Postpartum Haemorrhage (PPH)

Definition | Types | Risk Factors | Signs and Symptoms | Investigations | Management | References

Definition

Postpartum Haemorrhage (PPH) is defined as blood loss of 500 mL or more within 24 hours after vaginal delivery, or 1000 mL or more following a caesarean section. PPH can occur immediately after birth (primary PPH) or up to 12 weeks postpartum (secondary PPH).

Types of PPH

• Primary PPH: Occurs within 24 hours of delivery and is typically due to uterine atony, trauma, retained placental tissue, or coagulopathy.
• Secondary PPH: Occurs between 24 hours and 12 weeks postpartum and is usually due to retained placental tissue or infection.

Risk Factors

• Prolonged labour or rapid labour.
• Overdistended uterus (due to multiple pregnancy, polyhydramnios, or large baby).
• Induction of labour.
• Use of uterine relaxants (e.g., magnesium sulfate).
• Caesarean section.
• Placental abruption or placenta previa.
• History of PPH in previous pregnancies.
• Uterine fibroids.
• Advanced maternal age.
• Pre-eclampsia or eclampsia.

Signs and Symptoms

• Excessive vaginal bleeding.
• Signs of hypovolemic shock (e.g., tachycardia, hypotension, pallor).
• Uterine atony (a soft and boggy uterus).
• Drop in haemoglobin or haematocrit levels.
• Cold, clammy skin.
• Reduced urine output.
• Altered mental status in severe cases.

Investigations

• Clinical Assessment: Rapid assessment of vital signs, blood loss estimation, and uterine tone.
• Blood Tests: Full blood count (FBC), coagulation profile, cross-match for blood transfusion.
• Ultrasound: May be used to check for retained placental tissue or uterine abnormalities.

Management

Management of PPH requires a multidisciplinary approach, involving immediate resuscitation, medical management, and possibly surgical intervention.

• Immediate Resuscitation:
  • ABC (Airway, Breathing, Circulation) assessment and management.
  • Start intravenous fluid resuscitation with crystalloids or colloids.
  • Administer oxygen via face mask.
  • Insert a urinary catheter to monitor urine output.
• Medical Management:
  • Uterotonics: Administer oxytocin (10 IU intramuscularly or 20–40 IU in 500 mL IV fluid) to stimulate uterine contractions.
  • Consider additional uterotonics such as ergometrine, misoprostol, or carboprost if bleeding persists.
  • Consider tranexamic acid (1 g IV) to reduce blood loss if uterotonics are insufficient.
• Surgical Management:
  • Bimanual Uterine Compression: To compress the uterus and control bleeding.
  • Uterine Tamponade: Use of a Bakri balloon or packing with gauze to apply pressure inside the uterus.
  • Surgical Intervention: If bleeding is uncontrolled, surgical options include uterine artery ligation, B-Lynch suture, or hysterectomy.
• Blood Transfusion: Transfuse blood products as necessary, including red cells, fresh frozen plasma, and platelets.

References

1. NHS (2024) Postpartum Haemorrhage. Available at: https://www.nhs.uk/conditions/postpartum-haemorrhage/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Intrapartum Care: Postpartum Haemorrhage. Available at: https://www.nice.org.uk/guidance/ng121 (Accessed: 24 June 2024).
3. Royal College of Obstetricians and Gynaecologists (2024) Green-top Guideline No. 52: Postpartum Haemorrhage. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/ (Accessed: 24 June 2024).

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