Primary PPH

Aetiology

The commonest cause of PPH is uterine atony (failure of the uterus to contract effectively).
Other common causes are:

Retained placenta or fragments of placenta

Vulvar or vaginal lacerations or haematoma

Atony and retained placenta are 80% of all cases, lacerations comprise the bulk of the other 20%.
Cervical lacerations, uterine rupture, broad ligament haematoma and extra genital bleeding also need to be excluded.

Epidemiology

Most studies quote an incidence of around 5%,⁹⁸⁰¹ but a figure of 12% of vaginal deliveries was recorded in one Australian tertiary referral hospital.⁰⁵⁰¹

Risk factors

The most frequent cause of PPH is uterine atony, a condition in which the uterine corpus does not constrict properly, allowing continued blood loss from the placental site. Risk factors for atony include the following:

Overdistended uterus (eg, multiple gestation, fetal macrosomia, hydramnios)

Fatigued uterus (eg, augmented or prolonged labor, amnionitis)

Obstructed uterus (eg, retained placenta or fetal parts, placenta accreta)

 

Factors relating to the pregnancy:

Antepartum haemorrhage in this pregnancy

Placenta praevia (15x risk)

Multiple pregnancy (5x risk)

Pre-eclampsia or pregnancy induced hypertension (4x risk)

Nulliparity (3x risk)

Previous PPH (3x risk)

Asian ethnic origin (2x risk)

Maternal obesity (2x risk)

 

• Factors relating to delivery:

  Emergency Caesarean section (9x risk)⁰⁵⁰²

  Elective CS (4x risk) - especially if >3 repeat procedures⁰⁶⁰¹

  Retained placenta (5x risk)

  Mediolateral episiotomy (5x risk)

  Operative vaginal delivery (2x risk)

  Labour of >12 hours (2x risk)

  >4kg baby (2x risk)

  Maternal pyrexia in labour (2x risk)

  Uterine inversion may be associated with hemorrhage of approximately 2 L. No definitive study findings have demonstrated the relationship between traction on the umbilical cord and uterine inversion, although many clinicians indicate that a correlation may exist.

  Uterine rupture may be associated with little vaginal bleeding, but it should be considered in the presence of severe abdominal pain and unstable hemodynamic findings.

   

• Pre-existing maternal haemorrhagic conditions:

  Factor 8 deficiency - Haemophilia A carrier

  Factor 9 deficiency - Haemophilia B carrier

  Von Willebrands disease

Presentation

Symptoms: Continuous bleeding, which fails to stop after delivery of placenta - third stage

Signs: Loss of >1000ml may be accompanied by clinically apparent shock i.e. tachycardia, hypotension

Investigations

Thorough examination of the lower genital tract. This may require theatre/anaesthesia.

FBC, Clotting screen, Cross match

Hourly urine output

Continuous pulse/BP or CVP monitoring

ECG, pulse oximetry

Associated diseases

HELLP (Haemolysis, Elevated Liver enzymes and Low platelets)

Management

In a woman with excessive postpartum bleeding, simultaneously perform the physical examination and resuscitation. Focus the examination on determining the cause of the bleeding. The patient may not have the typical hemodynamic changes of shock early in the course of the haemorrhage due to physiologic maternal hypervolemia. Occult PPH always is an important consideration when unstable haemodynamic findings are present without evidence of excessive blood loss.

Bimanual palpation of the uterus may reveal bogginess, atony, or uterine enlargement, with a large amount of accumulated blood. Palpation may also reveal hematomas in the perineum or pelvis.

During suctioning, careful visual inspection of the cervix and vagina under good light may reveal the presence and extent of lacerations.

Examine the placenta for missing portions, which suggest the possibility of retained placental tissue.

Check for oozing from skin puncture sites or intravenous sites in patients with excessive bleeding as this could indicate a coagulopathy.

 

Non-drug

Ideally one of the emergency drills to be practised by the team on labour ward.

Calling and alerting expert assistance. If the perceived blood loss is 500-1000ml and there are no signs of clinical shock, basic measures, (cross match 2 units, FBC, Clotting screen, IV access and monitoring clinical observations ) should suffice.

However loss of greater than 1000mls or any signs of shock should lead to full alert of the clinical team.

Experienced midwife, obstetric registrar, (alert consultant), anaesthetic registrar (alert consultant), alert haematologist, alert transfusion service, call porters for transport of specimens and blood products.

Nurse patient with head down tilt.

Drugs

Oxygen should be given by mask at 8 litres per minute.

Transfuse cross matched blood (6 units initially) a.s.a.p.

Until then infuse crystalloid or colloid as required.

If 3.5 litres given and no blood available, give O NEG, or uncross matched blood of own blood group.

Use a warming device and a pressure cuff.

Do not use a blood filter.

Do not use dextrans.

Give up to 1 litre of FFP and 10 units of cryoprecipitate if clinically indicated.

There is evidence that nitroglycerine may help with retained placenta.⁰⁸⁰¹

A new haemostatic agent- recombinant Factor VII a - has had some clinical success, but its efficacy and safety is untested in clinical trials as yet.

Surgical

Secure IV access with 2 x14 gauge cannulae.

Stop the bleeding.

Exclude other causes than atony.

Ensure bladder empty and bi-manually compress the uterus and rub up a contraction.

Give IV syntocinon 10 units or IV ergometrine 500 mcg.

Commence syntocinon infusion 30 units in 500ml.

IM Carboprost 500mcg.

Resort to surgery early. At laparotomy inject carboprost directly into the myometrium.

Bilateral ligation of the uterine arteries or bilateral ligation of the internal iliac (hypogastric) arteries.

An alternative to ligation is embolisation with gelatine sponge.⁹⁸⁰² One case of amenorrhoea has been reported following this, secondary to necrosis of the uterine wall and obliteration of the cavity.⁰⁶⁰²

Uterine Bracing suture, (the B-Lynch suture⁹⁷⁰¹) to anterior and posterior uterine walls has been shown to be effective and safe,^{0503, 0701} with reports of successful pregnancy following its use.^0504,0603

Hysterectomy should be considered early, especially in cases of placenta accreta or uterine rupture.

For each woman who dies in the UK following peripartum hysterectomy, more than 150 survive. The most commonly reported causes of haemorrhage were uterine atony (53%) and morbidly adherent placenta (39%). Women were not universally managed with uterotonic therapies. Fifty women were unsuccessfully managed with B-Lynch or other brace suture prior to hysterectomy, 28 with activated factor VII and 9 with arterial embolisation. ⁰⁷⁰²

Complications

Shock

Collapse

Disseminated Intravascular Coagulation

Prognosis

The Confidential Enquiry into Maternal Deaths for 2000-2002 reported 17 deaths related to obstetric haemorrhage in that triennium. This gives a rate of 8.5 per million.

Prevention

The Active Management of the Third stage of Labour; prophylactic oxytocics should be routinely used in the third stage of labour as they decrease the risk of PPH by 60%.⁹⁶⁰¹ For most women syntometrine ( ergometrine 0.5mg with 5i.u oxytocin) is the drug of choice. Oxytocin alone (10i.u) is preferred by some clinicians in women with hypertension.

Secondary PPH

This commonly presents in primary care as prolonged or excessive bleeding once the woman has returned home after delivery.

Aetiology

The two commonest causes are:

Infection- endometritis. Occurs in 1-3% after spontaneous vaginal delivery. It is the most common cause of postnatal morbidity between day 2 and day 10.

Retained products of conception (RPOC)

Endometritis risk factors

Caesarean section, prolonged rupture of membranes, severe meconium staining in liquor,¹⁵ long labour with multiple examinations, manual removal of placenta,¹⁶ mothers age at extremes of reproductive span, low socio-economic status, maternal anaemia, prolonged surgery, internal fetal monitoring and general anaesthetic.

Assessment

History: As above, also extended labour, difficult 3rd stage, ragged placenta, primary PPH.
Examination: Systemic illness, fever, rigors, tachycardia, tissue visible within loss. Suprapubic area may be tender, with elevated fundus that feels boggy in RPOC.

Investigation

FBC

Blood cultures are positive in 10-30%

Check MSU

High vaginal swab, also gonorrhoea/chlamydia

Ultrasound; may be used if RPOC suspected, although there may be difficulty distinguishing between clot and products. RPOC are unlikely if a normal endometrial stripe is seen.

Management

Speculum examination will allow visualisation of cervix and lower genital tract to exclude lacerations. If clot is visible within the cervical os, it may be removed with tissue forceps (though few GP regularly carry these), allowing the cervix to close.

If infection suspected, combinations of broad spectrum e.g. amoxicillin, gentamicin and metronidazole, can be given.⁰³⁰¹ Patient may need to be referred if too unwell to tolerate oral medication; IV clindamycin and gentamicin tds until afebrile for greater than 24 hours.⁰⁴⁰¹ Oral follow up treatment is not required. Use doxycyline if chlamydia is suspected.

If retained products of conception are suspected elective curettage with antibiotic cover may be required.

Patient may require iron supplementation if Hb has fallen. Warn of the risk of constipation.

Prognosis

90% of cases treated with antibiotics improve within 48-72 hours. If this is not the case, the patient should be re-evaluated.