POSTPARTUM HEMORRHAGE

Prepared by

Dr. Hani Mahdi

Modified Oct. 2017
 Definitions:
The American College of Obstetricians and Gynecologists’ (ACOG)
reVITALize program defines postpartum hemorrhage as cumulative blood
loss greater than or equal to 1,000 mL or blood loss accompanied by signs
or symptoms of hypovolemia within 24 hours after the birth process
(includes intrapartum loss) regardless of route of delivery
Traditionally Postpartum hemorrhage traditionally defined as blood loss
• > 500 mL after vaginal delivery
• > 1,000 mL after cesarean delivery
• Other definitions include
• blood loss after delivery that causes hemodynamic instability
• 10% decline in hematocrit after delivery
 Definitions: cont.
• The Royal College of Obstetricians and Gynaecologists defines
PPH as
• minor: blood loss 500-1,000 mL
• major: blood loss > 1,000 mL, further divided into
• moderate (blood loss 1,000-2,000 mL)
• severe (blood loss > 2,000 mL)
• blood loss of > 40% considered life-threatening (about
2,800 ml in a 70 kg woman)
• Postpartum hemorrhage can be further characterized as
• primary: excessive blood loss in the first 24 hours after delivery
• secondary: excessive blood loss 24 hours to 12 weeks after delivery
Incidence

• Primary postpartum hemorrhage 7% to 25%

• Secondary postpartum hemorrhage reported in about
1% of pregnancies
Complications of PPH
• Postpartum hemorrhage reported to account for about 140,000
maternal deaths annually worldwide
• Between 2003 and 2009, PPH was directly responsible for 20% of maternal
deaths worldwide and 8% of maternal deaths in high-income countries.
Potential complications of PPH:
• Adult respiratory distress syndrome
• shock, disseminated intravascular coagulation
• acute renal failure
• loss of fertility
• pituitary necrosis (Sheehan syndrome)
Less severe clinical outcomes:
• iron deficiency anemia
• fatigue
• delayed lactogenesis
Maternal Physiology: Cool Facts
• Blood volume
• 60 kg gravid women about 6 L by 30 weeks
• Uterus weight
• Pre pregnancy: 40 – 70 grams
• Third trimester: 1,200 grams
• Uterine cavity capacity
• Pre pregnancy: 10 mL
• Third trimester: 5,000 mL
• Blood Flow
• Pre pregnancy: 2% cardiac output
• Third trimester: 17% cardiac output: 600 – 800 mL/min
In postpartum women, it is important to
recognize that the signs or symptoms
of considerable blood loss (eg,
tachycardia and hypotension) often do
not present or do not present until
blood loss is substantial
RISK FACTORS ASSOCIATED WITH PPH
• PPH often occurs in the absence of risk factors.
•Researchers have identified numerous antenatal and intrapartum
factors associated with increased risk of PPH. Most factors are not
strongly predictive of PPH.
• Risk assessment tools are readily available and have been shown to
identify 60–85% of patients who will experience a significant obstetric
hemorrhage.

• A maternal risk assessment should be conducted antenatally and at

the time of admission and continuously modified as other risk factors
develop during labor or the postpartum period
Admission Risk Assessment & Testing
Low Medium High
(Clot only) (Type and Screen) (Type & Crossmatch)
No previous uterine Prior cesarean birth(s) or Placenta previa, low lying
incision uterine surgery placenta
Singleton pregnancy Multiple gestation Suspected placenta accreta,
percreta, increta
≤4 previous vaginal >4 previous vaginal births Hematocrit <30 AND other
births risk factors
No known bleeding Chorioamnionitis Platelets <100,000
disorder
No history of PPH History of previous PPH Active bleeding (greater
than show) on admit
Large uterine fibroids Known coagulopathy
*Pre-transfusion testing strategy should be standardized to facility conditions depending on blood
bank resources, speed of testing, and availability of blood products.*
 Ongoing Risk Assessment:
At least q shift and at every handoff
During Labor Birth/Postpartum
• Prolonged second stage • Vacuum- or forceps-assisted
• Prolonged oxytocin use birth
• Active bleeding • Cesarean birth (especially
urgent/emergent cesarean)
• Chorioamnionitis
• Retained placenta
• Magnesium Sulfate
treatment
Causes:
primary postpartum hemorrhage
usually caused by one or more of
"the 4 Ts" (tone, tissue, trauma, or
thrombin)
 1- Uterine Atony (tone) 70%
• Tone - abnormalities of uterine •Risk factors for Uterine Atony
contraction uterine atony)
•placenta previa
• Most common cause of primary •multiple gestation
PPH (70%) •previous postpartum
• Atony can be caused by: hemorrhage
• overdistension of uterus •polyhydramnios
• uterine muscle exhaustion •macrosomia (neonate > 4000 g)
• intra-amniotic infection •rapid labor
• functional or anatomic distortion of
uterus •prolonged labor > 12 hours
• uterine-relaxing medications •induction of labor
• bladder distension, which may •oxytocin use
prevent uterine contraction •high parity
•age > 40 years (not multiparous)
 2- Trauma 20%
• Damage within or outside of the
genital tract, including lacerations
of the cervix, vagina, or perineum
(including episiotomies with or
without extensions)
• Extensions, lacerations at
cesarean section
• Uterine rupture
• Uterine inversion
• Hematoma, including broad
ligament hematoma
• Extragenital bleeding, such a
subcapsular liver rupture
• Risk Factors for Trauma of the
Genital Tract:
• delivery by cesarean section
• Assisted vaginal delivery
• episiotomy, especially
mediolateral
• precipitous delivery
• malposition
• previous uterine surgery
• high parity
• excessive cord traction
3-Tissue 10%
• Retained products of conception
such as placenta or membrane,
including abnormal placentation
(especially placenta accreta)
• Retained cotyledon, or
succenturiate lobe
• Retained blood clots
• Risk factors for Retention of
Tissue or Products of
Conception:
• previous uterine surgery
• high parity
• atonic uterus (due to retained
blood clots)
• abnormally adherent placenta
 4- Thrombin 1%
• Abnormalities of coagulation, including pre-existing conditions, such as
• hemophilia A
• von Willebrand disease
• Conditions acquired in pregnancy, such as:
• idiopathic thrombocytopenic purpura
• thrombocytopenia, often due to preeclampsia with HELLP syndrome
• Disseminated intravascular coagulopathy (DIC)
• Placental abruption
• amniotic fluid embolus
• sepsis
• prolonged intrauterine fetal demise
• Therapeutic anticoagulation
Secondary Postpartum Hemorrhage
• Often idiopathic
• Retained products of conception
• Subinvolution of placental site
• Infection (postpartum endometritis)
• Inherited coagulation defects, such as von Willebrand
disease
 Prevention
• Active management of the third stage of labor:
1) oxytocin administration,
2) uterine massage, and
3) umbilical cord traction
4) Uterine massage
• Prophylactic oxytocin, by dilute intravenous infusion (bolus dose of 10
units), or intramuscular injection (10 units), remains the most effective
medication with the fewest adverse effects
• The World Health Organization, ACOG, American Academy of Family
Physicians, and Association of Women’s Health, Obstetric and Neonatal
Nurses recommend administering uterotonics (usually oxytocin) after all
births for the prevention of postpartum hemorrhage
PLANNING
• Management of risk — Identify and counsel women with risk factors for
PPH
• PPH protocols — Ideally, each hospital labor and delivery unit should have
a PPH protocol for patients with estimated blood loss exceeding a
predefined threshold (often 1000 mL).
• The protocol should provide a standardized approach to evaluating and
monitoring the patient with PPH, notifying a multidisciplinary team, and
treatment.
• PPH kits - kits including medications and instruments that may be needed
to manage PPH so that this equipment is readily available when needed
• Training and simulation —team training, clinical drills and debriefings after
PPH
General principles of management
The goal is to:
• Restore or maintain adequate circulatory volume to
prevent hypoperfusion of vital organs
• Restore or maintain adequate tissue oxygenation
• Reverse or prevent coagulopathy
• Eliminate the obstetric cause of PPH
Treatment overview:
• Use team approach
• Initiate full resuscitative measures for postpartum patients
with estimated blood loss ≥ 1,000 mL and continued
bleeding, or signs of hypovolemic shock (activation of a
massive transfusion protocol).
• Call experienced medical staff (Obstetrician, midwife,
Anesthesia, Hematologist, and Laboratory).
• Alert one member of the team to record event.
• Don’t forget communication with patient and her family
Immediate action
• Provide intravenous fluid and possibly blood replacement by
starting two large bore IV’s with normal saline or other
crystalloid fluids.
• Elevating the foot of the bed or having an assistant elevate
the patient’s legs will improve venous return and raise the
patient’s blood pressure.
• Open the airway and give supplemental oxygen to maintain
oxygen saturation of greater than 95 percent.
• Ventilate the patient if needed, with 100 percent oxygen.
Frequently monitor
• Fluid replacement and use of blood products
• Vital signs, especially temperature and blood pressure as
they are more often affected with shock
• CBC and coagulation studies
• The prevention of hypothermia and acidosis is an essential
component in the successful management of massive
hemorrhage.
• Patients should be kept warm. All fluids should be warmed
using any of the commonly available fluid warmers
• Identify and treat source of bleeding
Measurement of blood loss
• Cumulative measurement of blood loss at every delivery.
• Collect blood in graduated measurement containers
• Use visual aids (eg, posters) that correlate the size and
appearance of blood on specific surfaces (eg, maternity pad,
bed sheet, lap sponge)
• Measure the total weight of bloody materials and subtract
the known weight of the same materials when dry.
• Bedside evaluation by the provider.
Blood tests:
• Blood type and cross match recommended in case
transfusion is needed
• Complete blood count (CBC) and coagulation studies
should be obtained and repeated periodically as
clinically needed
• Coagulation studies should include:
• prothrombin time
• partial thromboplastin time
• Fibrinogen assay
Blood tests cont.
• Bedside evaluation of clotting status may be
undertaken on recently lost blood using the clot
observation test to rule out coagulopathy

• 5 mL of patients blood placed in clean redtop tube

• Normal blood clots within 8-10 minutes and remains intact
• Low fibrinogen concentration indicated by:
- failure to clot,
- or partial or complete dissolution of clot within 30-60 minutes
Trauma Assessment of Blood Loss
Class Blood Loss Total Deficit Signs/Symptoms
Volume

I <1000 mL 15% Orthostatic Tachycardia

II <1500 mL 15-25% Resting tachycardia,
orthostatic hypotension
III <2,500 mL 25-40% Resting hypotension,
oliguria
IV >2,500 mL >40% Obtunded, Cardiovascular
collapse
Management of PPH
 Management of PPH due to
Uterine Atony

Exclude other causes of PPH

Empty the bladder
 Uterotonics for Atonic Hemorrhage:
• Oxytocin (Pitocin®, Syntocinon®)
• Methylergonovine (Methergine®)
• Carboprost
• Misoprostol (Cytotec®)
Oxytocin (Pitocin®, Syntocinon®)
Methylergonovine (Methergine®)
Carboprost
Misoprostol (Cytotec®)
Tranexamic Acid
• Tranexamic acid should be considered in the setting of
obstetric hemorrhage when initial medical therapy fails.
• Earlier use is likely to be superior to delayed treatment
(sooner than 3 hours from the time of delivery).
Uterine Artery Embolization
• Candidates for UAE:
• Hemodynamically stable,
• Persistent slow bleeding
• Failed less invasive therapy (uterotonic agents, uterine massage, uterine
compression, and manual removal of any clots).
• Embolization with absorbable gelatin sponges, coils, or microparticles.
• Studies (n=15) have shown that UAE for postpartum hemorrhage has a
median success rate of 89%, ranging from 58% to 98%
• After UAE, infertility has been reported in up to 43% of women
• The risk uterine necrosis, deep vein thrombosis, or peripheral neuropathy
appears to be less than 5%
Surgery and procedures:
• Surgical intervention recommended if bleeding is refractory to
uterotonics and other conservative interventions
• For women with secondary postpartum hemorrhage and excessive or
continuing bleeding, surgical treatment is necessary regardless of
ultrasound findings
TEMPORIZING MEASURES
• External aortic compression:
• Apply pressure with a closed fist on the abdominal aorta slightly to
the patient's left and immediately above the umbilicus.
Surgery and procedures:
• Uterine tamponade:
• Tamponade options include
• Bimanual uterine massage/compression:
• Place 1 hand in vagina and push up against body of uterus
while other hand Compresses fundus from above through
abdominal wall.
Massage anterior aspect of uterus with abdominal hand
and posterior aspect with vaginal hand
Bimanual Uterine Compression
Surgery and procedures: cont.
• Uterine balloon tamponade :
(condom catheter, Foley catheter, and Sengstaken–Blakemore
esophageal tube):
 Foley catheter (insert ≥ 1 bulb and instill with 60-80 mL of saline)
 SOS Bakri tamponade balloon
• insert balloon and instill with 300-500 mL of saline
• can be left in place for 8-48 hours
• prior to removal, deflate balloon but leave in place in case
bleeding recurs
• Uterine sandwich (a combination of external compression with
internal tamponade)
 Insertion of Uterine Tamponade Balloon
Under ultrasound guidance, the balloon portion of the catheter is inserted into the
uterus, making certain that the entire balloon is inserted past the cervical canal and
internal ostium.
Surgical Intervention
• Uterine compression sutures:((Hemostatic Brace Sutures)
• Suture techniques include B-lynch technique
• Hayman suture -modified compression suture may be performed without
hysterotomy
• Cho Technique
• Test for Uterine Compression Sutures
• An assistant stands between the legs of the patient to determine the
extend of bleeding.
• Then the uterus is exteriorized and bimanual compression is performed.
• The test is positive if the bleeding stops and the compression sutures will
stop the bleeding
Hayman stitch
Two to four vertical compression sutures are placed, as needed, but in contrast to
the B-Lynch technique, these sutures pass directly from the anterior uterine wall to
the posterior uterine wall. A transverse cervicoisthmic suture can also be placed if
needed to control bleeding from the lower uterine segment.
 Cho Technique
#1 chromic catgut is used to place sutures in a small rectangular array to compress the
anterior and posterior uterine walls against one another at sites of heavy bleeding. The
through and through sutures extend from the serosa of the anterior wall to the serosa of the
posterior wall. After creating a square, the ends are tied down as tight as possible to compress
the myometrium. Two to five squares/rectangles are made, as needed.
Surgical Intervention
• Bilateral uterine artery ligation (O'Leary sutures) must be performed
before excessive blood loss has occurred
• To further diminish blood flow to the uterus, similar sutures can be
placed across the vessels within the uteroovarian ligaments
• Hypogastric artery ligation: Less successful than earlier thought;
difficult technique; generally reserved for practitioners experienced in
the procedure
• Hysterectomy, subtotal or total (if hysterectomy is performed for
uterine atony, documentation of other therapy attempts is
recommended)
 Internal iliac artery ligation
Internal iliac (hypogastric)
artery ligation is performed less
frequently

The procedure has been found

to be considerably less
successful than originally
thought
 Retained Placenta
• If placenta not spontaneously expelled within 30 minutes of delivery, administer
oxytocin 10 units intramuscularly or IV in combination with controlled cord
traction
• In absence of hemorrhage, consider observation for another 30 minutes after
initial 30 minutes prior to attempt at manual extraction
Manual extraction
• Ultrasound evaluation for retained tissue or placenta
recommended before uterine instrumentation
• Ultrasound-guided blunt instrument may help remove retained
placental tissue and reduce risk for uterine perforation
• Administer single dose of antibiotics (ampicillin or first-generation
cephalosporin) if manual extraction attempted
Abnormally Adherent Placenta
(accreta, increta, or percreta)
• If diagnosis known or strongly suspected prior to delivery:
• counsel patient on likely need for hysterectomy and blood transfusion
• prepare blood products, clotting factors, and cell saver technology prior to
delivery
• plan delivery at location with access to blood bank and skilled surgeons
• Abdominal hysterectomy is often required for postpartum hemorrhage due to
placenta previa or accreta, and should be considered sooner rather than later
• Uterine conserving options may be considered for small focal accretas, such as:
• hemostatic multiple square suturing (Cho square technique) - eliminates
space in uterine cavity by suturing anterior and posterior uterine walls
• partial or complete removal via laparotomy
• Uterine artery embolization may be considered for cases of placenta previa with
accreta if intra-arterial balloons can be placed in radiology department before
woman undergoes cesarean section
Damage to the genital tract
• Lower genital tract trauma: repair tears in perineum, vagina, and cervix
• Management approach for hemorrhage due to a ruptured uterus:
• Assess rupture via exploratory laparotomy to determine best surgical
option, including
• primary repair (rupture of previous cesarean section scar can often be successfully
repaired by revision of the edges of prior incision followed by primary closure)
• hysterectomy (may be necessary in a life-threatening situation)
• Type of surgery performed dependent on
• site and extent of rupture
• patient's clinical condition
• patient's desire for future childbearing
• reconstruction of the uterus, if possible
• neighboring structures, such as broad ligament, parametrial vessels, ureters, and
bladder
Regardless of the patient’s wishes for the avoidance of hysterectomy, this
procedure may be necessary in a life-threatening situation
Hysterectomy:
• May be indicated for massive hemorrhage unresponsive to other interventions
• Resort to hysterectomy sooner rather than later, especially in cases of placenta
accreta or uterine rupture as hysterectomy should not be delayed until woman is
in extremis or while less definitive surgical procedures are performed
• Subtotal (supracervical) hysterectomy is the operation of choice in most cases of
postpartum hemorrhage requiring hysterectomy, except in women with trauma
to cervix or lower segment
• Potential indications for hysterectomy include:
placenta accreta or placenta previa (most common)
uterine rupture
atony, after other management attempted
trauma
sepsis
Surgery for hematomas:
• For postpartum hemorrhage due to genital tract hematoma, incision
and drainage is necessary with suturing of the incision, and if
appropriate, packing the vagina
• genital tract hematomas can lead to significant blood loss
• progressive enlargement of the mass indicates need for incision and drainage
• ≥ 1 source of bleeding is often identified after incision
• hemostasis is usually achieved by:
• draining the blood within the hematoma (if necessary place drain in situ)
• packing the vagina when appropriate
Uterine Inversion
• Rare
• Important to recognize quickly
• Suspect if shock disproportionate to blood loss
• Replace uterus immediately
• Watch for vasovagal reflex
Uterine relaxants may help restore normal anatomy (terbutaline)
Manual replacement with or without uterine relaxants is usually effective
• procedure involves digital application of upward pressure against inverted fundus
• in case of inversion before separation of placenta, do not remove placenta until uterus
has been manually put back into position
Laparotomy required if failed manual replacement, using
• Huntington procedure (use of forceps for upward traction of the inverted corpus)
• Haultain procedure (incision of cervical os followed by digital replacement of corpus and
repair of incision)
Uterine Inversion
Manual Replacement
Clotting Disorders

- Administer blood products as indicated

Fluid and Blood Products
Transfusion in PPH
Fluid and electrolytes:
• For patients with minor hemorrhage (blood loss 500-
1,000 mL) and no clinical signs of shock include:
• establishment of IV access ( large bore canula)
• crystalloid IV infusion
• In women with major hemorrhage (blood loss > 1,000
mL and continued bleeding, and/or clinical shock),
infuse maximum of 3.5 L of clear fluids while awaiting
compatible blood
 Blood products:
• Blood transfusion indicated with major postpartum
hemorrhage (blood loss > 1,000 mL)
• Purpose: to replace coagulation factors and red cells for
oxygen-carrying capacity, not for volume replacement
• British Committee for Standards in Hematology (BCSH)
recommends that the main therapeutic goals of management of
massive blood loss is to maintain
• hemoglobin > 8 g/dL
• platelet count > 75 x 109/L
• prothrombin < 1.5 x mean control
• activated prothrombin times < 1.5 x mean control
• fibrinogen > 1.0 g/L
 Blood products cont.
• Blood component therapy:
• packed red cells 240 mL (red cells, white cells, and plasma) to increase
hematocrit 3 percentage points and hemoglobin by 1 g/dL per unit
• platelets 50 mL (platelets, red cells, white cells, and plasma) to increase
platelet count 5,000-10,000 mm3 per unit
• Concurrent replacement with coagulation factors and platelets to avoid
dilutional coagulopathy, including:
• fresh frozen plasma 250 mL (fibrinogen, antithrombin III, and factors V and
VIII) to increase fibrinogen by 10 mg/dL per unit
• cryoprecipitate 40 mL (fibrinogen, factors VIII and XIII, von Willebrand
factor) to increase fibrinogen by 10 mg/dL per unit
 Transfusion and Massive Obstetric
Hemorrhage
• Massive transfusion usually is defined as
• transfusion of ≥ 10 red blood cell (RBC) units within 24 hours
• transfusion of > 4 RBC units in 1 hour with anticipated need for further blood
product transfusion
• replacement of > 50% of total blood volume (TBV) by blood products within 3 hours
• The recommended initial transfusion ratio for packed red blood cells:
fresh frozen plasma:platelets has been in the range of 1:1:1 and is
designed to mimic replacement of whole blood.
• Administration of cryoprecipitate also should be considered in the setting
of placental abruption or amniotic fluid embolism(where fibrinogen is low)
• In emergency situations, type specific or type O Rh-negative blood also
should be readily available.
Common mistakes made in the
assessment and management of PPH
1. Underestimating blood loss
2. Delay in noticing vital sign trends
3. Delay in laboratory assessment for anemia and coagulopathy
4. Delay in instituting blood component therapy
5. Delay in surgical interventions
6. Delay in making the mental shift from normal delivery to life-
threatening emergency
7. Poor communication between the OB, nurse, and
anesthesiologist
8. Lack of preoperative preparation for massive hemorrhage
Management of PPH: organizing the team (Pingirl)