Primary Postpartum Hemorrhage




By Dr. Jennifer Markowitz


28-year-old Courtney is pregnant for the first time. She is excited to welcome twin daughters, and relieved that thus far her pregnancy has been uneventful. A week after her due date, Courtney goes into labor. 25 hours later both girls are finally delivered. But Courtney senses that something is wrong. She feels dizzy. Her doctor tells her that she is bleeding more than expected. Courtney’s doctor explains that her uterus is not contracting like it should. The doctor massages Courtney’s uterus to try to get it to contract. Courtney is also given an IV infusion of a medication called oxytocin to promote uterine contraction. Soon her uterus responds and the bleeding stops. With additional IV fluids, she begins to feel better. 


What is Postpartum Hemorrhage?


According to the American College of Obstetrics and Gynecology (ACOG), postpartum hemorrhage is defined as 1,000 mL total blood loss or blood loss accompanied by symptoms and signs of low blood volume within 24 hours after delivery of a fetus, or after fetal loss. (1) ACOG defines primary postpartum hemorrhage as occurring any time from before the placenta is delivered until 24 hours after the fetus is delivered. (1) Late or secondary postpartum hemorrhage, on the other hand, is defined as occurring between 24 hours and 6 weeks after delivery. (2) It is estimated that primary postpartum hemorrhage affects 3% to 5% of women delivering babies. (6) Although it is rare, it can have serious complications, resulting in 12% of maternal deaths in the United States and 25% of maternal deaths worldwide. (6) Nevertheless, postpartum hemorrhage is often preventable. (6) Awareness of the signs and symptoms can help. (6) Women can also talk to their healthcare providers early on about the information in this article. 


What are the Signs and Symptoms of Postpartum Hemorrhage?


Depending on the amount of blood loss, women with postpartum hemorrhage may not have any signs or symptoms. (6) If bleeding is severe enough to cause low blood volume, women may experience symptoms such as: (6)


- Dizziness upon standing

- Nausea

- Shortness of breath

- Chest pain

- One of the earliest signs may be a fast heart rate. (6)


Other signs include: (6)

-Low blood pressure 

-Decreased urine output 


What are Risk Factors for Postpartum Hemorrhage?

While 20% of women who have postpartum hemorrhage don’t have any risk factors, it is more commonly seen in certain situations: (6)


-Antepartum hemorrhage, or hemorrhage prior to delivery (6)

-Past history or family history of postpartum hemorrhage (2)

-Maternal anemia (6)

-Maternal obesity (6)

-Preeclampsia, or high blood pressure during pregnancy (6)

-Abnormal location of the placenta (2)

-Placental abruption, when the placenta separates from the uterus too early during childbirth (3)

-Sickle cell anemia (2)

-Gestational diabetes (2)

-Disorders of blood clotting (2)

-Asian or Hispanic ethnicity (2)

-Primiparity, or first-time pregnancy (6)

-Multifetal gestation, or pregnancy with multiple fetuses (6)

-More than 5 past deliveries of living babies (7)

-Fetal macrosomia, or abnormally large fetus (6)

-Relaxant anesthetics (7)

-Polyhydramnios or excessive amniotic fluid (6)

-Prolonged labor (6)

-Rapid labor (7)

-Augmented labor, or labor that is assisted with medication (7)

Chorioamnionitis, or infection of the placenta, the membranes within it, and/or the amniotic fluid (4)

-Uterine fibroids (7)


What Causes Postpartum Hemorrhage?


The causes of postpartum hemorrhage can be remembered using a mnemonic device called the Four T’s. (3)


These are Tone, Trauma, Tissue, and Thrombin. (6)


Tone: This refers to uterine atony, or lack of muscle tone in the uterus, which prevents the uterus from contracting normally. (6) Uterine atony is the most common cause of postpartum hemorrhage, occurring in 70-80% of cases. (1) Any risk factor that causes overdistention of the uterus (for example pregnancy with multiple fetuses) can put a woman at risk of uterine atony. (7)


Trauma: Trauma refers to a variety of causes including tears or lacerations occurring as part of the birth process or due to episiotomy, and blood collections known as hematomas. (6,7) Rarely the uterus can invert (turn inside out), leading to bleeding. (6) Another rare complication is rupture of the uterus, which is more common after caesarean delivery. (6) 

Tissue: Parts of the placenta may be abnormally retained within the uterus, keeping it from contracting normally. (6) If the placenta has invaded the uterus (known as placenta accreta) the risk of hemorrhage is also increased. (6)


Thrombin: Some women may have problems with blood clotting, which can either be the result or cause of hemorrhage. (6) Some women are born with abnormal blood clotting and doctors are able to determine this based on lab tests. (6)


Another important cause of postpartum hemorrhage is chorioamnionitis, or infection of the placenta, the membranes within it, and/or the amniotic fluid. (3)





What are the Complications of Postpartum Hemorrhage?


Postpartum hemorrhage can lead to a variety of complications. These may include: (6)

-Fatigue 

-Low blood pressure upon standing 

-Anemia (low red blood cell count)

-A form of abnormal blood clotting called dilutional coagulopathy

-A form of abnormal blood clotting called dilutional -coagulopathy

-Decreased blood flow to the heart muscle

-Decreased blood flow to the pituitary gland, located at the base of the brain, which can result in an inability to make the hormone oxytocin, which is necessary for lactation (breast feeding)

-Postpartum depression, which appears to be associated with maternal anemia and having a negative delivery experience; mothers who have a depressed mood while pregnant and/or stressors after delivery are also at risk (2)

-Death (4)


How can Postpartum Hemorrhage be Prevented?


Postpartum hemorrhage is often preventable, so discuss it with your doctor in advance. (6) Avoiding routine episiotomy can reduce the risk of bleeding from a laceration. (6) Avoiding delivery with forceps can reduce the risk of bleeding from trauma. (6) A major part of preventive treatment is active management of the third stage of labor. (6) This involves several steps. (6) One is administering the IV medication oxytocin, or Pitocin, during or right after the baby’s first shoulder is delivered. (6) Next is providing controlled traction on the umbilical cord while delivering the placenta (called the Brandt-Andrews maneuver). (6) Once the placenta has been delivered, the uterus is massaged to help it contract. (6) Oxytocin can also be given after placental delivery. (6) A different drug called misoprostol (Cytotec) has been studied as an alternative to oxytocin. (6) It is less expensive and does not have to be given via IV. (6) But, it appears to be less effective, and is associated with more side effects, such as nausea, diarrhea, and fever. (6)


What is the Treatment for Postpartum Hemorrhage?


Treatment of postpartum hemorrhage begins with determining the cause. Using the Four T’s mnemonic:


Tone, or uterine atony: IV oxytocin is administered to promote contraction of the uterus, along with IV normal saline to increase blood volume. (7) Depending on the woman’s response to this, additional medications may be given. (6, 7) The drug carboprost (Hemabate), a type of prostaglandin, can be injected into a muscle of the body or, during a caesarean section, injected directly into the muscle of the uterus in order to promote contraction. (6) Other medications to promote contraction include methylergonovine (Methergine), which is injected into a muscle of the body, and misoprostol (Cytotec), which is given rectally, under the tongue, or orally. (6) Importantly, carboprost should not be given to women with asthma and methylergonovine should not be given to women with high blood pressure. (7)


Trauma: Lacerations are sutured (sewn up), blood clots drained, and if the uterus is inverted it is placed back in its normal position. (6)


Tissue: The placenta is inspected to see if any portions are missing and potentially retained within the uterus; any retained parts of the placenta are manually removed from the uterus; a technique called curettage involving an instrument may be used to help remove the pieces of placenta. (6)


Thrombin: Blood is checked for clotting and lab tests are obtained; if needed blood clotting proteins, platelets, and fresh frozen plasma, which contains clotting proteins, are administered. (6)


When postpartum hemorrhage is severe, blood transfusion may be needed. (6) In the most severe cases a massive transfusion protocol may be needed, in which clotting proteins are given along with blood. (6) This is because with massive blood loss, blood clotting proteins are also lost. (6)

Various approaches can be used to stop the bleeding in these cases. (6) Gauze sponges or balloons may be used to pack the uterus and provide pressure to stop bleeding. (6, 7) In some cases tying off the uterine arteries, or doing a procedure to block off the vessels from within (known as embolization) may stop the bleeding. (6) Compression sutures, in which sutures are tied between the bottom and the top of the uterus to contract it, are also sometimes used. (6)  In the most severe cases hysterectomy may be required in order to save a woman’s life. (6)


The Takeaway:


Postpartum hemorrhage is a rare and potentially serious condition, however it is often preventable. With a team approach healthcare providers are now able to offer numerous approaches to treatment, with the goal of preserving a woman’s life and her future ability to bear children.



References:

1. American College of Obstetricians and Gynecologists. “Postpartum hemorrhage. ACOG practice bulletin No. 183.” Obstet Gynecol. October 2017; 130(4): e168-e186


2. Buettel L. “Secondary postpartum hemorrhage: risk factors, assessment, and intervention.” Am Nurse Today. July 2016; 11(7): 1. 


3. Cleveland Clinic. “Placental Abruption.” Dec 2014. https://my.clevelandclinic.org/health/diseases/9435-placental-abruption


4. Dulay AT. Merck Manual Professional Version. “Chorioamnionitis.” June 2019. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/intra-amniotic-infection


5. Eckerdal P, Kollia N, Lofblad J, et al. “Delineating the association between heavy postpartum hemorrhage and postpartum depression.” PLoS ONE. January 2016. 11(1): e0144274.


6. Evensen A, Anderson J.M., and Fontaine P. “Postpartum hemorrhage: prevention and treatment.” Am Fam Physician. April 2017; 95(7):442-449.


7. Moldenhauer J.S. Merck Manual Professional Version. “Postpartum hemorrhage.” June 2018.  https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-and-complications-of-labor-and-delivery/postpartum-hemorrhage

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