Last week Dr Williamdon Adims told the story of a woman who had PPH, and as usual, we follow up stories with a corresponding educating post on the subject matter. So, here it is.
Postpartum haemorrhage (PPH) is a blood loss within 24 hours of delivery of 500 ml or more. PPH accounts for nearly a quarter of all maternal deaths, causing 140,000 deaths each year globally, this is like one woman dying in every 4 minutes. In low- income countries, it is the leading cause of maternal mortality. Even when vaginal deliveries are appropriately handled, studies show that 3% will result to PPH.
Types
PPH is classified into two types,
•Primary
•Secondary
Primary is defined as a blood loss of 500ml or more through vaginal delivery or of 1500ml due to Caesarian section within 24 hours of delivery. This is seen in about 5% of all deliveries.
Secondary is defined as heavy vaginal blood loss occurring at least 24 hours after the end of the third stage of labour.
Causes of PPH
Causes of PPH are usually referred to as the “4Ts”
• Tone
Poor contraction of the uterus following child birth, and resulting to continuous bleeding is known as uterine atony. It is the most common cause of PPH. Factors that may contribute to uterine atony are infection and retained placental (not all of the placenta being delivered) tissue.
• Tissue
Retained placental or fetal tissue as well as placental abnormalities such as placenta accreta (placenta grows too deeply into the uterine wall and part or all remain attached after birth) and percreta (the placenta grows through the uterus, extending to nearby organs), may lead to bleeding.
• Trauma
Even when delivery is monitored properly, injury to the birth canal which includes the uterus, cervix, vagina and the perineum can happen. These organs receive more blood supply during pregnancy and therefore amount of blood lost is significant.
• Thrombin
When there is a disorder of the enzyme (thrombin) that facilitates blood clotting, excessive bleeding is the result. Other blood coagulation disorders could also be implicated.
Risk factors
It occurs more commonly in those who:
• Are anaemic
• Are obese
• Are older than 40 years of age
• Are Asian
• Have had caesarean section
• Medications are used to start labor
• Require the use of a vacuum or forceps
• Had posterior vagina incision during delivery
• Had bleeding before delivery
• Have heart disease
• Had prolonged labor,
• Have preeclampsia
• Gave birth to a larger than average baby
• Have multiple birth
• Have Von Willebrand Disease (a blood clotting disorder)
Signs and symptoms
Initial signs and symptoms correspond with that of circulatory shock and include an increased heart and breathing rate, and dizziness. As bleeding progresses, there’s hypothermia (cold), decreased blood pressure and restlessness or unconsciousness. This condition can be seen up to six weeks following delivery.
Complications
Heavy PPH leads to complication like kidney failure, disseminated intravascular coagulation, liver dysfunction, acute respiratory distress syndrome and even death.
Other complications are anaemia, myocardial ischemia (obstruction of blood flow to the heart), postpartum depression and delay or failure of lactation caused by anterior pituitary ischemia.
Management
• Uterine massage
Uterine massage is a simple treatment as it helps the uterus to contract to reduce bleeding. Although the evidence around the effectiveness of uterine massage is inconclusive, it is common practice after the delivery of the placenta.
• Medications
Intravenous oxytocin is the drug of choice for postpartum hemorrhage. Oxytocin functions as a uterotonic, helping the uterus to contract quickly with long lasting effect. The risk of PPH is reduced if oxytocin is given after placental delivery instead of at the time of anterior shoulder delivery.
Other drugs include ergotamine, syntocinon, ergometrine, a combination of syntocinon and ergometrine called syntometrine, carbetocin, traxenamic acid and misoprostol.
• Surgery
Surgery is used if medical management fails or if there are cervical lacerations or tear or uterine rupture. When the bleeding is caused by uterine rupture, a repair can be performed but in majority of cases, removal of the womb is needed.
• Medical Devices
The World Health Organization recommends that non-pneumatic anti-shock garment (NASG) be used in delivery activities outside of a hospital setting. The NASG is a first aid device used to stabilize a mother with hypovolemic shock due to blood loss, long enough to reach a hospital. External aortic compression devices (EACD) and uterine balloon tamponade may also be used.
I hope this was enlightening.
Stay safe!
Maureen
Medtrix 