Postpartum haemorrhage

Postpartum haemorrhage (PPH) is an obstetric emergency that is a major contributor to maternal morbidity and mortality. Early recognition relies on accurate quantification of blood loss, together with frequent ongoing assessment of patient-specific risk factors, vital signs, and symptoms of haemorrhage.

Meticulous physical examination of the uterus, cervix, vagina, vulva, and perineum can facilitate an accurate diagnosis and prompt treatment of the underlying cause to prevent progression to haemorrhagic shock.

The four Ts mnemonic highlights the most common causes of PPH: tone (uterine atony, by far the most frequent cause); trauma (obstetric lacerations/expanding haematomas/uterine rupture); tissue (retained products of conception or placenta accreta spectrum disorders); and thrombin (acquired or inherited coagulopathy). Steps to address uterine atony form a routine part of the initial management in every patient with PPH.

First-line treatment for PPH comprises immediate resuscitation with intravenous fluids (and blood product transfusion if needed), along with uterine massage and administration of a uterotonic and intravenous tranexamic acid. All of these must ideally be initiated within 15 minutes of a diagnosis. Additional management steps are dependent on the underlying cause of bleeding.

In women with refractory PPH, more aggressive interventions may be needed. Options include: temporary compressive measures; uterine tamponade; uterine artery embolisation; surgical interventions, with hysterectomy sometimes necessary as a life-saving intervention.

The use of obstetric haemorrhage care bundles has been shown to improve outcomes in patients with PPH.

Active management of the third stage of labour is the single most important intervention to prevent PPH. Identification of high-risk women in the antenatal period is also paramount.

Postpartum haemorrhage (PPH) is excessive blood loss that occurs within 24 hours of delivery (primary PPH) or >24 hours and up to 12 weeks postpartum (secondary PPH).

Quantitative definitions of primary PPH differ between guidelines.

• Primary PPH was traditionally defined as estimated blood loss (EBL) >1000 mL following caesarean delivery or >500 mL after a vaginal birth.[1]Escobar MF, Nassar AH, Theron G, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet. 2022 Mar;157 Suppl 1(suppl 1):3-50. https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.14116 http://www.ncbi.nlm.nih.gov/pubmed/35297039?tool=bestpractice.com [2]Hunt BJ, Allard S, Keeling D, et al. A practical guideline for the haematological management of major haemorrhage. Br J Haematol. 2015 Sep;170(6):788-803. https://onlinelibrary.wiley.com/doi/full/10.1111/bjh.13580 http://www.ncbi.nlm.nih.gov/pubmed/26147359?tool=bestpractice.com [3]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-86. http://www.ncbi.nlm.nih.gov/pubmed/28937571?tool=bestpractice.com

• Guidelines from the UK Royal College of Obstetricians and Gynaecologists (RCOG) define primary PPH as the loss of ≥500 mL from the genital tract within 24 hours of birth.[4]Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage: green-top guideline no. 52. BJOG. 2017 Apr;124(5):e106-49. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.14178 http://www.ncbi.nlm.nih.gov/pubmed/27981719?tool=bestpractice.com This definition is endorsed by the World Health Organization.[5]World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012 [internet publication]. https://www.who.int/publications/i/item/9789241548502 http://www.ncbi.nlm.nih.gov/pubmed/23586122?tool=bestpractice.com PPH can be categorised as minor (EBL 500-1000 mL) or major (EBL >1000 mL) and major PPH is further sub-categorised as moderate (EBL 1000-2000 mL) or severe (EBL >2000 mL).[4]Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage: green-top guideline no. 52. BJOG. 2017 Apr;124(5):e106-49. https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.14178 http://www.ncbi.nlm.nih.gov/pubmed/27981719?tool=bestpractice.com

• The American College of Obstetricians and Gynecologists (ACOG) now endorses the reVITALIZE criteria for diagnosing primary PPH.[3]Committee on Practice Bulletins-Obstetrics. Practice bulletin no. 183: postpartum hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-86. http://www.ncbi.nlm.nih.gov/pubmed/28937571?tool=bestpractice.com These criteria define primary PPH as an EBL ≥1000 mL (including intrapartum loss) regardless of mode of delivery or any volume of blood loss accompanied by signs and symptoms of hypovolaemia.[6]Menard MK, Main EK, Currigan SM. Executive summary of the reVITALize initiative: standardizing obstetric data definitions. Obstet Gynecol. 2014 Jul;124(1):150-3. http://www.ncbi.nlm.nih.gov/pubmed/24901267?tool=bestpractice.com

The reVITALIZE diagnostic criteria are intended to promote early detection of PPH by tackling visual underestimation of EBL and placing greater focus on clinical symptoms and signs of haemorrhage.[1]Escobar MF, Nassar AH, Theron G, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet. 2022 Mar;157 Suppl 1(suppl 1):3-50. https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.14116 http://www.ncbi.nlm.nih.gov/pubmed/35297039?tool=bestpractice.com [6]Menard MK, Main EK, Currigan SM. Executive summary of the reVITALize initiative: standardizing obstetric data definitions. Obstet Gynecol. 2014 Jul;124(1):150-3. http://www.ncbi.nlm.nih.gov/pubmed/24901267?tool=bestpractice.com