What are the immediate, early, and delayed complications of postpartum hemorrhage (PPH) in a postpartum patient?

Complications of Postpartum Hemorrhage by Timing

Immediate Complications (During Active Hemorrhage)

The most critical immediate complications are hypovolemic shock, tissue hypoxia, and evolving coagulopathy, which can rapidly progress to multiorgan failure and cardiac arrest if not promptly addressed. 1, 2

• Hypovolemic shock and hypotension develop from acute blood volume loss, leading to tissue hypoperfusion and onset of anaerobic metabolism 2
• Evolving coagulopathy occurs in 17% of cases when blood loss exceeds 2000 mL, manifested by fibrinogen levels dropping below 2 g/L 1, 3
• Disseminated intravascular coagulation (DIC) can complicate the hemorrhage, particularly with amniotic fluid embolism, placental abruption, or HELLP syndrome 1, 3
• Multiorgan failure results from prolonged tissue hypoxia if resuscitation is delayed 2
• Cardiac arrest and maternal death represent the terminal events if timely intervention fails—a maternal death occurs approximately every 5 minutes globally from PPH 2

Critical Pitfall:

Do not wait for laboratory confirmation of DIC before initiating massive transfusion protocol when blood loss exceeds 1,500 mL—immediate blood product administration in fixed ratios is mandatory while addressing the underlying cause 1, 3

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Early Complications (Within 24 Hours to 6 Weeks)

Early complications primarily involve surgical and treatment-related sequelae, including infection, thromboembolic events, and medication-specific adverse effects. 1

Surgical and Procedural Complications:

• Infection in women requiring uterine packing, balloon tamponade, or emergency surgical procedures 1
• Poor wound healing and adhesion formation from emergency surgical interventions 1
• Non-target embolization complications from uterine artery or internal iliac artery embolization procedures 1
• Endometritis or abscess formation requiring drainage, particularly with retained products of conception 4
• Ovarian vein thrombosis as a vascular complication 4, 5

Hematoma-Related Complications:

• Bladder flap, subfascial, or perivaginal space hematomas (small hematomas <4 cm may not be clinically significant, but those >5 cm require intervention) 4
• Infected hematomas requiring drainage 4

Treatment-Specific Complications:

• Bronchospasm from prostaglandin F2α or ergometrine use, particularly dangerous in women with asthma 1
• Respiratory depression from opioid analgesia, especially problematic in women with underlying respiratory disease 1
• Thromboembolic complications from immobility and coagulopathy, particularly after cesarean section 1

Critical Pitfall:

Avoid using prostaglandin F2α in women with asthma due to severe bronchoconstriction risk 1

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Delayed Complications (Beyond 6 Weeks)

The primary delayed complication is significantly increased risk of recurrent PPH in subsequent pregnancies, with a 3.5-fold increased risk. 1

Long-Term Reproductive Complications:

• Recurrent PPH in future pregnancies occurs at 3.5 times the baseline risk 1
• Uterine scarring and adhesions from surgical interventions may affect future fertility and placentation 1

Secondary (Late) PPH Complications:

While secondary PPH itself occurs between 24 hours and 6 weeks postpartum, its complications include:

• Vascular uterine abnormalities (VUA) or pseudoaneurysm formation from failure of placental bed vessel obliteration 4, 5
• Subinvolution of the placental bed leading to persistent bleeding 4, 5
• Retained products of conception (RPOC) with or without superimposed infection 4, 5

Diagnostic Considerations for Delayed Complications:

Transvaginal ultrasound with Doppler is the initial imaging modality to identify RPOC, vascular abnormalities, or pseudoaneurysm in delayed presentations 5. CT with IV contrast is reserved for hemodynamically stable patients when ultrasound is inconclusive 5.