Obstetrics and Gynecology: Postpartum Hemorrhage

by Mala Arora, Rajalaxmi Walavalkar

Blood loss greater than this or a 10% change in hematocrit is defined as PPH. In women with anemia, loss of smaller volumes can result in hemodynamic instability. Hence, any amount of blood loss that threatens a woman’s hemodynamic status is defined as PPH. To make women strong enough to withstand PPH by correcting anemia during the antenatal period will go a long way in preventing mortality. Women with a previous history of PPH, multifetal pregnancy, uterine myomas, and uterine scars should be offered institutional delivery. However, many cases of PPH may have no identifiable risk factors. Primary PPH occurs within 24 hours of delivery and is associated with a higher mortality rate than secondary PPH. The majority of cases of primary PPH are due to uterine atony (70%). Other causes include genital tract trauma (20%), retained tissue (10%), and coagulopathy (1%). A Cochrane review compared active versus expectant management of third stage of labor and concluded that active management of third stage of labor (AMTSL) lowers maternal blood loss and reduces the risk of PPH by 60%. In low resource settings, where all birthing women may not have an IV access, misoprostol tablets can be administered vaginally or rectally by a skilled birth attendant as part of active management of third stage of labor. If hemorrhage continues, oxytocin infusion is commenced and ergotamine and/or prostaglandins are administered in addition. All healthcare professionals and birth attendants should be trained to prevent and treat PPH. Periodic audit of maternal mortality and near miss cases should be conducted in all delivery suites to identify loopholes and improvise management protocols. A chart outlining AMTSL as well as protocols for management of PPH should be available, along with an emergency obstetric kit, a PPH drug box, and a PPH examination kit (see Appendix E). Patients with secondary PPH should be evaluated for retained products and sepsis. Evacuation of the uterus under ultrasound guidance and use of antibiotics will arrest bleeding. Uterine artery embolization should be considered in resistant cases. Patients who survive PPH may suffer serious psychological and medical sequelae. Immediate medical complications are anemia, sepsis, difficulty in lactation, delayed wound healing, and exacerbation of latent infections like tuberculosis. Serious long-term sequelae are Sheehan and Asherman syndrome.

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