Postpartum Hemorrhage

Postpartum hemorrhage (PPH) accounts for a large proportion of maternal mortality and morbidity worldwide and is the leading direct obstetric cause of maternal death.¹ Occurring in around 5% of deliveries, PPH represents a threat particularly in developing countries.^1,2 PPH is defined through the volume of blood lost during delivery – according to the World Health Organization, PPH is defined in all delivery methods as blood loss from the genital tract of over 500 mL, with major PPH occurring with blood loss over 1000 mL and severe PPH over 2000 mL.¹ However, this metric is contested as a total method to determine PPH. Because visual estimation of blood loss is relatively inaccurate, physicians have utilized blood collection drapes and the weighing of swabs as aids in estimating total blood loss.^1,2

PPH is thought to result from an atonic uterus, where the loss of myometrial tone causes unchecked maternal blood flow to the placental bed.³ A mnemonic (the 4 T’s) is also used to describe three more causes, retained placental tissue, uterine tears, and clotting disorders (tone, tissue, trauma, and thrombin).³ Upon the occurrence of PPH, physicians simultaneously manage four components: communication, resuscitation, monitoring investigation, and arrest of bleeding.³ Drug treatments of PPH include oxytocin administration as first line management as well as misoprostol as another first line management option.³ However, it has been shown that oxytocin is more effective than misoprostol if used for the first time – thus, a combinational treatment is not necessary.³ Other less common drug treatments include tranexamic acid and ergometrine.³ Physical and surgical treatments include uterine compression, bimanual uterine compression, balloon or condom tamponade, external aortic compression, uterine artery embolization, and non-pneumatic anti-shock garments.⁴ Furthermore, patient monitoring of values such as continuous heart rate, blood pressure, respiratory rate, and peripheral oxygen saturation should be measured consistently.⁵

Anesthesiologists play an important role in PPH management both before onset and during treatment. Depending on the scenario, patients could receive an epidural bolus of a quick onset local anesthesia (for repair of a surgical laceration), intravenous opioids (no epidural catheter), or a neuraxial block (no epidural catheter and significant blood loss), among other options.⁶ General anesthesia has shown to have high risk for complications and should be carefully considered as a last resort option.⁶ Postpartum analgesia also remains an important component of maternal-fetal care, with postpartum pain management critical to enable a successful recovery. For instance, prolonged neuraxial analgesia with an epidural catheter would be a viable alternative to opioid based analgesia.⁶ Because women with PPH may experience a higher degree of pain due to surgical manipulation of the lower pelvic regions, treatment is individually reviewed on a case by case basis.⁶

Several risk factors for PPH include chorioamnionitis, maternal anemia, maternal obesity, and preeclampsia, among many others – however, 20% of PPH cases occur in women without any apparent risk factors.⁷ An effective strategy to prevent PPH has been active management of the third stage of labor (AMTSL), which includes administration of oxytocin with or soon after delivery of the anterior shoulder, controlled cord traction, and uterine massage after delivery of the placenta.⁷

PPH remains a major, yet common, complication of pregnancies worldwide. However, with appropriate detection, high-quality emergency obstetric care services, prevention practices, and management, PPH can be successfully treated.

Citations:

1. Rani PR. Recent Advances in the Management of Major Postpartum Haemorrhage – A Review. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. 2017; Available from:

2. Borovac-Pinheiro A, Pacagnella RC, Cecatti JG, Miller S, El Ayadi AM, Souza JP, et al. Postpartum hemorrhage: new insights for definition and diagnosis. American Journal of Obstetrics and Gynecology. 2018 Aug;219(2):162–8.

3. Weeks A. The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next? BJOG: An International Journal of Obstetrics & Gynaecology. 2015 Jan;122(2):202–10.

4. Ashigbie P, Pharm B. Background Paper 6.16 Postpartum Haemorrhage. Background Paper. 2004;35.

5. Muñoz M, Stensballe J, Ducloy-Bouthors A-S, Bonnet M-P, De Robertis E, Fornet I, et al. Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfusion [Internet]. 2019 Apr 10 [cited 2020 Jun 8]; Available from: http://doi.org/10.2450/2019.0245-18

6. Ring L, Landau R. Postpartum hemorrhage: Anesthesia management. Seminars in Perinatology. 2019 Feb;43(1):35–43.

7. Evensen A. Postpartum Hemorrhage: Prevention and Treatment. 2017;95(7):10.