Postpartum Hemorrhage
Postpartum Hemorrhage
Postpartum Hemorrhage
Late
◦ Hemorrhage that occurs after the first 24 hours
Examples of definitions for postpartum
hemorrhage
Organization Definition of PPH
•Blood loss ≥500 mL within 24 hours after birth.
[1]
World Health Organization •Severe PPH: Blood loss ≥1000 mL within the same time
frame.
•Cumulative blood loss ≥1000 mL or blood loss
[2] accompanied by signs or symptoms of hypovolemia within
American College of Obstetricians and Gynecologists
24 hours after the birth process (includes intrapartum loss)
regardless of route of delivery.
•Minor PPH (500 to 1000 mL) and major PPH (>1000 mL).
[3]
Royal College of Obstetricians and Gynaecologists Subdivisions of major PPH include moderate (1001 to 2000
mL) or severe (>2000 mL).
•Active bleeding >1000 mL within the 24 hours following
[4]
International expert panel birth that continues despite the use of initial measures,
including first-line uterotonic agents and uterine massage.
[5] •Any amount of bleeding that threatens the patient's
Society of Obstetricians and Gynaecologists of Canada
hemodynamic stability.
References: World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization; 2012.
American College of Obstetricians and Gynecologists. ACOG Practice Bulletin Number 183, October 2017: Postpartum hemorrhage. Obstet Gynecol 2017; 130:e168.
Prevention and management of postpartum haemorrhage: Green-top guideline No. 52. BJOG 2017; 124:e106.
Abdul-Kadir R, McLintock C, Ducloy AS, et al. Evaluation and management of postpartum hemorrhage: Cnsensus from an international expert panel. Transfusion 2014; 54:1756.
Leduc D, Senikas V, Lalonde AB, et al. Active management of the third stage of labour: Pevention and treatment of postpartum hemorrhage. J Obstet Gynaecol Can 2009; 31:980.
Hemostatis upon
placental separation
Mechanical hemostasis :
contraction of the
myometrium
Clotting : local decidual
hemostatic factors
Risk Factor
• Retained placenta (OR 3.5, 95% CI 2.1-5.8)
• Failure to progress during the second stage of labor (OR 3.4, 95% CI 2.4-4.7)
• Placenta accreta (OR 3.3, 95% CI 1.7-6.4)
• Lacerations (OR 2.4, 95% CI 2.0-2.8)
• Instrumental delivery (OR 2.3, 95% CI 1.6-3.4)
• Large-for-gestational-age (LGA) newborn (OR 1.9, 95% CI 1.6-2.4)
• Hypertensive disorders (OR 1.7, 95%CI 1.2-2.1)
• Induction of labor (OR 1.4, 95%CI 1.1-1.7)
• Augmentation of labor with oxytocin (OR 1.4, 95% CI 1.2-1.7).
Sheiner E, Sarid L, Levy A, Seidman DS, Hallak M. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage:
a population-based study. J Matern Fetal Neonatal Med. 2005 Sep. 18(3):149-54.
Other risk fx
• Personal or family history of previous PPH • Leiomyoma
• Obesity • Couvelaire uterus
• High parity • Bleeding diathesis, acquired bleeding
diathesis
• Asian or Hispanic race
• Anemia
• Precipitous labor
• Drugs
• Uterine overdistention
• Chorioamnionitis
• Uterine inversion
Cause of hemorrhage
APPROXIMATE INCIDENCE
FOUR TS CAUSE (%)
Tone Atonic uterus 70
Trauma Lacerations, hematomas, 20
inversion, rupture
Tissue Retained tissue, invasive 10
placenta
Thrombin Coagulopathies 1
Symptoms related to blood loss with
postpartum hemorrhage
Blood loss, % (mL) Blood pressure, mmHg Signs and symptoms
Palpitations, lightheadedness, mild
10 to 15 (500 to 1000) Normal
increase in heart rate
Weakness, sweating, tachycardia
15 to 25 (1000 to 1500) Slightly low
(100 to 120 beats/minute)
Restlessness, confusion, pallor,
25 to 35 (1500 to 2000) 70 to 80 oliguria, tachycardia (120 to
140 beats/minute)
Lethargy, air hunger, anuria,
35 to 45 (2000 to 3000) 50 to 70 collapse, tachycardia (>140
beats/minute)
Adapted from: Bonnar J. Massive obstetric haemorrhage. Baillieres Best Pract Res Clin Obstet Gynaecol
2000; 14:1.
Management
• Resuscitation and management of obstetric hemorrhage and, possibly, hypovolemic shock
• Identification and management of the underlying cause(s)
Acute medical management of PPH
Prevention
Prevention
Prevention
Prevention
Antenatal and intrapartum risk fx for PPH
Risk assessment tool
Prevention Oxytocin administration
(IM/IV, 10 IU))
1. Risk Factors?
2. Assessment?
Thank You