Who is at risk for uncontrolled postpartum (after childbirth) hemorrhage?

From the Guidelines

Women at risk for uncontrolled postpartum hemorrhage include those with placental abnormalities, uterine atony, coagulation disorders, multiple pregnancies, polyhydramnios, prolonged labor, instrumental delivery, cesarean section, or previous postpartum hemorrhage. Additional risk factors include obesity, advanced maternal age, induction of labor, chorioamnionitis, and pre-eclampsia 1. Management typically follows a stepwise approach starting with uterine massage and uterotonics like oxytocin (10-40 units IV), methylergonovine (0.2mg IM), carboprost (0.25mg IM), or misoprostol (800-1000mcg rectally) 1. If bleeding continues, surgical interventions may be necessary, including uterine tamponade with a Bakri balloon, compression sutures, uterine artery ligation, or hysterectomy. Blood product replacement is crucial, with transfusion protocols often including packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate in a balanced ratio 1. Early recognition of these risk factors allows for preventive measures such as active management of the third stage of labor, which includes prophylactic oxytocin administration, controlled cord traction, and uterine massage to reduce hemorrhage risk by up to 60% 1.

Some key points to consider:

• The most common cause of early postpartum hemorrhage is uterine atony 1
• Placental abnormalities, such as placenta accreta, can increase the risk of postpartum hemorrhage 1
• Tranexamic acid can be used to reduce the risk of postpartum hemorrhage, especially in women with placental abnormalities 1
• Blood product replacement should be guided by laboratory values and clinical judgment 1
• The use of thromboembolism prophylaxis after cesarean delivery should be individualized based on a woman's risk factors for venous thromboembolism 1

From the FDA Drug Label

In any event the cases reported did not require specific therapy for the elevated blood pressure. Use in patients with chorioamnionitis. During the clinical trials with carboprost tromethamine, chorioamnionitis was identified as a complication contributing to postpartum uterine atony and hemorrhage in 8/115 (7%) of cases, 3 of which failed to respond to carboprost tromethamine Overdosage with oxytocin injection (synthetic) depends essentially on uterine hyperactivity whether or not due to hypersensitivity to this agent Hyperstimulation with strong (hypertonic) or prolonged (tetanic) contractions, or a resting tone of 15 to 20 mm H2O or more between contractions can lead to tumultuous labor, uterine rupture, cervical and vaginal lacerations, postpartum hemorrhage

The following individuals are at risk for uncontrolled postpartum hemorrhage:

• Patients with chorioamnionitis 2
• Patients who have had a history of:
  • Asthma
  • Hypo- or hypertension
  • Cardiovascular disease
  • Renal disease
  • Hepatic disease
  • Anemia
  • Jaundice
  • Diabetes
  • Epilepsy may be at higher risk due to the potential for complications 2
• Patients who experience uterine hyperactivity or hypersensitivity to oxytocin may be at risk for postpartum hemorrhage due to hyperstimulation 3

From the Research

Risk Factors for Uncontrolled Postpartum Hemorrhage

• Women of color are at a disproportionate risk of developing a life-threatening postpartum hemorrhage 4
• All pregnant women are considered at risk due to the lack of specificity and sensitivity of risk assessment tools 4
• Uterine atony is estimated to account for 70% to 80% of postpartum hemorrhage cases, making it the single most common cause 5
• The incidence of postpartum hemorrhage is increasing, making it imperative to identify drugs that could target prevention and/or treatment of these postpartum hemorrhages for women living in high, middle, and low-income countries 6

Patient Populations at Risk

• Women undergoing vaginal delivery, especially those with moderate to severe anemia 5
• Women who have had a cesarean section, as the incidence of placenta previa and accreta is likely to become more common 7
• Women living in resource-limited countries, where the incidence of postpartum hemorrhage is higher 4

Factors Contributing to Uncontrolled Postpartum Hemorrhage

• Delayed identification and intervention in a hemorrhage 4
• Inadequate blood and fluid replacement 7
• Limited access to effective uterotonic agents and other treatments 6
• Increased use of cesarean section, which can lead to a higher risk of postpartum hemorrhage 7