Postpartum haemorrhage

Overview Of Postpartum haemorrhage

Postpartum hemorrhage (PPH) refers to excessive bleeding following childbirth, typically defined as the loss of more than 500 milliliters of blood after a vaginal delivery or more than 1000 milliliters after a cesarean section. It is one of the most common complications of childbirth and can be life-threatening if not managed promptly. PPH is classified into two types: primary and secondary. Primary PPH occurs within the first 24 hours after delivery, while secondary PPH occurs between 24 hours and six weeks postpartum. This condition is characterized by continuous bleeding that does not stop on its own, and it can result from several causes, such as uterine atony (failure of the uterus to contract), trauma during delivery, or retained placenta. Prompt recognition and intervention are critical to prevent severe complications, including shock, organ failure, or death.

Causes of Postpartum haemorrhage

• Postpartum hemorrhage can occur due to various reasons, and the underlying cause often determines the treatment approach. Common causes include: - Uterine atony: The most common cause of PPH, uterine atony occurs when the uterus fails to contract properly after delivery. This failure prevents the blood vessels in the uterus from being compressed, resulting in continued bleeding. Risk factors include prolonged labor, over-distended uterus (due to multiple pregnancies or a large baby), or excessive use of uterine stimulants (e.g., oxytocin). - Trauma to the birth canal: Lacerations or tears in the cervix, vagina, or perineum during childbirth can result in significant blood loss. This is more common in forceps-assisted deliveries, episiotomies, or rapid deliveries. - Retained placenta: If the placenta is not completely expelled or if part of it remains attached to the uterine wall, bleeding can continue after childbirth. This can be accompanied by infection or uterine infection (endometritis). - Coagulation disorders: Women with bleeding disorders, such as disseminated intravascular coagulation (DIC) or von Willebrand disease, may experience prolonged or excessive bleeding after childbirth. - Placenta accreta: This occurs when the placenta abnormally adheres to the uterine wall, preventing its complete separation and leading to heavy bleeding after delivery. - Uterine inversion: A rare but serious complication in which the uterus turns inside out during delivery, leading to severe bleeding and requiring immediate medical intervention. - Retained clots: Clots that remain in the uterus after delivery can obstruct the uterine contraction process and cause prolonged bleeding. - Pre-existing conditions: Certain pre-existing conditions, such as preeclampsia, gestational diabetes, or obesity, can increase the risk of PPH.

Risk Factors of Postpartum haemorrhage

• Several factors increase the likelihood of postpartum hemorrhage, including: - Previous PPH: Women who have experienced postpartum hemorrhage in a previous pregnancy are at an increased risk of recurrence. - Multiple pregnancies (multiparity): Women who have had more than one child are more likely to experience uterine atony or other complications that can lead to bleeding. - Over-distended uterus: An excessively large baby, multiple pregnancies (twins or more), or excess amniotic fluid can stretch the uterus, impairing its ability to contract and increasing the risk of bleeding. - Prolonged or rapid labor: Long labor (especially in the second stage) or very rapid labor can increase the risk of uterine trauma, uterine atony, and subsequent bleeding. - Assisted deliveries: Use of forceps or vacuum extraction during delivery can lead to trauma to the birth canal, increasing the risk of bleeding. - Retained placenta or placenta accreta: These conditions, where the placenta fails to detach or adheres abnormally to the uterine wall, can lead to significant bleeding after delivery. - Pre-eclampsia or hypertension: High blood pressure during pregnancy can contribute to clotting disorders and bleeding complications during delivery. - Coagulation disorders: Women with clotting disorders, such as hemophilia, von Willebrand disease, or platelet dysfunction, are at greater risk of prolonged bleeding. - Obesity: Women who are overweight or obese may be more likely to experience complications such as uterine atony, which can lead to PPH. - Cesarean section: Women undergoing cesarean delivery are at increased risk for uterine trauma, infection, and placenta abnormalities, all of which can contribute to postpartum hemorrhage.

Prevention of Postpartum haemorrhage

• While some risk factors for postpartum hemorrhage cannot be avoided, several strategies can help minimize the likelihood of severe bleeding: - Active management of the third stage of labor: This includes administering oxytocin and performing controlled cord traction to ensure the placenta is delivered effectively and reduce the risk of hemorrhage. - Proper prenatal care: Monitoring for and managing conditions like preeclampsia, anemia, or uterine abnormalities before delivery can help reduce the risk of complications during childbirth. - Minimizing trauma during delivery: Careful management of the delivery process, including avoiding unnecessary interventions like forceps use and managing a slow or rapid labor, can reduce the risk of birth canal trauma. - Avoiding prolonged labor: Timely intervention during labor to prevent it from becoming prolonged can help reduce the likelihood of uterine atony and excessive blood loss. - Blood transfusion readiness: Preparing for potential blood loss during labor and delivery, especially in women with known risk factors, can ensure prompt access to transfusion if needed.

Prognosis of Postpartum haemorrhage

• The prognosis for postpartum hemorrhage depends on the timeliness of treatment and the severity of the bleeding. With prompt intervention, most women recover fully without long-term complications. However, delayed treatment or massive blood loss can result in: - Hemorrhagic shock: Severe blood loss can lead to shock, which can cause organ failure and may be life-threatening. - Anemia: Excessive bleeding may lead to iron-deficiency anemia, requiring further medical management. - Infection: If the uterus or reproductive organs are injured or if there is retained placenta, there is an increased risk of infection, such as endometritis. - Hysterectomy: In cases of severe, uncontrolled bleeding, a hysterectomy may be necessary to stop the bleeding, which can affect future fertility.

Complications of Postpartum haemorrhage

• Potential complications of postpartum hemorrhage include: - Hemorrhagic shock: Severe blood loss can cause a drop in blood pressure, leading to organ failure, shock, and, in extreme cases, death. - Anemia: Excessive blood loss may result in significant anemia, which can lead to fatigue, weakness, and an increased risk of other complications. - Infection: Retained placental tissue or trauma to the birth canal can lead to infections, such as endometritis or pelvic infections, which can delay recovery and affect overall health. - Coagulation disorders: Prolonged or excessive bleeding can lead to clotting issues, such as disseminated intravascular coagulation (DIC), which can cause widespread clotting and bleeding complications. - Future fertility issues: Severe cases requiring hysterectomy or surgical intervention may impact a woman’s ability to have children in the future.

Related Diseases of Postpartum haemorrhage

• Conditions related to postpartum hemorrhage include: - Placenta accreta: A condition where the placenta abnormally attaches to the uterine wall, making it difficult to detach after childbirth, leading to severe bleeding. - Retained placenta: When part or all of the placenta remains in the uterus after delivery, it can result in continued bleeding and infection. - Uterine rupture: A rare but serious complication in which the uterus tears during labor, leading to massive bleeding and potentially life-threatening consequences. - Endometritis: Infection of the uterine lining, often following a traumatic or complicated birth, which can contribute to prolonged bleeding. - Coagulation disorders: Women with conditions such as von Willebrand disease or thrombocytopenia may be at increased risk for excessive bleeding after childbirth.

Treatment of Postpartum haemorrhage

Treatment for postpartum hemorrhage depends on the underlying cause and severity of the bleeding. Common interventions include: - **Uterine massage**: Manual uterine massage is often performed to stimulate uterine contractions and reduce bleeding, especially in cases of uterine atony. - **Oxytocin administration**: Oxytocin is commonly used to stimulate uterine contractions and help control bleeding. It is often given intravenously or intramuscularly after delivery. - **Uterotonic drugs**: In addition to oxytocin, other drugs, such as misoprostol, ergometrine, or prostaglandins, may be administered to stimulate the uterus to contract and control bleeding. - **Manual removal of the placenta**: If the placenta is retained, it may need to be manually removed to prevent further bleeding. - **Surgical interventions**: In severe cases, surgical procedures, such as a dilation and curettage (D&C), a hysterectomy (removal of the uterus), or uterine artery embolization, may be necessary to stop the bleeding. - **Blood transfusion**: If there is significant blood loss, a blood transfusion may be required to replace lost blood and restore blood volume. - **Balloon tamponade**: A balloon catheter can be inserted into the uterus and inflated to apply pressure, helping to control bleeding by constricting blood vessels.