POSTPARTUM HEMORRHAGE (PPH) Part 2

Last week, we started a topic on postpartum hemorrhage (PPH). We defined PPH, explained the types, risk factors and causes. This week, we will conclude with other causes of PPH, symptoms, diagnosis, prevention and treatment.

Other causes of PPH include:

• Uterine inversion – a less common condition in which the uterus (womb) turns inside out following birth.

• Uterine rupture – occurs when the uterus ruptures during labor. This is more likely if there is a uterine scar from a previous C-section or uterine surgery.

• Bleeding disorders that are diagnosed at birth or during pregnancy

• Use of induction medications – induction medications used pre-delivery may cause uterine muscle to become less sensitive, making post-delivery uterine contractions difficult.

• Abnormal placentation – multiple cesarean sections combined with abnormal placental implantation can result in hemorrhage. With rising cesarean section rates, clinicians may use targeted ultrasound and MRI to diagnose this condition prior to delivery and then prepare a multidisciplinary team for a surgery that can avoid severe bleeding. This often leads to the surgical removal of the womb (hysterectomy). However, if the placental invasion is not too deep, the womb can be saved.

SYMPTOMS

Persistent, excessive bleeding after delivery is the most common symptom of postpartum hemorrhage. Other symptoms include:

• Low red blood cell count

• Signs of low blood pressure such as dizziness, blurred vision, feeling faint or excessive tiredness

• Increased heart rate

• Feeling disoriented

• Fetal bradycardia – a condition where the fetal heart rate is slower than 110 beats per minute before delivery

• Maternal tachycardia – a condition where the mother’s heart rate is abnormally high after delivery

• Vomiting or nausea

• Increased abdominal tenderness, pelvic pain or acute discomfort

• Fever chills

• Pale skin, intense ringing in the ears

• Loss of uterine contractions and excessive vaginal bleeding

DIAGNOSIS

Postpartum hemorrhage is diagnosed through visual, physical examinations, a thorough review of patient medical history and lab tests. One common method for estimating blood loss is to measure the volume of collected blood and weigh the blood-soaked pads or sponges from delivery. Other diagnosis includes:

• Continuous monitoring of pulse rate and blood pressure.
• Blood tests to determine the concentration of red blood cells (hematocrit) and clotting factors.
• Ultrasound scans to obtain a detailed image of the uterus, placenta and other organs.
• Pelvic exam to assess the vagina, uterus, and cervix in order to pinpoint the source of the bleeding.

PREVENTION

The best way to prevent postpartum hemorrhage is to identify those who are at high risk before delivery. This is dependent on patients’ disclosure of medical history and symptoms to the obstetric gynecologist. Ensuring adequate iron intake and red blood cell levels during pregnancy can help to reduce the severity of postpartum hemorrhage if it occurs.

Antenatal screening and treatment for anaemia.

Avoid excessive weight gain.

Women of African, Southeast Asian, or Mediterranean descent should be tested for sickle cell disease.

Sonograms should be performed on women who are at high risk of having an invasive placenta.

If the patient is at high risk of hemorrhage, delivery should be done in a facility with a blood bank and in-house surgical services.

Identify religious patients who may not consent to blood transfusion.

Avoid regular episiotomy (a cut made in the tissue between the vaginal opening and the anus during childbirth to make the vaginal opening larger for the baby to pass through).

Avoid forceps and other instrumented deliveries as much as possible.

Use warm compresses on the perineum when recommended.

Furthermore, some experts advise breastfeeding as soon as possible after giving birth to stimulate the release of oxytocin or the injection could be given after delivery. This aids in the contraction of the womb and helps with the expulsion of the placenta.

Shortly after giving birth, emptying the bladder via voiding in vaginal delivery or the use of catheter in Caesarean section birth may also help prevent PPH.

Training of midwives and obstetricians in postpartum care to prevent hemorrhage.

TREAMENT

In most cases, PPH is treated as an emergency. The goal is to stop the source of the bleeding as soon as possible and to replace blood volume. Treatment of PPH includes:

Massaging the uterus to help the muscles contract in vaginal delivery.

Use of IV fluids and medications such as oxytocin to stimulate contractions.

Removing retained placental tissue.

Putting pressure on the uterine walls with a catheter or balloon.

Repairing vaginal, cervical, and uterine tears or lacerations.

Using sterile gauze to pack the uterus.

Uterine artery embolization (sealing the blood vessels that supply the uterus).

Tying off the blood vessels by the delivery OBGyn.

Transfusion of blood.

CONCLUSION

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide, accounting for roughly one-quarter of all maternal deaths. Excess maternal mortality requires a multidisciplinary team’s coordinated approach to prevention, early detection, and intervention. Although some women have PPH risk factors that can be identified during pregnancy, labor, or births, the majority of women with severe PPH do not have any risk factor. As a result, all pregnant women should be considered at risk of PPH and monitored appropriately before, during and after birth.