Snapshot A 17 year-old G1P1 woman undergoes a spontaneous delivery of a 4200 g (9 lb 4 oz) newborn boy with Apgar scores of 8 and 9 at 1 and 5 minutes. She began experiencing the onset of regular contractions 8 hours before delivery. She was administered IV oxytocin for the last 5 hours of labor. After the placenta was delivered, she experienced postpartum hemorrhage with an estimated blood loss of 1200 mL. Introduction Overview postpartum hemorrhage is defined as blood loss of ≥ 500 mL after vaginal delivery or > 1000mL of blood after cesarean delivery leading cause of maternal mortality Epidemiology Incidence occurs in approximately 5-13% of pregnancies in the US and industrialized countries ETIOLOGY Pathophysiology usually occurs immediately after the delivery of the placenta potential etiologies uterine atony most common (90% of postpartum hemorrhages) defined as a boggy and enlarged uterus normally, the uterus contacts and compresses down on spiral arteries uterine atony and failure of contraction can lead to rapid and severe hemorrhage retained placental tissue occurs when separation of placenta from uterine wall or expulsion of placenta is incomplete may occur with placenta accreta complete detachment and expulsion of the placenta allows uterine retraction and ↑ occlusion of blood vessels trauma (i.e., lacerations) uterine rupture most common in patients with previous cesarean delivery scars cervical laceration is most commonly associated with forceps delivery vaginal sidewall laceration is associated with operative vaginal delivery lower vaginal trauma may occur due to episiotomy coagulation disorder underlying bleeding disorders should be considered in woman with the following risk factors history of menorrhagia family history of bleeding disorders personal history of severe bruising without known injury epistaxis of > 10min duration acquired coagulation abnormalities (i.e., DIC) disseminated intravascular coagulation (DIC) may be related to abruptio placentae (see illustration), HELLP syndrome, intrauterine fetal demise, and amniotic fluid embolism uterine inversion occurs when the uterine fundus is pulled inferiorly into the uterine cavity Presentation Symptoms heavy vaginal bleeding signs and symptoms of hypovolemic shock tachycardia quick, shallow breathing weakness and fatigue confusion cool and clammy skin Treatment Medical fluid resuscitation blood transfusion fresh frozen plasma and cryoprecipitate infusions if abnormal coagulation test findings manage underlying causes uterine atony bimanual uterine massage to stimulate contractions oxytocin administration Surgical suturing of lacerations uterine artery ligation uterine arteries provide 90% of uterine blood flow hysterectomy curative for bleeding arising from the uterus, cervix, and vagina Complications Hemodynamic instability and organ failure incidence up to 60% of women wiht postpartum hemorrhage treatment fluids and blood transfusion Sheehan syndrome (i.e., postpartum hypopituitarism) pituitary gland is prone to infarction from hypovolemic shock due to severe postpartum hemorrhage incidence rare treatment supplementation of pituitary hormones