POSTPARTUM HEMORRHAGE

Anila Khan May, 2015

Defining PPH
Incidence & Prevalence
Pathophysiology & Etiologies
Work up & Management
Review Questions

Definition
Postpartum patient with:
Excessive bleeding after delivery
>500 mL after vaginal birth / >1000 mL after cesarean
10% decline in hemoglobin
Not necessarily obvious vaginal bleeding

Symptomatic as a result of excessive bleeding

Pallor, lightheadedness
Hypotension, tachycardia, oliguria

Classification
Primary/Early: First 24 hours after delivery
Secondary/Late/Delayed: 24 hours 12 wks after delivery

Incidence and Prevalence

Number two cause of

maternal death
worldwide
Complicates up to 5%
of pregnancies
worldwide

Pathophysiology & Etiology

Uterine artery blood flow in late pregnancy
500-700 mL/min
Accounts for 15% of cardiac output
Normal response after delivery
Placenta completely separates from uterus
Myometrium contracts and constricts the vessels supplying the

placental bed
Coagulation pathways activate and form clot at the site of previous
placental attachment

Etiologies: Tone, Tissue, Trauma, Thrombosis

Tone: Uterine Atony

Most common cause of PPH
Accounts for 80% of PPH
Complicates 1 in 20 births
Lack of effective contraction of the

uterus after delivery

Contracted fundus does not rule out

atony of lower uterus

Risk factors
Uterine overdistention
Multiple gestation
Polyhydramnios
Macrosomia

Uterine fatigue after prolonged labor

Tissue: Retained Placenta

Abnormal implantation of the placenta in the uterus
Placenta Accreta: placental vili attach directly to the myometrium
rather than to the decidua basalis
Placenta Increta: invade the myometrium
Placenta Percreta: penetrate through the myometrium
Retention of accessory/succenturiate lobe
Other risk factors
Placenta previa
Previous cesareans
Previous D&C
Grand multiparity
Uterine leiomyomas
Extreme preterm (<24wk)

Trauma
Lacerations: perineal, vaginal, cervical, uterine
Result in more bleeding than in non-pregnant state due to
increased blood supply to these tissues
Risk Factors
Instrumental delivery
Prolonged or vigorous labor

Incisions: hysterotomy, episiotomy

Uterine rupture
Patients with previous cesareans

Thrombosis: Bleeding Diathesis

Acquired or inherited factor deficiencies
Von Willebrand disease
Hemophilia
Thrombocytopenia
ITP: idiopathic thrombocytopenic purpura
HELLP: hemolysis, elevated liver enzymes, low platelets
DIC: disseminated intravascular coagulation

Work Up & Management

Manually compress and massage uterus
If due to uterine atony, will likely control bleeding
Explore uterine cavity to ensure that
All placental parts have been delivered
Uterus is in tact

Inspect cervix and vagina for trauma/lacerations

Work Up & Management

If uterus is boggy, suspect atony
Continue massage
Uterotonics: increase uterine
contractions to decrease bleeding
Oxytocin/Pitocin
Rapid, dilute infusion; not as bolus
Methylergometrine/Methergine
Vasoconstrictive: C/I in hypertension
Prostaglandin

F2a/Carboprost/Hemabate
Bronchoconstrictive: C/I in Asthma

Prostaglandin E1/Misoprostol/Cytotec

Uterine artery embolization

B Lynch Suture
Hysterectectomy

Work Up & Management

If bleeding continues to persist, consider coagulopathy
Uterine packing
FFP/cyroprecipitate
Investigate cause and treat
Avoid hysterectomy

Question 1
A 19-year-old G1 woman presents in labor at term. Her
prenatal course was uncomplicated. She delivers a 3500
gram infant spontaneously after oxytocin augmentation of
labor. Postpartum, she experiences excessive bleeding.
Which of the following defines postpartum hemorrhage in
this patient?
A. Greater than 500 cc
B. Greater than 750 cc
C. Greater than 1000 cc
D. Greater than 1500 cc
E. Any amount of bleeding that leads to hypovolemia

Question 2
A 28-year-old G3P3 woman experiences profuse vaginal
bleeding of 700 cc in one hour following an uncomplicated
spontaneous vaginal delivery of a 4150 gram infant. The
placenta delivered spontaneously without difficulty. Prior
obstetric history is notable for a previous low transverse
cesarean section. The patient had no antenatal complications.
Which of the following is the most likely cause of this patients
hemorrhage?
A. Vaginal or cervical lacerations
B. Uterine inversion
C. Uterine atony
D. Uterine dehiscence
E. Uterine rupture

Question 3
A 37-year-old G2P1 woman with poorly controlled chronic
hypertension presents in labor at term. Her prenatal course was
uncomplicated. She delivers a 3500 gram infant spontaneously
after oxytocin augmentation of labor. Immediately postpartum,
she experiences excessive bleeding. Her blood pressure is
130/90; pulse 84; and she is afebrile. On examination, uterine
fundus is firm and the placenta is intact. Which of the following
is the most appropriate next step in management?
A. Exploration for lacerations
B. Methylergonovine
C. B Lynch suture
D. IV push of oxytocin
E. Uterine artery embolization

Question 4
A 36-year-old G1 woman presents in active labor. Her past medical
history and prenatal course were complicated by chronic
hypertension and superimposed preeclampsia. She received
magnesium sulfate for seizure prophylaxis and oxytocin
augmentation. She undergoes an uneventful spontaneous vaginal
delivery. Postpartum, she has a 1000 ml hemorrhage due to uterine
atony. Her blood pressure is 130/80; pulse 96; and she is afebrile.
Which of the following uterotonic agents is contraindicated in this
patient?
A. Oxytocin
B. Methylergonovine
C. Prostaglandin F2-alpha
D. Prostaglandin E2
E. Misoprostol

References
http://www.who.int/mediacentre/factsheets/fs348/en /
http://www.uptodate.com/contents/overview-of-postpartum

hemorrhage
http://emedicine.medscape.com/article/275038-overview
http://resources.ama.uk.com/glowm_www/graphics/figures/v1/0
730/pph_5.jpg
Lutomski
J, Byrne B, Devane D, Greene R. Increasing trends in atonic p
ostpartum haemorrhage in Ireland: an 11-year population-based
cohort study. BJOG. Feb 2012;119(3):306-14
Dildy
GA 3rd. Postpartum hemorrhage: new management options. Cli
n Obstet Gynecol 2002; 45:330.
Combs CA, Murphy EL, Laros RK Jr. Factors associated with po
stpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;