Post-partum haemorrhage

This is bleeding from the genital tract after the delivery of a baby. It can be broadly divided into primary and secondary types, the dist...

This is bleeding from the genital tract after the delivery of a baby.

It can be broadly divided into primary and secondary types, the distinction being the timing of the onset of the bleed relative to the delivery.

A primary postpartum haemorrhage is a loss (usually defined as more than 500ml) in the first 24 hours after delivery.

It is important to note that in pregnancy the clinical parameters may be unreliable; for example, apparent normotension can be due to pre-eclampsia combined with blood loss.

Risk factors for postpartum haemorrhage

 

• women with risk factors for postpartum haemorrhage should be advised to give birth in an obstetric unit where more emergency treatment options are available.
  • antenatal risk factors:
    • previous retained placenta or postpartum haemorrhage
    • maternal haemoglobin level below 8.5 g/dl at onset of labour
    • body mass index greater than 35 kg/m2
    • grand multiparity (parity 4 or more)
    • antepartum haemorrhage
    • overdistention of the uterus (for example, multiple pregnancy, polyhydramnios or macrosomia)
    • existing uterine abnormalities e.g fibroids
    • low-lying placenta
    • maternal age (35 years or older)
  • risk factors in labour:
    • induction
    • prolonged first, second or third stage of labour
    • oxytocin use
    • precipitate labour
    • operative birth or caesarean section.

Prevention of postpartum haemorrhage

 

• traditionally, oxytocin and ergot preparations have been used as uterotonic agents for postpartum haemorrhage prophylaxis mostly as part of active management of the third stage of labour
  • a major disadvantage, mainly related to ergot preparations, is the relatively high incidence of side-effects such as nausea, vomiting and increase in blood pressure
• misoprostol may prevent severe postpartum haemorrhage but the evidence is inconsistent
  • misoprostol or intramuscular postaglandins are not more effective than conventional injectable uterotonics - both lead to more adverse effects
  • the review concludes that neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women.

 

Primary postpartum haemorrhage

 

This is PPH occurring around the time of childbirth, and is arbitrarily set at losses of more than 500mls within 24 hrs of delivery. However, blood loss during childbirth is often underestimated and most women lose more than 500 mls.

PPH is said to occur in 2 - 8% of deliveries.

An oxytocic administered with delivery of the anterior shoulder, followed by controlled cord traction to deliver the placenta, will reduce the incidence of PPH.

 

Aetiology of PPH (4Ts)

Uterine atony (Tone) is the commonest cause of postpartum haemorrhage (90%).

Other causes include:

1. retained placenta (Tissue)
2. soft tissue lacerations (Trauma)
3. uterine inversion
4. coagulation disorders eg. von Willebrands disease, idiopathic thrombocytopaenia, liver disease(Thrombin)

Complications

1. death – 5% of all mortality in pregnancy
2. acute tubular necrosis
3. puerperal sepsis
4. pituitary necrosis - Sheehan's syndrome
5. post-partum anaemia with associated psychological symptoms, eg lethargy, depression

Secondary postpartum haemorrhage

 

Secondary post-partum haemorrhage is the presence of any excess, frank bleeding 24 hours after delivery. It most usually occurs 8 to 10 days after this time. It occurs after approximately 1% of all deliveries.

Causes include:

• retained products of conception
• displacement of blood clot
• infection
• abnormal involution of the placental site
• choriocarcinoma

An offensive discharge pv implies an infectious aetiology. This is managed by 'blind' systemic, broad-spectrum antibiotics while waiting for culture results from a high vaginal swab.