1. Postpartum hemorrhage
Felipe A. Medeiros
Assistant Professor
Department of Anesthesiology
The University of Texas medical Branch
March 14th, 2016

2. Overview
Severe bleeding is the single most significant cause of maternal death worldwide
More than half of all maternal deaths occur within 24 hours of delivery
In addition to death, serious morbidity may follow postpartum hemorrhage (PPH):
Adult respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis

3. Definition
There is no single, satisfactory definition of postpartum hemorrhage
Estimates of blood loss at delivery are notoriously inaccurate
Diagnosis usually is based on subjective observations
Estimated blood loss in excess of 500 mL following a vaginal birth or a loss of greater than 1,000 mL following cesarean birth
A decline in hematocrit levels of 10%

4. Definition Early or primary PPH Late or Secondary PPH
Within the first 24h of delivery
More common – occurs in 4-6% of pregnancies
Associated with greater degree of blood loss and morbidity
Late or Secondary PPH
Between 24 hours and 6–12 weeks postpartum
Occurs in approximately 1% of pregnancies
Often the specific etiology is unknown

5. Etiology Late PPH: **Early PPH: Uterine atony
Lacerations of vagina and cervix
Retained placental tissue—especially placenta accreta
Coagulopathy
Uterine inversion
Late PPH:
Infection
Placental site subinvolution
Retained placental fragments

6. Early PPH – Uterine atony
Most common cause of severe PPH - accounts for 80% of cases
Risk factors
Uterine overdistention (polyhydramnios, multiple gestation, fetal macrosomia)
High parity
Precipitous or prolonged labor
Intraamniotic infection
Use of uterine-relaxing agents (terbutaline, magnesium sulfate, halogenated anesthetic agents, and nitroglycerin)
Cesarean delivery
Induced / augmented labor
AMA
Hypertensive disease
Presentation:
Postpartum bleeding
Finding of the characteristic soft, poorly contracted uterus

7. Early PPH – Uterine atony
Prophylaxis: ACOG recommends prophylactic administration of uterotonic agents to prevent uterine atony. Active management of the third stage of labor , including uterine massage and oxytocin administration, decreases blood loss and transfusion requirements compared with expectant management
Treatment:
Bimanual uterine massage
Uterotonics
Surgical management

8. Early PPH – Uterine atony / Uterotonics
Dose and route
Half- life
Side effects
Contra-indication
Oxytocin
 IU/min IV infusion
> 6 min
Tachycardia
Hypotension
Myocardial ischemia
Free water retention
None
Ergonovine/ methylergonovine
0.2 mg IM
May be repeated once after 1h
2-4h
Nausea and vomiting
Arteriolar constriction
Hypertension
Preeclampsia
CAD
15-Methyl
prostaglandin F 2α
0.25 mg IM
May be repeated every 15 min up to 2 mg
Fever, Chills
Diarrhea
Bronchoconstriction
Reactive airway disease
Pulmonary HTN
Hypoxemia
Misoprostol
 µg per rectum, sublingual, or buccal

9. Early PPH – Uterine atony
Surgical treatment
Intrauterine baloon tamponade
Hypogastric artery ligation – rarely used
Bilateral uterine artery ligation (O’Leary sutures)
B-Lynch technique
Hemostatic multiple square suturing
(suturing both anterior and posterior uterine walls)
Hysterectomy
B-Lynch sutures

10. Early PPH – Lower genital tract lacerations
Risk factors:
Forceps delivery
Vacuum extraction
Fetal macrosomia
Precipitous labor and delivery
The use of episiotomy
Presentation:
Persistent bleeding in the presence of adequate uterine tone
Pelvic pain and shock may be the only presenting signs and symptoms
A retroperitoneal hemorrhage may occur after laceration of one of the branches of the hypogastric artery (usually following c-section)

11. Early PPH – Lower genital tract lacerations
Treatment
Packing the vagina
Hemostasis and suture of lacerations
Genital tract hematomas may present in the absence of laceration. Progressive enlargement of the mass indicates a need for incision and drainage

12. Early PPH – Retained placental tissue
Risk factors:
Previous uterine surgery
Non spontaneous expulsion of placenta
Presentation:
Failure to deliver the placenta completely within 30 minutes after delivery of the infant and occurs in approximately 3% of vaginal deliveries.
Non integrity of placenta upon examination
Detection of an echogenic mass in the uterus on US
Treatment:
Ultrasonography can help diagnose a retained placenta
Manual removal
Curettage

13. Early PPH – Placenta accreta
Placenta that in whole or in part invades the uterine wall and is inseparable from it
Risk factors:
Prior cesarean delivery is a major risk factor
Placenta previa.
Other uterine procedures
Short cesarean-to-conception
interval
Advanced maternal age
Smoking
20% have no identifiable risk
factors

14. Early PPH – Placenta accreta
Treatment
Intrauterine baloon tamponade
Uterine compression sutures
Angiographic arterial embolization
Bilateral surgical ligation of the uterine arteries
Peripartum hysterectomy

15. Early PPH – Uterine inversion
Definition:
Uterine corpus descends to, and sometimes through, the uterine cervix
Associated with severe postpartum hemorrhage, and hemodynamic instability may be worsened by concurrent vagal reflex–mediated bradycardia
Risk factors:
Umbilical cord traction

16. Early PPH – Uterine inversion
Treatment:
Replacement of the uterine corpus
To restore normal anatomy, relaxation of the uterus may be necessary. Terbutaline, magnesium sulfate, halogenated general anesthetics, and nitroglycerin have been used for uterine relaxation
If manual replacement is unsuccessful, laparotomy is required

17. Early PPH - Coagulopathy
Risk factors:
HELLP syndrome,
Abruptio placentae
Prolonged intrauterine fetal demise
Sepsis
Amniotic fluid embolism
Significant hemorrhage may lead to consumption coagulopathy
PMH / Family hx of coagulopathy
Presentation:
Diffuse bleeding
Treatment:
Appropriate testing should be ordered, with blood products infused as indicated

18. Management of PPH

19. Practice points
Excessive postpartum bleeding causes severe maternal M&M
Be aware of risk factors for PPH and take indicated preventive measures
Vigilant postpartum monitoring can allow earlier detection of PPH and treatment
Algorithms are available to guide management for the various causes of PPH
Management requires team work between surgeons and anesthesiologists
Anesthesiologist should be aware of the common causes of PPH and their treatment options

20. Reference list
Scavone, BM . Chestnut's Obstetric Anesthesia: Principles and Practice, Chapter 38,
ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol Oct;108(4):
Rouse DJ. What is new in postpartum hemorrhage? Best articles from the past year. Obstet Gynecol Sep;122(3):693-4
Int J Gynaecol Obstet Dec;123(3): doi: /j.ijgo Epub 2013 Aug 30.