Postpartum hemorrhage (PPH) is defined as blood loss of 500 ml or more within 24 hours of childbirth.
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It is a leading cause of maternal morbidity and mortality worldwide. PPH can occur due to various factors, including uterine atony, retained placental tissue, genital tract trauma, and coagulation disorders. The immediate causes of postpartum hemorrhage can be categorized as follows:
1. Uterine Atony:
- Primary Cause: Failure of the uterus to contract effectively after childbirth, leading to inadequate hemostasis and excessive bleeding.
- Risk Factors: Overdistended uterus (e.g., multiple gestation, polyhydramnios), prolonged labor, precipitous labor, uterine overdistention (e.g., macrosomia, polyhydramnios), uterine fibroids, magnesium sulfate administration for preeclampsia or eclampsia.
- Clinical Presentation: Soft, boggy uterus on palpation, continued or heavy vaginal bleeding despite controlled cord traction, retained placenta or placental fragments.
2. Retained Placental Tissue:
- Primary Cause: Incomplete expulsion of the placenta or retained placental fragments following childbirth, leading to ongoing bleeding from the placental site.
- Risk Factors: Placenta accreta, increta, or percreta, previous uterine surgery (e.g., cesarean section), adherent retained placenta, manual removal of the placenta, placental anomalies.
- Clinical Presentation: Prolonged third stage of labor, persistent or heavy bleeding despite uterine massage and contraction, signs of infection (if retained tissue becomes necrotic).
3. Genital Tract Trauma:
- Primary Cause: Injury to the genital tract structures (vagina, cervix, perineum) during childbirth, leading to lacerations or tears that result in bleeding.
- Risk Factors: Instrumental delivery (forceps or vacuum extraction), episiotomy, rapid or precipitous delivery, macrosomia, malpresentation (e.g., breech or shoulder dystocia).
- Clinical Presentation: Visible tears or lacerations on examination, brisk bleeding from laceration sites, signs of perineal or vaginal hematoma, pain or discomfort in the perineal area.
4. Coagulation Disorders:
- Primary Cause: Impaired coagulation function or coagulopathy, leading to inadequate blood clotting and persistent bleeding.
- Risk Factors: Preexisting coagulation disorders (e.g., von Willebrand disease, hemophilia), acquired coagulopathies (e.g., disseminated intravascular coagulation [DIC], amniotic fluid embolism), massive transfusion, sepsis, liver dysfunction (e.g., HELLP syndrome, acute fatty liver of pregnancy).
- Clinical Presentation: Abnormal laboratory findings (prolonged prothrombin time [PT], activated partial thromboplastin time [aPTT], low platelet count), diffuse bleeding from multiple sites, signs of hypoperfusion or shock.
5. Uterine Rupture:
- Primary Cause: Full-thickness separation or tear in the uterine wall, typically at a previous cesarean scar site or uterine incision, leading to catastrophic hemorrhage.
- Risk Factors: Previous uterine surgery (e.g., cesarean section, myomectomy), uterine anomalies, previous uterine rupture, grand multiparity, excessive uterine stimulation (e.g., oxytocin augmentation), trauma during labor.
- Clinical Presentation: Sudden onset of severe abdominal pain, abnormal fetal heart rate patterns, signs of hypovolemic shock, loss of uterine tone, palpable fetal parts outside the uterus.
6. Other Rare Causes:
- Amniotic Fluid Embolism: Rare but potentially fatal complication characterized by embolization of amniotic fluid components into the maternal circulation, leading to disseminated intravascular coagulation, hypoxia, and cardiovascular collapse.
- Uterine Inversion: Inversion of the uterus into the uterine cavity or vagina, leading to obstruction of uterine blood flow and hemorrhage.
- Placental Abruption: Premature separation of the placenta from the uterine wall, resulting in concealed or external hemorrhage and fetal compromise.
Immediate Management:
- Uterine Massage: Manual massage of the uterine fundus to stimulate uterine contractions and control bleeding.
- Uterotonic Medications: Administration of uterotonic agents (e.g., oxytocin, misoprostol, methylergonovine) to promote uterine contraction and reduce bleeding.
- Bimanual Uterine Compression: Application of bimanual compression to the uterus to enhance uterine contraction and control hemorrhage.
- Fluid Resuscitation: Intravenous fluid administration to restore intravascular volume and support hemodynamic stability.
- Blood Transfusion: Transfusion of blood products (packed red blood cells, fresh frozen plasma, platelets) to correct anemia and coagulation abnormalities.
- Surgical Intervention: Emergency procedures such as manual removal of retained placental tissue, repair of genital tract lacerations, or cesarean hysterectomy in refractory cases.
Postpartum hemorrhage requires prompt recognition, aggressive intervention, and coordinated management to prevent maternal morbidity and mortality. Effective communication, teamwork, and adherence to established protocols are essential for optimizing outcomes in cases of PPH.