Complications
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Multidisciplinaire richtlijn Postpartumzorg in de eerste lijn (deel 1)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022Guideline multidisciplinaire des soins postnatals dans la première ligne de soins (partie 1)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022Multidisciplinaire richtlijn Postpartumzorg in de eerste lijn (deel 2)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2024Guideline multidisciplinaire des soins postnatals dans la première ligne de soins (partie 2)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2024In the immediate postpartum period, complications of PPH and massive transfusion can include transfusion-related acute lung injury (TRALI), acute respiratory distress syndrome (ARDS), transfusion-associated circulatory overload (TACO), and transfusion-related electrolyte abnormalities.[2][163]
Transfusion reactions range from mild to severe. These reactions encompass allergic reactions to plasma proteins, anaphylaxis, acute febrile reactions against donor leukocytes, hemolytic reactions due to ABO incompatibility, and TRALI.
It is important to perform serial laboratory monitoring to recognize and correct electrolyte abnormalities, especially after the administration of more than 5-7 units of red blood cells. Patients undergoing massive transfusion, and especially those with underlying liver and renal disease, require close monitoring of plasma ionized calcium and potassium due to transfusion-related hypocalcemia and hyperkalemia. Calcium repletion typically involves the intravenous administration of calcium gluconate or calcium chloride, often requiring multiple doses.[112]
Venous thromboembolism (VTE) prophylaxis is recommended in patients receiving massive transfusions because of the increased risk for VTE.[68]
TRALI is a serious condition characterized by acute respiratory distress following a blood transfusion. It is thought to be caused by antibodies present in the donor blood that react with the recipient's leukocytes, leading to inflammation in the lungs. TACO is a condition in which the recipient's cardiovascular system becomes overloaded with fluid as a result of rapid or excessive transfusion. It can lead to symptoms such as shortness of breath, pulmonary edema, and increased blood pressure.
The treatment of transfusion reactions depends on the type and severity of the reaction. In general, the transfusion should be stopped immediately, the patient should be assessed for any signs of anaphylaxis or respiratory distress, and supportive care should be administered based on the specific symptoms and severity of the reaction. Close monitoring of patients undergoing massive transfusion and prompt recognition of complications is key for appropriate management.[112]
PPH is associated with an increased risk of postpartum infection and sepsis. This can be attributed to various factors, including invasive treatments for PPH and the presence of retained products of conception or blood clots in the uterus, which can serve as a focus for infection.[32][158][159]
The most common type of infection seen after PPH is endometritis. Other potential infections include urinary tract infections and wound infections, especially in cases of cesarean section, cesarean hysterectomy, or laparotomy.[158][159]
Evidence has further demonstrated the association between the use of invasive treatments for PPH and the risk of sepsis. Interventions such as intrauterine tamponade, hysterectomy, and laparotomy were found to be associated with an increased risk of sepsis and severe sepsis.[160]
Preventive measures to reduce the risk of infection after PPH include maintaining appropriate sterile techniques during invasive procedures, prompt removal of retained products of conception, and administration of prophylactic antibiotics when indicated. Early recognition and prompt treatment of infections after PPH are also paramount. It is important to counsel patients who experienced, or are at high risk for developing, postoperative infection from surgical treatment for PPH on the importance of seeking medical attention if they identify any signs and symptoms of infection.
Anemia is a common complication following PPH. The risk of anemia is influenced by the amount of blood lost during the hemorrhage. Other factors that can contribute to anemia after PPH include pre-existing anemia, inadequate iron stores, nutritional deficiencies, and underlying medical conditions.[161][162]
To reduce the risk of anemia after PPH, it is important to provide appropriate management of the hemorrhage itself, including prompt recognition, control of bleeding, and fluid resuscitation. Early detection of anemia through regular monitoring of hemoglobin levels can also help in initiating timely interventions.[161][162]
Management of anemia after PPH typically involves addressing the underlying cause and replenishing iron stores. Iron supplementation, either through oral iron supplements or intravenous iron therapy, may be recommended to restore hemoglobin levels. In some cases, blood transfusion may be necessary if the anemia is severe or if there are other complications.[161][162]
Postpartum care should include nutritional advice, including a balanced diet rich in iron, folate, and vitamin B12. Women should be advised on the importance of continuing iron supplementation if prescribed, as well as seeking medical attention if they experience symptoms of anemia.[161][162]
In the immediate postpartum period, complications of massive PPH may include hypovolemic shock and hypoperfusion injuries such as acute kidney injury, hepatic failure, ischemic stroke, myocardial ischemia or infarction, or Sheehan syndrome.[2][163]
One study reported an incidence of Sheehan syndrome of approximately 1% to 2% among all patients who had experienced hypotensive PPH.[164] Sheehan syndrome, also known as postpartum pituitary necrosis, is a condition characterized by pituitary gland damage or necrosis following severe PPH and hypovolemic shock, leading to tissue damage and subsequent hormone deficiencies. It may manifest as a late complication of severe PPH. Sheehan syndrome typically presents with symptoms related to hormonal deficiencies, which can include failure to lactate; amenorrhea; fatigue; weakness; cold intolerance; hypotension; hair loss; dry skin; and future infertility.[2][163] Treatment consists of hormone replacement therapy to address the hormonal deficiencies caused by pituitary gland damage.
Lactational delay is a potential consequence of PPH and can manifest as a delay in the onset of milk production, decreased milk supply, or difficulty with milk ejection. The disruption in the hormonal regulation of lactation due to PPH can interfere with the normal signaling mechanisms that stimulate milk production and release.[165]
With proper management and support, most women can overcome these challenges and establish successful breast-feeding.[165]
Management of lactational delay involves supportive measures to optimize breast-feeding. Milk production can be stimulated and breast-feeding outcomes improved by encouraging frequent and effective breast-feeding, ensuring proper latch and positioning, and promoting skin-to-skin contact between mother and baby. The use of a breast pump may be recommended to enhance milk production and maintain milk supply. Patients who are unable to breast-feed due to a prolonged maternal intensive care unit stay can practice early pumping or hand expression to prevent lactational delay or failure. Lactation consultants and healthcare providers play a crucial role in providing guidance and support to mothers experiencing lactational delay after PPH. They can offer education, counseling, and practical strategies to address breast-feeding difficulties and promote successful lactation.[165]
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