessment 
    • Quantitative blood loss measurements:
      • Volumetric assessment of blood is collected via suction or in graduated drapes.
      • Weight assessment of blood is collected on surgical sponges.
      • Efforts are made to collect and quantify all blood lost.
  • Imaging:
    • Ultrasound is the modality of choice.
    • May be help identify retained products of conception (especially in secondary postpartum hemorrhage)
  • Laboratory tests:
    • Useful for management, but not diagnosis
    • The following should be ordered once postpartum hemorrhage is diagnosed:
      • Type and crossmatch to prepare for a blood transfusion
      • CBC
      • Coagulation panel: PT, PTT, fibrinogen

Classification of hemorrhage

The 4 classes of hemorrhage are described by the Advanced Trauma Life Support manual, which can also classify postpartum hemorrhage.

Table: 4 classes of hemorrhage (Advanced Trauma Life Support manual)
Class Percentage of blood volume lost Clinical findings
Class I Up to 15% Mild tachycardia
Class II 15%–30%
  • Tachycardia
  • Tachypnea
  • Cool and clammy skin
Class III 30%–40%
  • Marked tachycardia
  • Marked tachypnea
  • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
  • Mental status changes
  • Diminished urine output
Class IV > 40%
  • Marked tachycardia
  • Marked tachypnea
  • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
  • Mental status changes
  • Minimal or absent urine output
  • Cold, pale skin

Management

Prevention and preparation

  • Active management of the 3rd stage of labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor:
    • Give oxytocin immediately after delivery of the infant.
    • Continuous uterine massage with gentle traction on the umbilical cord until placental delivery
    • Always inspect placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity after delivery for missing cotyledons.
  • Quantitative measurement of blood loss:
    • Better assessment of blood loss
    • Providers consistently underestimate visible blood loss.
  • Be prepared for postpartum hemorrhage in high-risk patients:
    • Appropriate personnel are nearby during delivery.
    • Ensure adequate IV access.
    • Uterotonic agents are immediately available.
    • Ensure the patient has a current type and screen (consider converting it to type and crossmatch if blood transfusions are likely).
    • Considered high risk:
      • Low-lying placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity or placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity previa
      • Active bleeding
      • Hematocrit < 30%
      • Known coagulopathy
      • Platelet count < 100,000
    • Important note: Postpartum hemorrhage can occur in anyone (e.g., a postterm, pregnant patient with prolonged induction of labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor may develop an intraamniotic infection).

Emergency stabilization

  • Call for help
    • Other colleagues (e.g., obstetrician, nurse, anesthesiologist)
    • Alert the blood bank.
    • Consider holding an OR on standby if equipment and personnel would not otherwise be immediately available.
  • Call for blood.
  • IV access:
    • Start 2, large-bore IV needles. 
    • Give IV fluids IV fluids Intravenous fluids are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids
    • IV access becomes increasingly difficult as a patient continues to bleed.
  • Tranexamic acid, an antifibrinolytic agent, is given to control bleeding; however, the benefit is reduced if postpartum hemorrhage is diagnosed more than 3 hours postdelivery.
  • Get labs to assist in resuscitation: 
    • CBC
    • Coagulation studies Coagulation studies Coagulation studies are a group of hematologic laboratory studies that reflect the function of blood vessels, platelets, and coagulation factors, which all interact with one another to achieve hemostasis. Coagulation studies are usually ordered to evaluate patients with bleeding or hypercoagulation disorders. Coagulation Studies: PT, PTT, INR, fibrinogen
  • Red top tube test (if a concern for DIC DIC Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage. Disseminated Intravascular Coagulation): 
    • Place 2–3 mL of the patient’s blood in a test tube and let the blood sit for 6 minutes. 
    • If the blood does not clot within 6–10 minutes, suspect DIC DIC Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage. Disseminated Intravascular Coagulation.
  • Consider the etiology (therapy is directed at the underlying cause).

Treatment for uterine atony

  • Step 1: uterine massage:
    • Instruct patient to empty the bladder to increase effectiveness.
  • Step 2: Give additional oxytocin.
  • Step 3: If uterine atony persists, give other uterotonic agents:
    • Methylergonovine
    • PGF 
    • Misoprostol
  • All 4 medications may be given if the patient has no contraindication.
  • Step 4: uterine packing:
    • Place balloons, sponges, etc. in the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall to provide compression.
    • Carefully count all foreign bodies placed inside the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall.
  • Step 5: surgery:
    • Surgical compression of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall:
      • Surgically placed sutures cinch down and/or compress the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall 
      • Example: B-lynch sutures 
    • Arterial ligation:
      • Ligate the vessels supplying the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall.
      • 1st: uterine artery ligation
      • 2nd: utero-ovarian artery ligation
    • Hysterectomy (last resort)
  • Alternative option: uterine artery embolization:
    • An interventional radiologist identifies the uterine artery via fluoroscopy and performs an embolization.
    • Requires the patient to be stable enough to undergo the procedure (uncommon)
Table: Uterotonic agents used in postpartum hemorrhage
Medication (generic) Class Route Contraindications
Oxytocin Natural hormone IV, IM None
Methylergonovine Ergot alkaloid IM Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
Carboprost (PGF) Prostaglandin analogue IM Severe hepatic, renal, and cardiovascular disease, and asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma
Misoprostol Prostaglandin analogue Oral, rectal None
Uterine massage

Uterine massage/manual compression for uterine atony

Image by Lecturio.

Treatment for retained products of conception

  • Suspect retained products of conception if the placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity is not delivered intact.
  • Management:
    • Manual exploration of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall to remove any retained pieces of membrane or placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity
    • Dilation and curettage
    • Uterine packing may be helpful

Treatment of trauma

  • Careful assessment for lacerations: 
    • Adequate lighting and equipment for pelvic exam
    • Inspect the entire cervix Cervix The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Externally, the cervix is lined by stratified squamous cells; however, the cervical canal is lined by columnar epithelium. Posterior Abdominal Wall (often difficult due to active bleeding and full dilation).
  • Management:
    • Suture repair of any bleeding lacerations
    • Surgical repair of uterine rupture
    • Apply compression to hematomas to prevent expansion of bleeding.

Treatment for thrombin disorders

Activate the hospital’s massive transfusion protocol and administer blood products:

  • Packed RBCs: 1 unit should ↑ hemoglobin by 1 g/dL and hematocrit by 3%
  • Platelets: 1 unit should ↑ platelet count 5,000–10,000
  • FFP: 
    • Contains all coagulation factors and plasma proteins 
    • 1 unit should ↑ fibrinogen 10 mg/dL
  • Cryoprecipitate: 
    • Contains fibrinogen (factor I), factor VIII, factor XIII, and von Willebrand factor
    • 1 unit should ↑ fibrinogen 10 mg/dL
Management of postpartum hemorrhage

Management of postpartum hemorrhage

Image by Lecturio.

Complications

  • DIC DIC Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage. Disseminated Intravascular Coagulation
  • Acute renal failure
  • Adult respiratory distress syndrome
  • Loss of fertility (hysterectomy)
  • Pituitary necrosis (Sheehan syndrome)

Clinical Relevance

  • Cesarean section: The operative delivery of 1 or more infants through surgical incision into the maternal abdomen, surgical opening of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall, and delivery of the infant(s). 
  • Prolonged labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor: longer-than-normal rate of labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor progression. Prolonged labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor increases the risk for obstetric complications including postpartum hemorrhage, intraamniotic infection, and fetal distress. 
  • Rapid labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor: shorter-than-normal rate of labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor progression. The normal duration of labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor is usually at least 3 hours. Rapid labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor increases the risk for postpartum hemorrhage.
  • Chorioamnionitis: an infection of the chorion and amnion. An infected uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall does not contract well, which leads to prolonged labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor and significantly increases a patient’s risk for postpartum hemorrhage. Chorioamnionitis is a common complication of prolonged rupture of membranes. Chorioamnionitis may lead to maternal sepsis and/or postpartum endometritis Endometritis Endometritis is an inflammation of the endometrium, the inner layer of the uterus. The most common subtype is postpartum endometritis, resulting from the ascension of normal vaginal flora to the previously aseptic uterus. Endometritis.
  • Multiple pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care: a pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care with more than 1 fetus (e.g., twins, triplets, quadruplets). Multiple pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care leads to overdistension of the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall, which is a risk factor for several obstetric complications, including postpartum hemorrhage and prelabor rupture of membranes Prelabor Rupture of Membranes Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, refers to the rupture of the amniotic sac before the onset of labor. Prelabor rupture of membranes may occur in term or preterm pregnancies. Prelabor Rupture of Membranes.
  • Abnormal placentation: placental implantation Implantation Endometrial implantation of embryo, mammalian at the blastocyst stage. Fertilization and First Week occurring in an abnormal site within the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall. Abnormal placentation also includes placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity accreta, which is an invasion of the placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity into the myometrium. Abnormal placentation increases the risk of postpartum hemorrhage due to retained products of conception.
  • Antepartum hemorrhage Antepartum hemorrhage Antepartum hemorrhage is defined as vaginal bleeding that occurs after 20 weeks of gestation and is unrelated to labor. The most important causes are placental abruption (most common), placenta previa (2nd most common), vasa previa, and uterine rupture. Antepartum Hemorrhage: obstetric bleeding during the 3rd trimester. Common causes include placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity previa, placental abruption, and preterm labor Preterm labor Preterm labor refers to regular uterine contractions leading to cervical change prior to 37 weeks of gestation; preterm birth refers to birth prior to 37 weeks of gestation. Preterm birth may be spontaneous due to preterm labor, preterm prelabor rupture of membranes (PPROM), or cervical insufficiency. Preterm Labor and Birth. Bleeding due to abnormal placentation may increase the risk of postpartum hemorrhage due to retained products of conception.
  • Disseminated intravascular coagulation Disseminated intravascular coagulation Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage. Disseminated Intravascular Coagulation ( DIC DIC Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage. Disseminated Intravascular Coagulation): a serious medical disorder in which multiple clots form and can lead to permanent organ damage. Systemic activation of blood coagulation occurs and results in the generation and deposition of excess fibrin. The systemic activation of the coagulation cascade uses many coagulation factors, which result in uncontrolled bleeding.
  • Hemolysis, elevated liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes, and low platelet count (HELLP) syndrome: a preeclampsia complication involving a triad of hemolysis, elevated liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver enzymes Enzymes Enzymes are complex protein biocatalysts that accelerate chemical reactions without being consumed by them. Due to the body's constant metabolic needs, the absence of enzymes would make life unsustainable, as reactions would occur too slowly without these molecules. Basics of Enzymes, and low platelets Platelets Platelets are small cell fragments involved in hemostasis. Thrombopoiesis takes place primarily in the bone marrow through a series of cell differentiation and is influenced by several cytokines. Platelets are formed after fragmentation of the megakaryocyte cytoplasm. Platelets ( thrombocytopenia Thrombocytopenia Thrombocytopenia occurs when the platelet count is < 150,000 per microliter. The normal range for platelets is usually 150,000-450,000/µL of whole blood. Thrombocytopenia can be a result of decreased production, increased destruction, or splenic sequestration of platelets. Patients are often asymptomatic until platelet counts are < 50,000/µL. Thrombocytopenia). Thrombocytopenia represents a hemostasis Hemostasis Hemostasis refers to the innate, stepwise body processes that occur following vessel injury, resulting in clot formation and cessation of bleeding. Hemostasis occurs in 2 phases, namely, primary and secondary. Primary hemostasis involves forming a plug that stops the bleeding temporarily. Secondary hemostasis involves the activation of the coagulation cascade. Hemostasis abnormality and increases the risk of postpartum hemorrhage.

References

  1. Belfort, M. A. (2021). Overview of postpartum hemorrhage. In Barss, V.A. (Ed.), UpToDate. Retrieved March 11, 2021, from https://www.uptodate.com/contents/overview-of-postpartum-hemorrhage
  2. Wormer, K. (2020). Acute postpartum hemorrhage. In Bryant, S. (Ed.), StatPearls. Retrieved March 11, 2021, from https://www.statpearls.com/articlelibrary/viewarticle/27638/ 
  3. The American College of Obstetrics and Gynecology Committee on Obstetrics. (2017). Practice Bulletin No. 183: Postpartum hemorrhage. Retrieved March 11, 2021, from https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage 
  4. The American College of Obstetrics and Gynecology Committee on Obstetrics. (2019). Committee Opinion No. 794: Quantitative blood loss in obstetric hemorrhage. Retrieved March 11, 2021, from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/12/quantitative-blood-loss-in-obstetric-hemorrhage 
  5. Tobian, A. (2021). Clinical use of Cryoprecipitate. UpToDate. Retrieved May 15, 2021, from https://www.uptodate.com/contents/clinical-use-of-cryoprecipitate

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