Postpartum Hemorrhage Clinical Guide Causes Diagnosis Management

## **Postpartum Hemorrhage (PPH): Complete SEO-Optimized Clinical Guide**

### **Definition**

**Postpartum hemorrhage (PPH)** is excessive bleeding following childbirth.

* **Primary (early) PPH:** ≥500 mL blood loss after vaginal delivery or ≥1000 mL after cesarean section within **24 hours** of birth.
* **Secondary (late) PPH:** Abnormal or heavy bleeding occurring **24 hours to 6 weeks postpartum**.

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## **Epidemiology and Importance**

* One of the **leading causes of maternal mortality worldwide**
* Can occur **without warning**, even in low-risk pregnancies
* Prompt recognition and structured management are lifesaving

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## **Pathophysiology (Why PPH Occurs)**

After delivery, placental separation exposes uterine blood vessels. Normal hemostasis depends on:

* Effective **uterine contraction**
* Intact **placental removal**
* Normal **coagulation mechanisms**

Failure of any of these leads to hemorrhage.

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## **Causes of PPH – The 4 Ts**

### **1. Tone (Uterine Atony – most common)**

* Uterus fails to contract effectively
* Causes: prolonged labor, overdistended uterus, grand multiparity, oxytocin overuse

### **2. Trauma**

* Genital tract lacerations (cervix, vagina, perineum)
* Uterine rupture or inversion

### **3. Tissue**

* Retained placental tissue
* Placenta accreta spectrum

### **4. Thrombin**

* Coagulation disorders
* DIC, severe preeclampsia, sepsis

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## **Risk Factors**

* Previous PPH
* Multiple pregnancy
* Prolonged or precipitate labor
* Instrumental delivery
* Placenta previa or accreta
* Polyhydramnios
* Severe anemia

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## **Clinical Features**

* Excessive vaginal bleeding
* Boggy or enlarged uterus
* Hypotension, tachycardia
* Pallor, dizziness, altered sensorium
* Reduced urine output (late sign)

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## **Diagnosis**

Primarily **clinical**

### Supportive Investigations:

* Hemoglobin and hematocrit
* Blood group and cross-match
* Coagulation profile
* Bedside ultrasound (retained tissue)

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## **Management of PPH (Stepwise and Life-Saving)**

### **Immediate Actions (Golden Hour)**

* Call for help
* Secure **two large-bore IV lines**
* Start crystalloids
* Oxygen via face mask
* Monitor vitals and urine output

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### **Uterotonic Drugs (First-Line Treatment)**

#### **Oxytocin**

* **Indication:** First-line uterine atony
* **Dose:** 10 IU IM or 20–40 IU IV infusion
* **Mechanism:** Increases uterine smooth muscle contraction
* **Adverse effects:** Hypotension (rapid IV), water intoxication
* **Monitoring:** Uterine tone, blood pressure

#### **Methylergometrine**

* **Dose:** 0.2 mg IM
* **Mechanism:** Sustained uterine contraction
* **Contraindications:** Hypertension, heart disease
* **Adverse effects:** Hypertension, nausea

#### **Carboprost (15-methyl PGF₂α)**

* **Dose:** 250 µg IM every 15 min (max 8 doses)
* **Contraindications:** Asthma
* **Adverse effects:** Bronchospasm, diarrhea

#### **Misoprostol**

* **Dose:** 800–1000 µg per rectal
* **Use:** When injectables unavailable
* **Adverse effects:** Fever, shivering

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### **Mechanical and Surgical Measures**

* Bimanual uterine massage
* Uterine balloon tamponade (Bakri balloon)
* Uterine artery ligation
* Internal iliac artery ligation
* **Hysterectomy** (last resort, life-saving)

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### **Blood and Coagulation Management**

* Packed RBC transfusion
* Fresh frozen plasma
* Platelets if thrombocytopenia
* Treat DIC aggressively

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## **Management of Secondary PPH**

* Antibiotics (endometritis)
* Evacuation of retained products
* Uterotonics
* Surgical intervention if needed

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## **Prevention of PPH**

### **Active Management of Third Stage of Labor (AMTSL)**

* Prophylactic oxytocin
* Controlled cord traction
* Uterine massage

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## **Complications**

* Hypovolemic shock
* Acute kidney injury
* Sheehan syndrome
* Maternal death

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## **Prognosis**

Excellent with **early recognition and structured management**. Delays increase morbidity and mortality.

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## **Key Takeaways for Exams and Practice**

* **Uterine atony is the most common cause**
* Always follow the **4 Ts approach**
* Treat clinically—do not wait for lab reports
* Hysterectomy is **life-saving, not failure**

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