Postpartum Hemorrhage

-Postpartum hemorrhage is a condition in which a woman loses a very large amount of blood after childbirth.

-An obstetric emergency.

-Key features: (1) cumulative blood loss ≥1000 mL or (2) bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process regardless of delivery route.

-The most common cause of PPH: Uterine atony

-Risk factors: trauma, retained placenta, membranes, failure to progress during the second stage of labor, lacerations, instrumental delivery, macrosomy, preeclampsia, eclampsia, HELLP syndrome, induction of labor, placental abruption, placenta previa, acquired or congenital coagulation defects.

-Prophylactic use of oxytocin during labor reduces the risk of PPH.

-Diagnosis:

Clinical: Tachypnea, tachycardia, hypotension, low oxygen saturation, and air hunger are signs of hypovolemia due to hemorrhage

Labs:Complete blood count, Prothrombin time, activated partial thromboplastin time, fibrinogen level, HCG, Thromboelastography (TEG) and rotational thromboelastometry (ROTEM), where available; Ultrasound, CT, MRI

-Treatment: Volume resuscitation, blood transfusion, Coagulopathy is treated medically, with transfusion of blood and blood products.

-Treat the cause of bleeding (manage atony, repair lacerations, remove any retained placental fragments, manually replace an inverted uterus if present, hysterectomy if there is uterine rupture.

Surgical: dilation and curettage, suction curettage, arterial embolization,Ligation of the uterine and utero-ovarian arteries. intrauterine balloon tamponade, pelvic packing, laparotomy,Hysterectomy in resistant cases

-Hyperfibrinolysis and fibrinogen depletion are common in the early stages of bleeding. Therefore, an early administration of tranexamic acid, an anti-fibrinolytic drug, can reduce death due to bleeding in women with postpartum hemorrhage related to atony or trauma.

-Tranexamic acid should not be mixed with blood or given through a line with blood, or mixed with solutions containing penicillin.

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