Postpartum Hemorrhage & Management Options

Traditionally Post Partum Hemorrhage (PPH) has been defined as blood loss of more than 500ml and if left untreated can lead to shock and death of the mother. ACOG defines PPH as a 10% drop in the hematocrit postdelivery or excessive blood loss requiring a need for blood transfusion.

Early PPH occurs within the first 24 hours after delivery and late PPH occurs more than 24 hours and less than 6 weeks.

PPH in developed countries ranks as the 3 rd or 4 th leading cause of maternal mortality and ranks number 1 in developing countries, accounting for 25%-43% of all maternal deaths.

Maternal Physiologic Adaptations During Pregnancy

During normal pregnancy there is a 42% increase in plasma volume & 24% increase in blood cell volume. However, in preeclamptic patients plasma volume expansion is 9% lower and they are also at a greater risk for blood loss compared to the general pregnant population.

During the 3 rd stage of labor, autotransfusion occurs due to the contraction and reduction of volume of the uterus.

Etiologies of Postpartum Hemorrhage

Uterine Atony

• A complication that can occur in 1 in 20 deliveries. Inadequate myometrial contraction after placental expulsion.
• Risk factors:
• Previous postpartum hemorrhage
• Overdistended uterus (Polyhydramnios, multiple gestation, fetal macrosomia)
• Fatigue
• Rapid or prolonged labor.
• Chorioamnionitis
• Use of tocolytics or general anesthesia
• High parity
• Antepartum hemorrhage
• Uterine abnormalities or fibroids
• Retained placental products
• High dose or prolonged pitocin
• Uterine rupture
• Uterine inversion
• Placenta Accreta

• Lower genital tract lacerations
• Hereditary coagulopathy

Prevention

Active management of third stage of labor and spontaneous delivery of the placenta is effective in the prevention of PPH. Dilute solutions of oxytocin and gentle traction of cord at time of c-section can reduce cesarean delivery related blood loss by 31% compared to manual removal of the placenta. Similarly, clamping the umbilical cord within 30 seconds of delivery and gentle cord traction followed by administration of IM or IV oxytocin before the delivery of the placenta reduces postpartum blood loss. Giving oxytocin before delivery of the placenta reduces the length of third stage of labor (5 minutes) and reduces the need for the manual removal of the placenta.

Management

• When encountering postpartum hemorrhage, manual digital exploration of the uterus should be quickly accomplished to rule out the possibility of retained placental fragments. If there is none detected manual massage of the uterus should be started and simultaneously pharmacologic agents should be given to control uterine bleeding.
• Oxytocin
• Oxytocin is routinely given for prevention and treatment of PPH. This is the first line agent because lesser side effects compared to other agents. It may be given IM (10 units) or IV (10-40 units/liter fluid). There are no absolute contraindications. However, an antidiuretic effect may develop with volume overload and high cumulative doses.
• Another side effect of oxytocin is hypertension.
• A recent randomized trial comparing two oxytocin regimens (333 mU/min vs. 2,667 mU/min) given for 30 minutes postpartum showed that with the higher doses, there is less need for additional uterotonic agents (39% vs. 19%).
• Ergot Alkaloids (Methergine)
• It is available as oral (0.2mg) and IM (0.2mg) preparations. The parenteral rout is preferred for quicker absorption. It is contraindicated in patients with hypertension due to potential for severe hypertension and myocardial ischemia. Although these agents have been a standard second line drug for many years, prostoglandins have been favored by clinicians due to their efficacy and safety.
• Prostaglandins
• Hemabate (15-methyl PGF2)
• It is administered in doses of 0.25 mg IM. A study showed that with refractory atonic PPH controlled bleeding in 88% of cases.
• Contraindication is asthma due to broncho-constrictive properties of the F class of prostoglandins.
• A study from the Cochrane Database of Systematic Reviews showed that “injectable prostaglandins are associated with reduced blood loss in the third stage of labor when compared to conventional injectable uterontonics but have more side effects”
• Prostoglandin E2 (Prostin E2) a natural oxytocic that contains 20 mg of dinoprostone in a vaginal suppository which can be given per vaginam or per rectum. Its side effects include temperature elevations due to its effects on hypothalamic thermoregulation and 1 in 10 may show diastolic hypotension because of its vasodilation effect.
• Misoprostol (Cytotec) is a synthetic prostaglandin E1. It is also used for gastric ulcers. It has been extensively studied. According to a study in the Cochrane Database of Systemic Reviews “Misoprostol should not replace injectable uterotonics in the routine management of the third stage of labor. Misoprostol for this indication is less effective, has more side-effects and is not necessarily less costly in developing countries (Mozambique 2001). There is currently insufficient evidence to justify the use of Misoprostol prophylactically when other uterotonics are not available." They showed that the use of oral Misoprostol compared to injectable uterotonics is associated with high risk of blood loss.
• One study showed that in 14 cases of PPH which were unresponsive to oxytocin and ergometrine or oxytocin alone, Misoprostol 1000 micrograms was give per rectum and PPH was controlled in all 14 cases within 3 minutes of administration.

From the above studies we can conclude that neither IM PG’s nor Misoprostol are preferred to conventional uterotonics in the management of third stage labor, especially in low risk women. Their use is more promising in PPH rather than as a preventive method.

Surgical Therapy

• Uterine packing
• Uterine artery ligation
• Internal Iliac (hypogastric) Artery Ligation
• Hysterectomy
• Suture Techniques

(some data from Clinical Obstetrics and Gynecology – Lippencott Williams & Wilkins, Inc.)