Postpartum hemorrhage
Encyclopedia
Hemorrhage after delivery, or postpartum hemorrhage, is the loss of greater than 500 ml of blood following vaginal delivery, or 1000 ml of blood following cesarean section. It is the most common cause of perinatal maternal death in the developed world and is a major cause of maternal morbidity worldwide.
Causes of postpartum hemorrhage are uterine atony
, trauma
, retained placenta
, and coagulopathy
, commonly referred to as the "four Ts":
is the drug of choice for postpartum hemorrhage. Misoprostol
may also be effective if oxytocin is not available.
A Cochrane database study suggests that active management (use of uterotonic drugs, cord clamping and controlled cord traction) of the third stage of labour reduces severe maternal bleeding and anemia
compared to expectant management. However, the review also found that active management reduced the baby’s birthweight and increased the mother's blood pressure, afterpains, nausea, vomiting, and use of drugs for pain relief. The number of women returning to hospital with bleeding also increased. Another Cochrane database study, focusing specifically on the timing of the administration of the uterotonic drug oxytocin
as part of the active management of the third stage of labour, suggested that administering the drug before the expulsion of the placenta did not have any significant influence on the incidence of postpartum hemorrhage when compared to administering the drug after the expulsion of the placenta.
Causes
| Cause | Incidence |
|---|---|
| Uterine atony | 70% |
| Trauma | 20% |
| Retained tissue | 10% |
| Coagulopathy | 1% |
Causes of postpartum hemorrhage are uterine atony
Uterine atony
Uterine atony is a loss of tone in the uterine musculature. Normally, contraction of the uterine muscle compresses the vessels and reduces flow. This increases the likelihood of coagulation and prevents bleeds. Thus, lack of uterine muscle contraction can cause an acute hemorrhage...
, trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
, retained placenta
Placenta
The placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply. "True" placentas are a defining characteristic of eutherian or "placental" mammals, but are also found in some snakes and...
, and coagulopathy
Coagulopathy
Coagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
, commonly referred to as the "four Ts":
- ToneMuscle toneIn physiology, medicine, and anatomy, muscle tone is the continuous and passive partial contraction of the muscles, or the muscle’s resistance to passive stretch during resting state. It helps maintain posture, and it declines during REM sleep.-Purpose:Unconscious nerve impulses maintain the...
: uterine atonyUterine atonyUterine atony is a loss of tone in the uterine musculature. Normally, contraction of the uterine muscle compresses the vessels and reduces flow. This increases the likelihood of coagulation and prevents bleeds. Thus, lack of uterine muscle contraction can cause an acute hemorrhage...
is the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony. - TraumaPhysical traumaTrauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
: trauma from the delivery may tear tissue and vessels leading to significant postpartum bleeding. - TissueTissue (biology)Tissue is a cellular organizational level intermediate between cells and a complete organism. A tissue is an ensemble of cells, not necessarily identical, but from the same origin, that together carry out a specific function. These are called tissues because of their identical functioning...
: retention of tissue from the placentaPlacentaThe placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply. "True" placentas are a defining characteristic of eutherian or "placental" mammals, but are also found in some snakes and...
or fetusFetusA fetus is a developing mammal or other viviparous vertebrate after the embryonic stage and before birth.In humans, the fetal stage of prenatal development starts at the beginning of the 11th week in gestational age, which is the 9th week after fertilization.-Etymology and spelling variations:The...
may lead to bleeding. - ThrombinThrombinThrombin is a "trypsin-like" serine protease protein that in humans is encoded by the F2 gene. Prothrombin is proteolytically cleaved to form thrombin in the first step of the coagulation cascade, which ultimately results in the stemming of blood loss...
: a bleeding disorder occurs when there a failure of clotting, such as with diseases known as coagulopathiesCoagulopathyCoagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
.
Medication
Intravenous oxytocinOxytocin
Oxytocin is a mammalian hormone that acts primarily as a neuromodulator in the brain.Oxytocin is best known for its roles in sexual reproduction, in particular during and after childbirth...
is the drug of choice for postpartum hemorrhage. Misoprostol
Misoprostol
Misoprostol is a drug that is used for the prevention of non steroidal anti inflammatory drug induced gastric ulcers, for early abortion, to treat missed miscarriage, and to induce labor. The latter use is controversial in the United States. Misoprostol was invented and marketed by G.D...
may also be effective if oxytocin is not available.
Protocol
A detailed stepwise management protocol has been introduced by the California Maternity Quality Care Collaborative. It describes 4 stages of obstetrical hemorrhage after a delivery and its application reduces maternal mortality.- Stage 0: normal - treated with fundal massage and oxytocinOxytocinOxytocin is a mammalian hormone that acts primarily as a neuromodulator in the brain.Oxytocin is best known for its roles in sexual reproduction, in particular during and after childbirth...
. - Stage 1: more than normal bleeding - establish large-bore intravenous access, assemble personnel, increase oxytocin, consider use of methergine, perform fundal massage, prepare 2 units of packed red cells.
- Stage 2: bleeding continues - check coagulation status, assemble response team, move to operating room, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider: uterine artery embolizationUterine artery embolizationUterine artery embolization is a procedure where an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body...
, dilatation and curettage, and laparotomyLaparotomyA laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...
with uterine compression stitches or hysterectomy. - Stage 3: bleeding continues - activate massive transfusion protocol, mobilize additional personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy.
A Cochrane database study suggests that active management (use of uterotonic drugs, cord clamping and controlled cord traction) of the third stage of labour reduces severe maternal bleeding and anemia
Anemia
Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...
compared to expectant management. However, the review also found that active management reduced the baby’s birthweight and increased the mother's blood pressure, afterpains, nausea, vomiting, and use of drugs for pain relief. The number of women returning to hospital with bleeding also increased. Another Cochrane database study, focusing specifically on the timing of the administration of the uterotonic drug oxytocin
Oxytocin
Oxytocin is a mammalian hormone that acts primarily as a neuromodulator in the brain.Oxytocin is best known for its roles in sexual reproduction, in particular during and after childbirth...
as part of the active management of the third stage of labour, suggested that administering the drug before the expulsion of the placenta did not have any significant influence on the incidence of postpartum hemorrhage when compared to administering the drug after the expulsion of the placenta.