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Updated: Jun 5 2020

Postpartum Hemorrhage

  • 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
    • 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
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