Postpartum Hemorrhage
Cumulative blood loss >=1000 mL or bleeding with signs of hypovolemia within 24 h of delivery.
Also known as: PPH, postpartum hemorrhage, uterine atony, obstetric hemorrhage
Overview
ACOG (2017): cumulative blood loss of >=1000 mL OR blood loss accompanied by signs/symptoms of hypovolemia within 24 hours after the birth process, regardless of delivery route. Primary PPH occurs within 24 h; secondary (late) PPH between 24 h and 12 weeks postpartum.
Epidemiology
Complicates ~4% of vaginal and ~6% of cesarean deliveries. Leading cause of maternal mortality worldwide; major contributor to severe maternal morbidity in the US.
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Risk factors
- Uterine atony: prolonged or augmented labor, chorioamnionitis, multiple gestation, polyhydramnios, fetal macrosomia, grand multiparity, magnesium sulfate, halogenated anesthetics
- Trauma: operative vaginal delivery, precipitous labor, episiotomy, large fetus, cesarean
- Retained placenta, placenta accreta spectrum (prior cesarean, placenta previa)
- Coagulopathy: HELLP, AFLP, DIC (abruption, IUFD, amniotic fluid embolism), anticoagulation, inherited bleeding disorders, ITP
- Uterine inversion (excessive cord traction with fundal placenta)
Pathophysiology
Normal hemostasis after delivery depends on rapid uterine contraction compressing the spiral arteries. Failure of any of the '4 Ts' — Tone (atony), Trauma (laceration/rupture), Tissue (retained products, accreta), Thrombin (coagulopathy) — produces hemorrhage. Atony accounts for ~80% of cases.
Clinical presentation
Symptoms
- Heavy vaginal bleeding immediately or shortly after delivery
- Lightheadedness, weakness, syncope
- Lower abdominal pain (rupture, inversion)
Signs / physical exam
- Tachycardia and hypotension (often late, particularly in young women with high cardiac reserve)
- Boggy uterus = atony; firm uterus with bleeding = laceration
- Cool, clammy skin; pallor; oliguria
Differential diagnosis
- Uterine atony — Soft, boggy uterus above the umbilicus; bleeding heavy and continuous; responds to bimanual massage
- Genital tract laceration — Firm, well-contracted uterus with continued bright red bleeding; visualize on speculum exam
- Retained placenta or fragments — Incomplete placenta on inspection; ultrasound shows echogenic material in cavity
- Placenta accreta/increta/percreta — Failure of placental separation; risk with prior cesarean and placenta previa
- Uterine inversion — Sudden hemorrhage with severe lower abdominal pain after cord traction; non-palpable fundus, mass in vagina
- Uterine rupture — Severe pain, loss of fetal station, hemodynamic collapse; classically with prior cesarean and induction
- Coagulopathy / DIC — Diffuse oozing from puncture sites, hematuria, abnormal labs (low fibrinogen, low platelets, prolonged PT/PTT)
Diagnostic workup
Diagnostic criteria
Clinical: cumulative blood loss >=1000 mL or signs of hypovolemia after delivery. Quantitative blood loss (QBL) is preferred over visual estimation.
Labs
- Type and crossmatch; CBC, fibrinogen, PT/PTT, INR
- ABG/lactate, BMP, ionized calcium
- Activate massive transfusion protocol early when ongoing brisk bleeding
Imaging
- Bedside ultrasound: retained products (echogenic material in cavity)
- Inspection of placenta for completeness; examination under anesthesia if needed
Diagnostic algorithm
| The 4 Ts | Cause | Approximate Frequency |
|---|---|---|
| Tone | Uterine atony | 70-80% |
| Trauma | Lacerations, rupture, inversion | 15-20% |
| Tissue | Retained placenta, accreta | 5-10% |
| Thrombin | Coagulopathy (DIC, inherited, anticoagulation) | 1-2% |
Treatment
First-line
- Call for help; large-bore IV access x 2; crystalloid resuscitation; activate massive transfusion protocol with balanced ratio (e.g., 1:1:1 PRBC:FFP:platelets) for severe hemorrhage
- Identify cause using '4 Ts': Tone, Trauma, Tissue, Thrombin
- Bimanual uterine massage and compression
- Uterotonics in stepwise fashion:
- - Oxytocin 10-40 units in 500-1000 mL IV (first-line; routinely given prophylactically)
- - Methylergonovine 0.2 mg IM every 2-4 h (contraindicated in hypertension/preeclampsia)
- - Carboprost (15-methyl PGF2-alpha, Hemabate) 0.25 mg IM every 15-90 min (contraindicated in asthma)
- - Misoprostol 600-1000 mcg sublingual, oral, or rectal
- Tranexamic acid 1 g IV (within 3 h of birth) reduces death from bleeding (WOMAN trial); can repeat once after 30 min if bleeding continues
- Repair lacerations; explore uterine cavity and manually remove retained products if present
- Uterine tamponade: Bakri balloon, gauze packing, or vacuum-induced uterine tamponade (Jada)
Refractory bleeding — escalation
- Uterine artery embolization (if hemodynamically stable and IR available)
- Surgical: B-Lynch suture, uterine artery (O'Leary) and utero-ovarian ligation, hypogastric (internal iliac) ligation
- Hysterectomy — definitive treatment; do not delay in unstable patients or with accreta spectrum
Uterine inversion
- Halt uterotonics, manually replace uterus, then restart uterotonics; tocolytic (terbutaline, nitroglycerin, or general anesthesia) to relax uterus may be needed
Second-line / adjunct
- Recombinant factor VIIa is rarely used for refractory coagulopathic hemorrhage after correction of underlying deficits
- Cell saver use is acceptable in obstetric hemorrhage when appropriate
Complications
- Hemorrhagic shock, DIC, AKI, ARDS
- Sheehan syndrome (pituitary infarction from postpartum hypotension) — failed lactation, amenorrhea, secondary adrenal insufficiency
- Transfusion-related complications (TRALI, TACO, allergic reactions)
- Postpartum venous thromboembolism (rebound thrombosis), Asherman syndrome (from aggressive curettage), hysterectomy with loss of fertility
- Maternal death
PANCE pearls
- Active management of the third stage of labor (prophylactic oxytocin, controlled cord traction, uterine massage) reduces PPH by ~60% and is standard of care.
- Tranexamic acid (TXA) should be given within 3 hours of birth for established PPH; the WOMAN trial showed reduced death from bleeding without increased thromboembolism.
- Methylergonovine is contraindicated in HTN/preeclampsia (severe hypertensive crisis); carboprost is contraindicated in asthma (bronchospasm).
- Sheehan syndrome should be considered in any postpartum woman with hypotension followed by failure to lactate, fatigue, or amenorrhea.
- Placenta accreta should be anticipated in patients with prior cesarean and current placenta previa — plan for cesarean hysterectomy at a tertiary center.
References
- ACOG PB 183 — ACOG Practice Bulletin 183: Postpartum Hemorrhage (Obstet Gynecol 2017)
- WOMAN Trial — WOMAN Trial Collaborators, Lancet 2017 — tranexamic acid for postpartum hemorrhage
- CMQCC — California Maternal Quality Care Collaborative OB Hemorrhage Toolkit V3.0
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