What is the timeframe for the occurrence of postpartum hemorrhage (PPH) after pregnancy?

From the Guidelines

Postpartum hemorrhage (PPH) can occur up to 6 weeks after delivery, with primary or early PPH occurring in the first 24 hours and late or delayed PPH occurring between 24 hours and 6 weeks. The definition of PPH has been expanded to include hemorrhage post terminations or early pregnancy loss [ 1 ]. According to the American College of Radiology Appropriateness Criteria, PPH can be categorized as primary or early if occurring in the first 24 hours after delivery, whereas late or delayed PPH occurs between 24 hours and 6 weeks [ 1 ].

Key Points to Consider

• Primary PPH is defined as any hemorrhage associated with signs or symptoms of hypovolemia within 24 hours of delivery, regardless of the type of delivery [ 1 ].
• Secondary PPH typically occurs due to retained placental fragments, infection, or subinvolution of the placental site.
• Risk factors include prolonged labor, multiple pregnancies, large babies, and previous history of PPH.
• Women should be aware of warning signs such as heavy bleeding, passing large clots, foul-smelling discharge, fever, or severe abdominal pain in the weeks following delivery.

Importance of Prompt Medical Attention

Prompt medical attention is essential if symptoms of PPH occur, as it remains a leading cause of maternal mortality worldwide and requires immediate intervention to prevent serious complications [ 1 ]. The American College of Radiology Appropriateness Criteria provide evidence-based guidelines for the diagnosis and treatment of PPH, including the use of imaging modalities such as pelvic ultrasound, contrast-enhanced CT, and CT angiogram [ 1 ].

Diagnosis and Treatment

The diagnosis of PPH is crucial, and imaging plays an important role in the diagnosis of many causes of PPH [ 1 ]. Conservative measures such as uterine tamponade, uterotonic medications, and correction of coagulopathies are the first line of treatment, and tailored intervention such as curettage, embolization, or surgical repair may be necessary in some cases [ 1 ].

From the Research

Postpartum Hemorrhage Timing

• Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide, with uterine atony accounting for 70% to 80% of cases 2.
• The studies provided do not specify the exact time frame after pregnancy when postpartum hemorrhage can occur, but they discuss the prevention and treatment of PPH using uterotonic agents such as oxytocin, methylergometrine, carboprost, and misoprostol 2, 3, 4, 5, 6.
• Uterotonic agents are used to prevent and treat PPH, and their effectiveness and side-effect profiles are compared in the studies 2, 3, 4, 5, 6.

Uterotonic Agents for PPH Prevention and Treatment

• Oxytocin is the first-line uterotonic agent for preventing PPH, and its effectiveness is compared to other agents such as methylergometrine, carboprost, and misoprostol in the studies 2, 3, 4, 5, 6.
• The studies discuss the use of combination therapies, such as oxytocin with methylergometrine or misoprostol, and their effectiveness in preventing PPH 2, 5, 6.
• The network meta-analysis in study 6 ranks the effectiveness of different uterotonic agents for preventing PPH, with ergometrine plus oxytocin combination, carbetocin, and misoprostol plus oxytocin combination being more effective than oxytocin alone.

Side-Effect Profiles of Uterotonic Agents

• The studies discuss the side-effect profiles of different uterotonic agents, including vomiting, hypertension, and fever 3, 5, 6.
• The ergometrine plus oxytocin combination has a higher risk of vomiting and hypertension, while the misoprostol plus oxytocin combination has a higher risk of fever 6.
• Carbetocin has a similar side-effect profile to oxytocin, although the quality of evidence is very low for some outcomes 6.