Postpartum Haemorrhage

Notes

Introduction

Obstetric haemorrhage, which includes both antepartum and postpartum haemorrhage, is the leading cause of maternal death worldwide.

Within the UK, maternal death from obstetric haemorrhage is uncommon, but still causes approximately 7 deaths per year. Postpartum haemorrhage (PPH) is a common cause of maternal morbidity and up to 40% of blood loss is considered life-threatening in PPH.

Definition

Postpartum haemorrhage (PPH) can be defined as either primary or secondary.

Primary PPH is defined as vaginal bleeding that occurs from delivery of baby to 24 hrs postpartum.

Secondary PPH is defined as vaginal bleeding from 24 hrs postpartum to 12 weeks postpartum.

Severity

The extent of blood loss in PPH is often underestimated.

The severity of PPH is dependent on the extent of blood loss and can be divided into minor, moderate or severe.

  • Minor: 500-1000mls
  • Moderate: 1000-2000mls
  • Severe: > 2000mls.

Risk factors

Risk factors for the development of PPH can be divided into both antenatal and intrapartum factors.

Antepartum

Major antepartum factors include multiple pregnancy, antepartum haemorrhage and previous history of PPH. Below is a list of the main risk factors for PPH.

  • Abruption
  • Placenta praevia
  • Multiple pregnancy
  • Pre-eclampsia, gestational hypertension
  • Previous PPH
  • Ethnicity (i.e.Asian)
  • Obesity (i.e. BMI > 30)
  • Anaemia
  • Uterine anomalies, fibroids

Intrapartum

The main intrapartum factors for PPH include retained placenta, C-section and induction of labour. A list of intrapartum risk factors is shown below.

  • C-Section (Emergency > Elective)
  • Induction of Labour (IOL)
  • Retained placenta
  • Episiotomy
  • Instrumental
  • Prolonged labour
  • > 4kg baby
  • Pyrexia in labour.

Aetiology

The aetiology of PPH can be remembered as the 'four T's'.

The four T's include Tone, Trauma, Tissue and Thrombin.

  • Tone (most common): reduction in urterine tone, typically the result of prolonged labour, big baby, twins, uterine anomalies, polyhydraminos.
  • Trauma: usually due to episiotomy, extensive perineal tears or uterine rupture 
  • Tissue: refers to retained placental tissue 
  • Thrombin: this refers to problems with coagulation that can occur in pre-eclampisa, disseminated intravascular coagulation (DIC) or haemophilia

Management

The management of PPH is critical because mother's can lose a significant amount of blood and develop shock.

General management

  • Observations
  • Airway/breathing
    • High flow oxygen
  • Cardiovascular
    • Two large bore Intravenous access
    • Bloods: FBC, Coag, U&S, LFTs, Crossmatch x4 units
    • Fluid resuscitation
  • Disability
    • Examine: ?trauma ?atony.
  • Exposure
    • Amount of blood loss?
    • Blood glucose level?
    • Febrile?
    • Catheter - monitor urine output 

Specific management

The specific management of a PPH can be divided into interventions aimed to reduce the risk of developing a PPH or stopping a PPH.

Reduce risk:

  • Anticipate those at higher risk:
    • Deliver on a doctor-led unit
    • Intravenous access
    • Bloods: FBC, G&S, Crossmatch in labour
  • “Active management of third stage”
    • Intramuscular Oxytocin.
    • Controlled cord traction (CCT) of placenta to aid delivery.
    • Reduces PPH risk by up to 60%.

Stopping PPH:

  • Uterine massage
  • Bimanuel compression
  • 0.5-1.0g Tranexamic Acid
  • Massive Obstetric Haemorrhage Call

Obstetric haemorrhage protocol

In the event of a major postpartum haemorrhage, the major haemorrhage protocol should be activated throughout switchboard (2222).

Activation of the major haemorrhage protocol means you are alerting blood bank to the need for urgent blood products. Immediate access to Oblood can be found in maternity but this is a limited resource. Once the haemorrhage protocol is activated, a 'runner' needs to send an FBC, crossmatch and coagulation to blood bank. A blood pack is then sent back to the patient via the 'runner' with group specific blood and fresh frozen plasma. Further products can be acquired following communication with blood bank

Obstetric haemorrhage team

  • Obstetric team (SHO/Reg/Cons)
  • Anaesthetic team (SHO/Reg/Cons)
  • Midwifery team (case midwife/Coordinating midwife)
  • Haematologist on call
  • Haematology lab
  • Porter
  • (Theatres)

Fluid & blood products

  • Crystalloid: up to 2L Hartmanns.
  • Colloid: up to 1.5L until blood arrives.
  • Blood: O-neg, group-specific or cross-matched depending on need.
  • Fresh Frozen Plasma (FFP): 4units FFP to every 4units blood (PRC) or if clotting prolonged.
  • Platelets: if Plt <75 and bleeding ongoing.
  • Cryoprecipitate: if Fibrinogen <2.

Pharmacotherapy

Uterine atony is the most common cause of PPH and uterotonic drugs are used to prevent it.

Uterotonic drugs

These medications work by increasing the force and frequency of smooth muscle contraction within the uterus.

  • Syntocinon
    • Oxytocin
    • 5-10 iU IM/IV and 40 iU infusion.
  • Ergometrine
    • Ergot alkaloid
    • 0.5mg IM/IV
    • Avoid if HTN.
  • Carboprost
    • Prostaglandin PGF2α
    • 0.25mg IM every 15mins, up to x8
    • Avoid if asthma.
  • Misoprostol
    • Prostaglandin PGE1
    • 800mcg PR or SL.

Surgical care

In the event that uterotonic medications are ineffective, or bleeding cannot be stopped, surgical intervention needs to be considered.

  • Examination under anaesthesia (EUA): look for retained membranes/placenta
  • Repair tear
  • Intrauterine balloon
  • Brace suture (i.e. B-Lynch suture)
  • Uterine artery embolization/ligation: If for embolisation need to liaise with interventional radiology department
  • Hysterectomy: Last resort if all other measure fail

Secondary PPH

Secondary PPH is often associated with endometritis (endometrial infection) or retained products of conception (RPOC).

In cases of secondary PPH, it is important to assess for infection with high vaginal and endocervical swabs. Concurrently, an ultrasound scan be be completed looking for any RPOC or collections. Mothers may needs antibiotics +/- surgical evacuation of retained products of conception (ERPC).

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