What is Acute Postpartum Hemorrhage?
Obstetric hemorrhage, or heavy bleeding during childbirth, is a common and potentially life-threatening complication. Previously, postpartum hemorrhage (PPH), which is the term for heavy bleeding after childbirth, was defined as losing more than 500 mL of blood during a vaginal birth or more than 1000 mL during a cesarean section. However, in 2017, the American College of Obstetrics and Gynecology redefined PPH. They now consider it to be a loss of more than 1000 mL of blood with signs of low blood volume within 24 hours of giving birth. This applies regardless of how the baby was delivered.
This new definition was created because people often underestimate how much blood is lost during childbirth. But any blood loss of more than 500 mL during a vaginal birth should still be viewed as abnormal, highlighting a potential need for medical intervention. PPH is further categorized into two types: primary and secondary. Primary PPH refers to bleeding that happens within the first 24 hours after giving birth, whereas secondary PPH is when the bleeding occurs between 24 hours and 12 weeks after delivery.
What Causes Acute Postpartum Hemorrhage?
Heavy bleeding after childbirth, or acute postpartum hemorrhage, can be caused by a whole host of factors. We can broadly split these causes into two categories: primary and secondary.
Primary causes include:
* Uterine atony (when the uterus doesn’t contract well)
* Cuts or tears in the genital tract
* Leftover placenta in the uterus
* Abnormal placentation (the placenta attaching in unusual places in the womb)
* Uterine inversion (the uterus turns inside out)
* Blood clotting disorders
Out of all these, uterine atony is the most common cause of heavy bleeding after childbirth. If a woman has had postpartum hemorrhage in a previous pregnancy, she is at a higher risk of experiencing it again, so doctors should do their best to determine the severity and cause of the previous hemorrhage.
Secondary causes of postpartum hemorrhage include:
* Remnants of the conception (pregnancy) still in the uterus
* Infections
* Subinvolution of the placental site (the place where the placenta was attached doesn’t shrink back to its normal size)
* Hereditary issues with blood clotting
Risk Factors and Frequency for Acute Postpartum Hemorrhage
Postpartum hemorrhage, or severe bleeding after childbirth, is the main reason for health issues and death in relation to childbirth. It happens in about 1% to 6% of all births. The main cause of this bleeding, a condition called uterine atony where the uterus doesn’t contract properly, is responsible for 70% to 80% of these cases.
- Postpartum hemorrhage is the main cause of serious health issues and death related to childbirth
- It is seen in roughly 1% to 6% of all deliveries.
- Uterine atony, a condition where the uterus doesn’t contract as it should after birth, is the most common cause of this bleeding, accounting for 70% to 80% of all such instances.
Signs and Symptoms of Acute Postpartum Hemorrhage
Patients with post-partum bleeding often experience several symptoms. The most obvious one is acute bleeding from the vagina after childbirth. More symptoms can develop as the condition worsens, indicating significant blood loss and possible shock. These may include:
- An increased heart rate
- Increased breathing rate
- Dizziness or faintness when standing up
- Feeling cold
- Drop in blood pressure
- Possibility of becoming unconscious
- Confusion
- Blurry vision
- Clammy skin
- Weakness
Testing for Acute Postpartum Hemorrhage
When a patient is first evaluated, a quick assessment to determine their condition and associated risk factors is carried out. For women who have just given birth, signs of blood loss such as a fast heart rate (tachycardia) and low blood pressure (hypotension) may not be immediately noticeable. So, if these symptoms are apparent, it could indicate a considerable loss of blood volume (more than 25% of total blood volume). Therefore, continually monitoring vital signs and estimating total blood loss plays a crucial role in safeguarding the patient’s health during postpartum hemorrhage (PPH).
Examining the patient during a hemorrhage can help pinpoint the likely source of the bleeding, especially considering any specific risk risks they may present. It’s crucial to rapidly assess the entire genital area for any cuts, swellings from fluid buildup (hematomas), or signs of a broken uterus. Additionally, a manual exam could be performed to check for any remaining placenta tissue, or an ultrasound could be consider by the bedside. A uterus that feels soft to touch, known as a “boggy” uterus, is generally found with uterine atony – a condition where the uterus does not contract properly after childbirth. Seeing a round lump or mass in the cervix or lower part of the uterus might indicate uterine inversion. This could happen due to excessive pulling on the umbilical cord or if the placenta is unusually adhered. If bleeding is widespread, even at places where injections or needles have been used (venipuncture sites), this could hint at a condition known as disseminated intravascular coagulation (DIC), which affects the blood’s ability to clot.
To better understand and manage the patient’s condition during a PPH, the doctor might order some laboratory tests even though treatments such as medication or administering blood shouldn’t wait for these results. They might order a ‘type and screen’ or ‘crossmatch’ test to prepare for a possible blood transfusion. A Complete Blood Count (CBC) can help monitor levels of hemoglobin, hematocrit, and platelets at different intervals. Do bear in mind that lab results often lag behind the actual condition of the patient. Moreover, coagulation studies and fibrinogen tests could be useful if DIC is suspected.
Treatment Options for Acute Postpartum Hemorrhage
The treatment of postpartum hemorrhage, or severe bleeding after childbirth, primarily involves rapidly stabilising the patient’s condition while also identifying and tackling the cause. Keeping the patient stable ensures that vital organs remain properly supplied with blood. Multiple intravenous (IV) lines should be installed for fluid administration, and early start to blood transfusion protocols is essential.
The treatment needs to target the root cause of the bleeding rapidly, with surgery as a potential course of action. This could be for repairing a difficult tear, correcting a uterine inversion (when the uterus turns inside out), helping with pain relief for removing retained products of does tissue left in the womb after birth), or for surgical inspection.
If the bleeding is due to uterine atony – which means the uterus isn’t able to contract properly after birth – treatment can include medicines, using a tamponade (device) inside the uterus, blocking the blood supply to the uterus, or surgery.
Medicine treatment typically starts with uterotonic drugs, which help the uterus contract more effectively. Commonly used drugs include oxytocin: a hormone, methylergonovine: a semi-synthetic drug (not for use with patients with high blood pressure), carboprost: a prostaglandin analog, not suitable for people with severe liver, kidney or heart disease, and misoprostol: a more slowly-acting prostaglandin analog.
If these treatments are not effective, a device may be used to apply pressure in the uterus. This can be an intrauterine balloon filled with saline, or gauze or catheters if a balloon is not available. It’s vital to keep track of everything used to prevent items being left in the uterus by mistake.
If bleeding continues, uterine artery embolization could be an option for a stable patient. In this process, X-ray imaging is used to find and block off the bleeding vessels. However, this is not a suitable solution if the patient’s condition is not stable. When necessary and all other options have failed, exploratory abdominal surgery could be needed to explore the cause of the bleeding such as morbidly adherent placenta and to potentially perform a hysterectomy (removal of the uterus).
If the bleeding is due to causes other than uterine atony, the treatment should be tailored to that specific reason. This might include repair to any tears or wounds, removing remaining tissue after birth, treating hematomas (blood clots), or treating a uterine inversion, for example. This also highlights the importance of quickly identifying the cause of postpartum hemorrhage.
What else can Acute Postpartum Hemorrhage be?
The potential causes of early postpartum hemorrhage (bleeding after childbirth), doctors need to consider include:
- Uterine atony (a condition where the uterus fails to contract after childbirth)
- Lacerations (cuts or tears, typically in the vagina or cervix)
- Uterine inversion (a rare condition where the uterus turns inside out during childbirth)
- Retained placenta (when parts of the placenta remains in the uterus after childbirth)
- Uterine rupture (a serious tear in the wall of the uterus).
These causes need consideration and rule out by doctors to arrive at the correct cause of the bleeding.
What to expect with Acute Postpartum Hemorrhage
Postpartum hemorrhage, or excessive bleeding after childbirth, is a major concern for both mothers and newborns in the United States. Yet, if managed quickly and properly, the health effects can be significantly reduced.
It’s also critical to remember that women who’ve had postpartum hemorrhage in a previous childbirth are more likely to experience it again in future deliveries. The appropriate use of medicines like oxytocin, administered either through a muscle or vein, has been shown to substantially improve patient outcomes.
Possible Complications When Diagnosed with Acute Postpartum Hemorrhage
When a woman has a postpartum hemorrhage, or severe bleeding after giving birth, she could be at risk of something called hypovolemic shock. This can happen if she loses about 20% of her blood. Signs of this condition can include rapid heartbeat, rapid breathing, a narrower difference between the systolic and diastolic blood pressure, and a delay in how quickly blood returns to the skin when pressure is applied and then released. This problem can potentially harm the liver, brain, heart, and kidneys by depriving them of the oxygen and nutrients they need.
Another possible complication linked with heavy blood loss during postpartum hemorrhage is called Sheehan syndrome or postpartum hypopituitarism. This is a condition where the pituitary gland at the base of the brain doesn’t produce adequate amounts of certain hormones.
There are also potential complications linked to the treatments used for postpartum hemorrhage. They include:
- Transfusion-related acute lung injury: A severe reaction to a blood transfusion.
- Infections: These can potentially arise from any medical treatment.
- Hemolytic transfusion reactions: This is a serious allergy-type reaction that can occur during a blood transfusion.
Preventing Acute Postpartum Hemorrhage
There are preventative measures doctors can take to help patients avoid complications after childbirth, such as heavy bleeding. These include actively managing the later part of labor with medication, massaging the uterus, and carefully pulling on the umbilical cord. Recognizing which patients are at higher risk before delivery is really important to prevent issues linked to heavy postpartum bleeding. This helps doctors figure out the best pathway and timing for the birth to take place in the best healthcare setting possible.
Patients who have had previous caesarean sections should have an ultrasound check before birth to help choose the best mode and location for delivery. If a patient has anemia (the level of red blood cells is too low), they should be treated with iron supplements taken orally or injected. This is particularly relevant for those with less than 30% hematocrit (a measurement related to red blood cells). Additionally, doctors should consider consulting with blood specialists about using special medications for boosting the production of red blood cells, especially for high-risk patients who don’t accept blood transfusions.
Standardized, team-based protocols have been effectively used to reduce serious complications after childbirth, particularly postpartum bleeding. Nurses and anesthesiologists should also be aware of the risks of postpartum bleeding and be ready to assist. Simulation training exercises for dealing with heavy postpartum bleeding have also been shown to improve patient outcomes.
