From the Guidelines
Postpartum hemorrhage (PPH) is concerning when blood loss exceeds 500 mL after vaginal delivery or 1000 mL after cesarean delivery, or when there is any blood loss accompanied by signs of hypovolemia such as hypotension, tachycardia, or decreased urine output, as stated in the most recent guidelines 1.
Causes and Risk Factors
The four main causes of PPH are:
- Uterine atony (the most common cause)
- Trauma to the birth canal
- Retained placental tissue
- Coagulation disorders The risk of PPH increases with conditions like prolonged labor, multiple gestation, polyhydramnios, macrosomia, and previous history of PPH.
Management
Initial management includes:
- Uterine massage
- Administration of uterotonics like oxytocin (10-40 units IV infusion) 1
- Methylergonovine (0.2 mg IM)
- Misoprostol (800-1000 mcg rectally)
- Carboprost tromethamine (250 mcg IM) Fluid resuscitation with crystalloids and blood products should be initiated if blood loss is significant. Bimanual compression of the uterus may be necessary while preparing for more invasive interventions. The use of tranexamic acid has been shown to reduce bleeding-related mortality in women with clinically diagnosed PPH, with the most recent study recommending early use (within 3 hours of birth) of intravenous tranexamic acid 1.
Diagnosis and Imaging
Imaging plays a crucial role in the diagnosis of many causes of primary PPH, including adherent placenta, retained products of conception (RPOC), and vascular uterine anomalies (VUA) 1. The diagnosis of RPOC is helpful to the clinician in determining whether surgical intervention is warranted.
Key Considerations
PPH is particularly concerning because it can rapidly progress to hemorrhagic shock, organ failure, and maternal death if not promptly recognized and treated. The most recent guidelines emphasize the importance of early recognition and treatment of PPH to reduce morbidity and mortality 1.
From the FDA Drug Label
Carboprost tromethamine injection is indicated for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management. The FDA drug label does not answer the question of when excessive bleeding after birth is concerning.
From the Research
Definition and Concerns of Postpartum Hemorrhage (PPH)
Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide, with uterine atony estimated to account for 70% to 80% of cases 2. Excessive bleeding after birth is concerning when it exceeds 1000 ml, especially in cases of caesarean section, where it can occur in more than 5-10% of cases 3.
Causes and Risk Factors of PPH
The common causes of PPH include:
- Uterine atony
- Abnormal placentation
- Uterine trauma
- Sepsis 3 Other risk factors for hospital admission related to excessive and/or prolonged postpartum vaginal blood loss after the first 24 h following childbirth include:
- History of secondary postpartum haemorrhage (PPH)
- Vaginal bleeding prior to 24 weeks' gestation
- Third trimester hospital admission
- Maternal smoking
- Prolonged or incomplete third stage of labor
- Primary PPH for blood loss >500 mL 4
Management and Treatment of PPH
Management options for PPH include:
- Uterotonic therapy
- Uterine compression sutures
- Balloon tamponade
- Blood-vessel ligation
- Uterine artery embolization 3, 5 In cases where medical and conservative surgical measures are unsuccessful, caesarean hysterectomy may be indicated 3. Combined therapy rather than oxytocin alone is recommended for preventing PPH, as it has an additive or synergistic effect and a greater risk reduction for PPH prevention 2.
Delayed Postpartum Hemorrhage
Severe delayed postpartum hemorrhage after cesarean section is rare, but can occur between 24 hours to 12 weeks postdelivery 6. The top differential diagnoses of both primary and secondary PPH are different, and as a result, the management may be different 6. Emergency physicians should be aware of the differential diagnosis and management of both primary and secondary PPH 6.