Which of the following clients is at highest risk of postpartum hemorrhage?
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Defining postpartum hemorrhage (PPH) has historically been difficult. Waiting for a patient to meet PPH criteria, particularly in resource-poor settings or in cases of sudden hemorrhage, may delay appropriate intervention. Any bleeding that has the potential to result in hemodynamic instability, if left untreated, should be considered PPH and managed accordingly. PPH can be divided into 2 types: early (< 24 hours after delivery) and late (24 hours to 6 weeks after delivery). Most cases of PPH (>99%) are early. Show Signs and symptomsThe clinical history should begin with consideration of signs and symptoms that are most crucial in managing potential circulatory collapse, identifying the cause of PPH, and selecting therapies, as follows. Severity of bleeding:
Intervention guides:
Predisposing factors and potential etiology:
Past surgical history The physical examination should focus on determining the cause of the bleeding. Important organ systems to assess include the following:
Specifically, examination should include the following:
See Presentation for more detail. DiagnosisLaboratory studies that may be helpful include the following:
Imaging studies to be considered include the following:
See Workup for more detail. ManagementPrehospital care includes the following:
Emergency department care includes the following:
Immediate consultation with an OB/GYN is vital. If no OB/GYN is available, a general surgeon should be consulted. Direct contact with the blood bank is essential for assuring timely arrival of any blood products ordered. See Treatment and Medication for more detail.  Next: BackgroundDefining postpartum hemorrhage (PPH) is problematic and has been historically difficult. Waiting for a patient to meet the postpartum hemorrhage criteria, particularly in resource-poor settings or with sudden hemorrhage, may delay appropriate intervention. Postpartum hemorrhage is traditionally defined as blood loss greater than 500 mL during a vaginal delivery or greater than 1,000 mL with a cesarean delivery. However, significant blood loss can be well tolerated by most young healthy females, and an uncomplicated delivery often results in blood loss of more than 500 mL without any compromise of the mother's condition. The addition of "a 10% drop in hemoglobin" to the definition provides an objective laboratory measure. However, this is not helpful in acute situations since it can take hours for losses to create laboratory changes in red blood cell measurements. Signs and symptoms of hypovolemia (lightheadedness, tachycardia, syncope, fatigue and oliguria) are also of limited utility as they can be late findings in a young and otherwise healthy female. As a result, any bleeding that has the potential to result in hemodynamic instability, if left untreated, should be considered postpartum hemorrhage and managed accordingly. Postpartum hemorrhage can be divided into 2 types: early postpartum hemorrhage, which occurs within 24 hours of delivery, and late postpartum hemorrhage, which occurs 24 hours to 6 weeks after delivery. Most cases of postpartum hemorrhage, greater than 99%, are early postpartum hemorrhage. Notably, most women are still under the care of their delivering provider during this time. With many women delivering outside of hospitals and early postpartum hospital discharge being a growing trend, postpartum hemorrhage that presents to the emergency department may be either early or late. Within this combined population, emergency medicine providers are likely to receive patients that fall into 1 of 3 categories:
Previous Next: PathophysiologyAt term, the uterus and placenta receive 500-800 mL of blood per minute through their low resistance network of vessels. This high flow predisposes a gravid uterus to significant bleeding if not well physiologically or medically controlled. By the third trimester, maternal blood volume increases by 50%, which increases the body's tolerance of blood loss during delivery. Following delivery of the fetus, the gravid uterus is able to contract down significantly given the reduction in volume. This allows the placenta to separate from the uterine interface, exposing maternal blood vessels that interface with the placental surface. After separation and delivery of the placenta, the uterus initiates a process of contraction and retraction, shortening its fiber and kinking the supplying blood vessels, like physiologic sutures or "living ligatures." If the uterus fails to contract, or the placenta fails to separate or deliver, then significant hemorrhage may ensue. Uterine atony, or diminished myometrial contractility, accounts for 80% of postpartum hemorrhage. The other major causes include abnormal placental attachment or retained placental tissue, laceration of tissues or blood vessels in the pelvis and genital tract, and maternal coagulopathies. An additional, though uncommon, cause is inversion of the uterus during placental delivery. The traditional pneumonic "4Ts: tone, tissue, trauma, and thrombosis" can be used to remember the potential causes. Here, a 5th is added; “T” for uterine inversion that will be called “traction.” Previous Next: FrequencyThe incidence of postpartum hemorrhage is about 1 in 5 pregnancies, but this figure varies widely due to differential definitions for postpartum hemorrhage. Previous Next: PrognosisThe prognosis depends on the cause of the PPH, its duration, the amount of blood loss, comorbid conditions, and the effectiveness of treatment. Prompt diagnosis and treatment are essential to achieving the best outcome for any given patient. Most reproductive-age women will do well if managed promptly in a setting with operative and blood-product resources available. Consequences include the sequelae of hemorrhage; aggressive fluid resuscitation; blood-product exposure; and procedures done to control uterine, cervical, vaginal, or peritoneal hemorrhage. MortalityAlthough accountable for only 8% of maternal deaths in developed countries, postpartum hemorrhage is the second leading single cause of maternal mortality, ranking behind preeclampsia/eclampsia. [1] Globally, postpartum hemorrhage is the leading cause of maternal mortality. The condition is responsible for 25% of delivery-associated deaths, [2] and this figure is as high as 60% in some countries. International initiatives to improve outcomes have invested in training birth attendants (traditional or otherwise) and nurse midwives on the active management of the third stage of labor (the period immediately after delivering of the infant). Most efforts focus on uterine atony, which is the primary cause of postpartum hemorrhage. This has included education on manual techniques to increase uterine contraction-retraction and making pharmacologic uterotonic agents (oxytocin and misoprostol) more available. [3, 4, 5] MorbidityPostpartum hemorrhage is a potentially life-threatening complication of both vaginal and cesarean delivery. Associated morbidity is related to the direct consequences of blood loss as well as the potential complications of hemostatic and resuscitative interventions. Consequences of uncontrolled hemorrhage Hypovolemic shock and associated organ failure including renal failure, stroke, myocardial infarction may occur. Postpartum hypopituitarism (Sheehan syndrome) may occur. Acute blood loss and/or hypovolemic shock during and after childbirth can lead to hypoperfusion of the pituitary and subsequent necrosis. Although often asymptomatic, it may present with an inability to breastfeed, fatigue, hypogonadism, amenorrhea, and hypotension. Death secondary to hypovolemic shock may occur. Consequences of fluid resuscitation Fluid overload can lead to extremity edema and pulmonary edema. The latter is less common in young healthy women, but it should be suspected in the setting of large fluid and blood product resuscitation. Dilutional coagulopathy occurs when crystalloids and/or serum-poor blood products are given in large volume. Risks from exposure to blood products The following may develop as a result of exposure of blood products:
Risks associated with surgical intervention The following may result following surgical intervention:
Need for permanent sterilization to control bleeding If the bleeding cannot be controlled conservatively (removal of products of conception, suturing disrupted tissues, application of pressure) then surgical intervention may be necessary. In severe cases, the following may occur:
Previous Next: Patient EducationPostpartum hemorrhage can be a frightening experience for patients. It is important to provide reassurance and communicate through each step of emergency care. Make patients aware of what to anticipate through their clinical course including expected procedures; transport; and the indication, risks, and benefits of interventions. Previous Clinical Presentation
References
Media Gallery of 0 Tables Back to List Contributor Information and Disclosures Author Maame Yaa A B Yiadom, MD, MPH Staff Physician, Department of Emergency Medicine, Cooper University Hospital, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School Coauthor(s) Daniela Carusi, MD, MSc Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director, Department of General Ambulatory Gynecology, Brigham and Women's Hospital Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Mark L Zwanger, MD, MBA, FACEP Emergency Medicine Physician Chief Editor Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE Chief, Department of Emergency Medicine, Sentara Norfolk General Hospital; Medical Ditector, Sentara Transfer Center; Professor and Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School; Board Member, American Academy of Emergency Medicine Additional Contributors Assaad J Sayah, MD, FACEP President and Chief Executive Officer, Cambridge Health Alliance Acknowledgements Special thanks to Dr. Donnie Bell for his assistance with the "Imaging" section for this topic. The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author, Michael P Wainscott, MD, to the development and writing of this article. What increases the risk for postpartum hemorrhage?The No. 1 risk factor for PPH is atony — or atypical uterine contraction post-placental delivery. Overdistension of uterine muscle. This factor occurs most commonly after twin or large-infant delivery.
What is the commonest cause of post partum hemorrhage?Most important and major finding in our study was that the most common cause of Post partum hemorrhage was uterine atony, which is loss of tone in the uterine musculature. Normally, contraction of the uterine muscle compresses the vessels and reduces flow.
Who is at risk for postpartum complications?Risk factors for postpartum complications
But women with chronic conditions such as cardiac disease, obesity or high blood pressure are at greater risk of dying or nearly dying from pregnancy-related complications. If you have these risk factors, monitoring your postpartum health is particularly important.
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