Postpartum bleeding

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Postpartum bleeding
Classification and external resources
ICD-10 O72
ICD-9 666
eMedicine article/275038
Patient UK Postpartum bleeding
MeSH D006473

Postpartum bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or 1,000 ml of blood within the first 24 hours following childbirth.[1] Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist.[2] Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breath rate.[3] As more blood is lost the women may feel cold, their blood pressure may drop, and they may become restless or unconscious.[3] The condition can occur up to six weeks following delivery.[2]

The most common cause is poor contraction of the uterus following childbirth. Not all of the placenta being delivered, a tear of the uterus, or poor blood clotting are other possible causes. It occurs more commonly in those who: already have a low amount of red blood, are Asian, with bigger or more than one baby, are obese or are older than 40 years of age. It also occurs more commonly following caesarean sections, those in whom medications are used to start labor, and those who have an episiotomy.[1]

Prevention involves decreasing known risk factors including if possible procedures associated with the condition and giving the medication oxytocin to stimulate the uterus to contract shortly after the baby is born. Misoprostol may be used instead of oxytocin in resource poor settings. Treatments may include: intravenous fluids, blood transfusions, and the medication ergotamine to cause further uterine contraction. Efforts to compress the uterus using the hands may be effective if other treatments do not work. The aorta may also be compressed by pressing on the abdomen. The World Health Organization has recommended non-pneumatic anti-shock garment to help until other measures such as surgery can be carried out.[1]

In the developing world about 1.2% of deliveries are associated with PPH and when PPH occurred about 3% of women died.[1] Globally it results in 44,000 to 86,000 deaths per year making it the leading cause of death during pregnancy.[1][4] About 0.4 women per 100,000 deliveries die from PPH in the United Kingdom while about 150 women per 100,000 deliveries die in sub-Saharan Africa. Rates of death have decreased substantially since at least the late 1800s in the United Kingdom.[1]

Definition[edit]

Depending on the definition in question, postpartum hemorrhage is defined as more than 500ml or 1000ml of blood loss in the first 24 hours following delivery.[1]

Signs and symptoms[edit]

Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breath rate.[3] As more blood is lost the women may feel cold, their blood pressure may drop, and they may become unconscious.[3]

Causes[edit]

Causes of postpartum hemorrhage[5]
Cause Incidence
Uterine atony 70%
Trauma 20%
Retained tissue 10%
Coagulopathy 1%

Causes of postpartum hemorrhage are uterine atony, trauma, retained placenta, and coagulopathy, commonly referred to as the "four Ts":[5]

  • Tone: uterine atony is the inability of the uterus to contract and may lead to continuous bleeding. Retained placental tissue and infection may contribute to uterine atony. Uterine atony is the most common cause of postpartum hemorrhage.[6]
  • Trauma: Injury to the birth canal which includes the uterus,cervix,vagina and the Perineum which can happen when the delivery is not monitored properly.The bleeding is substantial as all these organs become more vascular during pregnancy.
  • Tissue: retention of tissue from the placenta or fetus may lead to bleeding.
  • Thrombin: a bleeding disorder occurs when there is a failure of clotting, such as with diseases known as coagulopathies.

Prevention[edit]

Oxytocin is typically used right after the delivery of the baby to prevent PPH.[1] Misoprostol may be used in areas where oxytocin is not available.[1] Early clamping of the umbilical cord does not decrease risks and may cause anemia in the baby, thus is usually not recommended.[1]

Management[edit]

Medication[edit]

Intravenous oxytocin is the drug of choice for postpartum hemorrhage.[7] Ergotamine may also be used.[1]

Tranexamic acid, a medication to promote blood clotting, may also be used, however evidence is not yet strong.[1]

Medical devices[edit]

A nonpneumatic anti-shock garment (NASG)

The World Health Organization started recommending the use of a device called the nonpneumatic anti-shock garment (NASG) in 2012 for use in delivery activities outside of a hospital setting, the aim being to reverse shock in a mother suffering from obstetrical hemorrhage long enough to reach a hospital.[8]

Protocol[edit]

A detailed stepwise management protocol has been introduced by the California Maternity Quality Care Collaborative.[9] It describes 4 stages of obstetrical hemorrhage after childbirth and its application reduces maternal mortality.[10]

A Cochrane review suggests that active management (use of uterotonic drugs, cord clamping and controlled cord traction) during the third stage of labour reduces severe bleeding and anemia.[11] However, the review also found that active management increased the mother's blood pressure, nausea, vomiting, and pain. In the active management group more women returned to hospital with bleeding after discharge, and there was also a reduction in birthweight due to infants having a lower blood volume. Another Cochrane review looking at the timing of the giving oxytocin as part of the active management found similar benefits with giving it before or after the expulsion of the placenta.[12]

Epidemiology[edit]

Methods of measuring blood loss associated with childbirth vary, complicating comparison of prevalence rates.[13] A systematic review reported the highest rates of PPH in Africa (27.5%), and the lowest in Oceania (7.2%), with an overall rate globally of 10.8%.[13] The rate in both Europe and North America was around 13%.[13] The rate is higher for multiple pregnancies (32.4% compared with 10.6% for singletons), and for first-time mothers (12.9% compared with 10.0% for women in subsequent pregnancies).[13] The overall rate of severe PPH (>1000 ml) was much lower at an overall rate of 2.8%, again with the highest rate in Africa (5.1%).[13]

See also[edit]

References[edit]

  1. ^ a b c d e f g h i j k l Weeks, A (January 2015). "The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next?". BJOG : an international journal of obstetrics and gynaecology 122 (2): 202–10. PMID 25289730. 
  2. ^ a b Gibbs, Ronald S (2008). Danforth's obstetrics and gynecology (10th ed. ed.). Philadelphia: Lippincott Williams & Wilkins. p. 453. ISBN 9780781769372. 
  3. ^ a b c d Lynch, Christopher B- (2006). A textbook of postpartum hemorrhage : a comprehensive guide to evaluation, management and surgical intervention. Duncow: Sapiens Publishing. pp. 14–15. ISBN 9780955228230. 
  4. ^ GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.". Lancet. PMID 25530442. 
  5. ^ a b Anderson JM, Etches D (March 2007). "Prevention and management of postpartum hemorrhage". American Family Physician 75 (6): 875–82. PMID 17390600. 
  6. ^ "Overview of postpartum hemorrhage". 
  7. ^ WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization. 2012. ISBN 9789241548502. 
  8. ^ Craig, Elise (December 2013). "A Life Preserver For New Moms". Alpha. WIRED. p. 52. 
  9. ^ [1] CMQCC guidelines, accessed August 10, 2009
  10. ^ Barbieri RL. "Planning reduces the risk of maternal death. This tool helps". OBG Management (2009) 21 (8):8-10. 
  11. ^ Begley, C; Gyte G; Devane D; McGuire W; Weeks A (2011). "Active versus expectant management for women in the third stage of labour". Cochrane Database of Systematic Reviews (11). doi:10.1002/14651858.CD007412.pub3. 
  12. ^ Soltani H, Hutchon DR, Poulose TA. (2010). Soltani, Hora, ed. "Timing of prophylactic uterotonics for the third stage of labour after vaginal birth". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD006173.pub2. 
  13. ^ a b c d e Calvert, C; Thomas, SL; Ronsmans, C; Wagner, KS; Adler, AJ; Filippi, V (2012). "Identifying regional variation in the prevalence of postpartum haemorrhage: a systematic review and meta-analysis.". PloS one 7 (7): e41114. doi:10.1371/journal.pone.0041114. PMID 22844432. 

External links[edit]