Postpartum Hemorrhage Management

PPH Definition & Scope - Defining the Bleed

• PPH: Excessive bleeding after childbirth.
• Blood loss criteria:
  • Vaginal delivery: >500ml
  • Cesarean section: >1000ml
  • Any amount causing hemodynamic instability or a ≥10% drop in hematocrit.
• Types by onset:
  • Primary (Early): Within 24 hours postpartum (most common).
  • Secondary (Late): From >24 hours up to 12 weeks postpartum.

⭐ PPH is a leading cause of maternal mortality, particularly in low-resource settings.

• Clinical signs (e.g., tachycardia, hypotension) may appear before measured loss hits thresholds, especially with concealed hemorrhage.

PPH Etiology - The Four Culprits

📌 4Ts: Tone, Trauma, Tissue, Thrombin

⭐ Uterine atony is the single most common cause of PPH, responsible for approximately 70-80% of cases.

PPH Management - Flood Control Protocol

⭐ Active Management of Third Stage of Labor (AMTSL) significantly reduces PPH incidence by over 60%.

📌 Initial Response: "HELP"

• Help: Call multidisciplinary team (Obstetrician, Anesthetist, Blood Bank).
• Ensure IV access (2 large-bore), send bloods (X-match, FBC, Coags).
• Lay flat, O2, catheterize bladder.
• Palpate uterus: Fundal massage. Identify cause (4 T's: Tone, Trauma, Tissue, Thrombin).

Stepwise Management Algorithm:

Key Interventions:

• Uterotonics (Sequence may vary):
  • Oxytocin: 10-40 IU in $500\text{ml}$ NS IV infusion; or 10 IU IM.
  • Methylergometrine: $0.2\text{mg}$ IM/IV (slowly, ⚠️ CI: HTN, Cardiac disease).
  • Carboprost (PG F2α): $0.25\text{mg}$ IM (q15-90min, max 8 doses; ⚠️ CI: Asthma).
  • Misoprostol: $800-1000\text{mcg}$ PR/PO/SL.
• Mechanical Tamponade:
  • Intrauterine balloon (e.g., Bakri).
• Surgical:

  • Repair trauma.

  • Compression sutures (e.g., B-Lynch).

  • Arterial ligation (uterine, ovarian, internal iliac).

  • Hysterectomy (last resort).

PPH Complications - Aftermath & Alerts

• Early Complications:
  • Shock sequelae (organ damage: ARDS, AKI)
  • Anemia (transfuse if Hb < 7 g/dL or symptomatic)
  • Infection (endometritis, sepsis): fever, uterine tenderness
  • DIC: monitor coagulation, manage cause
• Delayed Complications:
  • Secondary PPH (>24h - 12wks): causes: retained products, infection
  • Asherman's syndrome (post-curettage)
  • Psychological sequelae (PTSD, depression)
• Long-term:

  ⭐ Sheehan's syndrome (postpartum pituitary necrosis) is a classic, albeit rare, long-term sequela of severe PPH leading to hypovolemic shock.

• ⚠️ Alerts:
  • Persistent/worsening bleeding despite uterotonics
  • Shock signs disproportionate to visible loss
  • Oliguria (urine output < 0.5 ml/kg/hr)
  • Altered mental status

High‑Yield Points - ⚡ Biggest Takeaways

• Uterine atony is the leading cause of PPH, accounting for 70-80% of cases.
• Active Management of Third Stage of Labor (AMTSL) significantly reduces PPH incidence.
• Initial management involves bimanual uterine massage and IV oxytocin infusion.
• Second-line uterotonics: Methylergonovine (contraindicated in hypertension), Carboprost (PGF2α, contraindicated in asthma), Misoprostol.
• Administer Tranexamic acid (TXA) within 3 hours of birth to reduce bleeding death.
• Consider the Four T's (Tone, Trauma, Tissue, Thrombin) for systematic etiology identification.