Postpartum Haemorrhage

This is excessive bleeding following delivery and is described as primary and secondary.

Aetiology

The most common cause of postpartum haemorrhage (PPH) is uterine atony.
Other common causes are:

• Retained placenta or fragments of placenta
• Vulvar or vaginal lacerations or haematoma

Atony and retained placenta are 80% of all cases; lacerations comprise the bulk of the other 20%.
Cervical lacerations, uterine rupture, broad ligament haematoma and extra genital bleeding also need to be excluded.

Epidemiology

Obstetric haemorrhage remains one of the major causes of maternal death in both developed and developing countries. In the 2003-2005 report of the UK Confidential Enquiries into Maternal Deaths, haemorrhage was the third highest direct cause of maternal death; a rate similar to the previous triennium.²

Most studies quote an incidence of around 5%,³ but a figure of 12% of vaginal deliveries was recorded in one Australian tertiary referral hospital.⁴

Risk factors

• Factors relating to the pregnancy:
  • Antepartum haemorrhage in this pregnancy
  • Placenta praevia (15 x risk)
  • Multiple pregnancy (5 x risk)
  • Pre-eclampsia or pregnancy-induced hypertension (4 x risk)
  • Nulliparity (3 x risk)
  • Previous PPH (3 x risk)
  • Asian ethnic origin (2 x risk)
  • Maternal obesity (2 x risk)
• Factors relating to delivery:
  • Emergency Caesarean section (CS) (9 x risk)⁵
  • Elective CS (4 x risk) - especially if >3 repeat procedures⁶
  • Retained placenta (5 x risk)
  • Mediolateral episiotomy (5 x risk)
  • Operative vaginal delivery (2x risk)
  • Labour of >12 hours (2 x risk)
  • >4 kg baby (2 x risk)
  • Maternal pyrexia in labour (2 x risk)
• Pre-existing maternal haemorrhagic conditions:
  • Factor 8 deficiency - Haemophilia A carrier
  • Factor 9 deficiency - Haemophilia B carrier
  • Von Willebrand's disease

Presentation

• Symptoms: continuous bleeding, which fails to stop after delivery of the placenta - third stage
• Signs: loss of >1000 ml may be accompanied by clinically apparent shock, i.e. tachycardia, hypotension

Investigations

• Thorough examination of the lower genital tract. This may require theatre/anaesthesia.
• FBC, clotting screen, crossmatch
• Hourly urine output
• Continuous pulse/blood pressure or central venous pressure monitoring
• ECG, pulse oximetry

Associated diseases

Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP). See separate article HELLP syndrome for more information.

Management

Ideally one of the emergency drills to be practised by the team on the labour ward.¹

• Call expert assistance.
• Secure IV access with 2 x 14-gauge cannulae.
• If the perceived blood loss is 500-1000 ml and there are no signs of clinical shock, basic measures, (crossmatch 2 units, FBC, clotting screen, IV access and monitoring clinical observations) should suffice.
• However, loss of greater than 1000 mls or any signs of shock should lead to full alert of the clinical team: experienced midwife, obstetric registrar (alert consultant), anaesthetic registrar (alert consultant), alert haematologist, alert transfusion service, call porters for transport of specimens and blood products.
• Consider arterial line monitoring ± transfer to ITU.
• Oxygen should be given by mask at 8 litres per minute.
• Transfuse crossmatched blood (6 units initially) as soon as possible.
  • Until then, infuse crystalloid or colloid as required.
  • If 3.5 litres are given and no blood is available, give O NEG, or uncross matched blood of own blood group.
  • Use a warming device and a pressure cuff.
  • Do not use a blood filter.
  • Do not use dextrans.
  • Give up to 1 litre of fresh frozen plasma (FFP) and 10 units of cryoprecipitate if clinically indicated.
  A new haemostatic agent- recombinant factor VIIa - has had some clinical success, but its efficacy and safety is untested in clinical trials as yet.^7,8
• Monitor temperature and urine output (catheterise).
• Stop the bleeding.
  • Ensure bladder empty and bimanually compress the uterus ± rub up a contraction. A Sengstaken-Blakemore tube has been used to compress the uterus. One series of 17 cases showed a 71% success rate in stopping the haemorrhage.⁹
  • Give IV syntocinon 10 units or IV ergometrine 500 micrograms.
  • Commence syntocinon infusion 30 units in 500 ml.
  • Give IM (into uterine wall) carboprost 500 micrograms if still atonic.
  • Try misoprostol 1000 micrograms rectally.
• Exclude other causes than atony:
  • Tissue (retained products of conception).
  • Trauma (of the genital tract).
  • Thrombin (abnormalities of coagulation).
• If pharmacological measures fail to control the haemorrhage, resort to surgery early:
  • Bilateral ligation of the uterine arteries or bilateral ligation of the internal iliac (hypogastric) arteries.
  • An alternative to ligation is embolisation with gelatin sponge.¹⁰ Amenorrhoea has been reported following this, secondary to necrosis of the uterine wall and obliteration of the cavity.¹¹
  • Uterine bracing suture, (the B-Lynch suture) to the anterior and posterior uterine walls has been shown to be effective and safe,¹² with reports of successful pregnancy following its use.^13,14
  • Hysterectomy should be considered early, especially in cases of placenta accreta or uterine rupture.

Complications

• Shock
• Collapse
• Disseminated intravascular coagulation

Prognosis

The Confidential Enquiry into Maternal Deaths for 2000-2002 reported 17 deaths related to obstetric haemorrhage in that triennium.¹⁵ This gives a rate of 8.5 per million.

Prevention

The active management of the third stage of labour; prophylactic oxytocics should be routinely used in the third stage of labour as they decrease the risk of postpartum haemorrhage (PPH) by 60%.^16,1 For most women syntometrine (ergometrine 0.5 mg with 5 IU oxytocin) is the drug of choice. By some clinicians, oxytocin alone (10 IU) is preferred in women with hypertension.

This commonly presents in primary care as prolonged or excessive bleeding once the woman has returned home after delivery.

Aetiology

The two most common causes are:

• Infection - endometritis. This occurs in 1-3% after spontaneous vaginal delivery. It is the most common cause of postnatal morbidity between day 2 and day 10. Risk factors: Caesarean section, prolonged rupture of membranes, severe meconium staining in liquor,¹⁷ long labour with multiple examinations, manual removal of placenta,¹⁸ mother's age at extremes of reproductive span, low socioeconomic status, maternal anaemia, prolonged surgery, internal fetal monitoring and general anaesthetic.
• Retained products of conception (RPOC)

Assessment

History: as above; also extended labour, difficult 3rd stage, ragged placenta, primary postpartum haemorrhage (PPH).
Examination: systemic illness, fever, rigors, tachycardia, tissue visible within loss. Suprapubic area may be tender, with elevated fundus that feels boggy in RPOC.

Investigation

• FBC
• Blood cultures are positive in 10-30%
• Check MSU
• High vaginal swab; also gonorrhoea/chlamydia
• Ultrasound - may be used if RPOC are suspected, although there may be difficulty distinguishing between clot and products. RPOC are unlikely if a normal endometrial stripe is seen

Management

• Speculum examination will allow visualisation of the cervix and lower genital tract to exclude lacerations. If a clot is visible within the cervical os, it may be removed with tissue forceps (although few GPs regularly carry these), allowing the cervix to close.
• When antibiotics are clinically indicated, a combination of ampicillin (clindamycin if penicillin-allergic) and metronidazole is appropriate. In cases of endomyometritis (tender uterus) or overt sepsis, then the addition of gentamicin is recommended.^19,1 The patient may need to be referred if too unwell to tolerate oral medication; IV clindamycin and gentamicin tds until afebrile for greater than 24 hours.²⁰ Oral follow-up treatment is not required. Use doxycyline if chlamydia is suspected.
• If retained products of conception are suspected, elective curettage with antibiotic cover may be required. Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings. A senior obstetrician should be involved in decisions and performance of any evacuation of RCOP, as these women are carrying a high risk of uterine perforation.
• The patient may require iron supplementation if Hb has fallen. Warn of the risk of constipation.

Prognosis

90% of cases treated with antibiotics improve within 48-72 hours. If this is not the case, the patient should be re-evaluated.

1. Prevention and management of postpartum haemorrhage, Royal College of Obstetricians and Gynaecologists (May 2009)
2. CEMACH - Saving Mothers' Lives; Confidential Enquiry into Maternal and Child Health (CEMACH) - Reviewing maternal deaths to make motherhood safer 2003-2005 Executive Summary; (2003-2005), December 2007.
3. Magann EF, Evans S, Hutchinson M, et al; Postpartum hemorrhage after vaginal birth: an analysis of risk factors. South Med J. 2005 Apr;98(4):419-22. [abstract]
4. Henry A, Birch MR, Sullivan EA, et al; Primary postpartum haemorrhage in an Australian tertiary hospital: a case-control study. Aust N Z J Obstet Gynaecol. 2005 Jun;45(3):233-6. [abstract]
5. Magann EF, Evans S, Hutchinson M, et al; Postpartum hemorrhage after cesarean delivery: an analysis of risk factors. South Med J. 2005 Jul;98(7):681-5. [abstract]
6. Silver RM, Landon MB, Rouse DJ, et al; Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006 Jun;107(6):1226-32. [abstract]
7. Bouwmeester FW, Jonkhoff AR, Verheijen RH, et al; Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII. Obstet Gynecol. 2003 Jun;101(6):1174-6. [abstract]
8. Verre M, Bossio F, Mammone A, et al; Use of recombinant activated factor VII in a case of severe postpartum haemorrhage. Minerva Ginecol. 2006 Feb;58(1):81-4. [abstract]
9. Seror J, Allouche C, Elhaik S; Use of Sengstaken-Blakemore tube in massive postpartum hemorrhage: a series of 17 cases. Acta Obstet Gynecol Scand. 2005 Jul;84(7):660-4. [abstract]
10. Pelage JP, Le Dref O, Mateo J, et al; Life-threatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology. 1998 Aug;208(2):359-62. [abstract]
11. Chitrit Y, Zafy S, Pelage JP, et al; Amenorrhea due to partial uterine necrosis after uterine artery embolization for control of refractory postpartum hemorrhage. Eur J Obstet Gynecol Reprod Biol. 2006 Jul;127(1):140-2. Epub 2005 Jul 15. [abstract]
12. Price N, B-Lynch C; Technical description of the B-Lynch brace suture for treatment of massive postpartum hemorrhage and review of published cases. Int J Fertil Womens Med. 2005 Jul-Aug;50(4):148-63. [abstract]
13. Api M, Api O, Yayla M; Fertility after B-Lynch suture and hypogastric artery ligation. Fertil Steril. 2005 Aug;84(2):509. [abstract]
14. Habek D, Vranjes M, Bobic Vukovic M, et al; Successful term pregnancy after B-Lynch compression suture in a previous pregnancy on account of massive primary postpartum hemorrhage. Fetal Diagn Ther. 2006;21(5):475-6. [abstract]
15. CEMACH - Why mothers die; Confidential enquiry into maternal deaths in the UK Confidential Enquiry into Maternal and Child Health (CEMACH) - Executive Summary; (2000-2002).
16. Soriano D, Dulitzki M, Schiff E, et al; A prospective cohort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage. Br J Obstet Gynaecol. 1996 Nov;103(11):1068-73. [abstract]
17. Tran SH, Caughey AB, Musci TJ; Meconium-stained amniotic fluid is associated with puerperal infections. Am J Obstet Gynecol. 2003 Sep;189(3):746-50. [abstract]
18. Dehbashi S, Honarvar M, Fardi FH; Manual removal or spontaneous placental delivery and postcesarean endometritis and bleeding. Int J Gynaecol Obstet. 2004 Jul;86(1):12-5. [abstract]
19. French L; Prevention and treatment of postpartum endometritis. Curr Womens Health Rep. 2003 Aug;3(4):274-9. [abstract]
20. French LM, Smaill FM; Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001067. [abstract]

• NHS. Scotland. Guidelines for The Management of Severe Obstetric Haemorrhage (Incorporating APH and PPH); October 2004
• Wainscott MP; Pregnancy, Postpartum Hemorrhage. eMedicine, October 2009.