Obstetric Haemorrhage
Last updated 4th October 2018 by Tom Heaton
Bleeding during delivery is common but usually minor, and well compensated for by the physiological changes of pregnancy.
However, major haemorrhage is a significant cause of maternal morbidity and mortality throughout pregnancy.
Life threatening haemorrhage occurs in around 6.7 per 1000 deliveries.
Bleeding in pregnancy can be categorized into 3 main categories:
However, major haemorrhage is a significant cause of maternal morbidity and mortality throughout pregnancy.
Life threatening haemorrhage occurs in around 6.7 per 1000 deliveries.
Bleeding in pregnancy can be categorized into 3 main categories:
- Bleeding in early pregnancy - before 24 weeks gestation
- Antepartum haemorrhage - after 24 weeks gestation
- Postpartum haemorrhage
- Early - <24 hours
- Late - 24h - 6 weeks
- Early - <24 hours
The aetiology of the bleeding is different in each category.
Bleeding in early pregnancy:
Antepartum haemorrhage
Early postpartum haemorrhage:
Late postpartum haemorrhage
Rarely, other causes can lead to major haemorrhage e.g. splenic or hepatic haemorrhage in pre-eclampsia patients.
Many of the principles in management will be similar in each category, but there will also be some significant differences.
Bleeding in early pregnancy:
- Ruptured ectopic
- Incomplete abortion
Antepartum haemorrhage
- Placenta praevia
- Placental abruption
- Uterine rupture
Early postpartum haemorrhage:
- Uterine atony
- Genital tract trauma
- Adherent placenta (e.g. accreta)
- Retained products of conception
- Coagulopathy
- Uterine inversion
Late postpartum haemorrhage
- Retained products of conception
- Puerperal sepsis
Rarely, other causes can lead to major haemorrhage e.g. splenic or hepatic haemorrhage in pre-eclampsia patients.
Many of the principles in management will be similar in each category, but there will also be some significant differences.
Massive Obstetric Haemorrhage
This is variably defined as:
Some important aspects include:
- Blood loss > 1500ml
- Hb drop > 4g/dl
- Transfusion requirements > 4 units PRBC
Some important aspects include:
- Uterine blood flow in pregnancy is 700-900ml/min (12% of cardiac output) - exsanguination can be rapid.
- Uterine bleeding can be hard to control
- The beneficial physiological changes of pregnancy to cope with haemorrhage (increased plasma volume, increased stroke volume) can mask the signs usually associated with it
- Blood loss can be hard to estimate because of the presence of amniotic fluid (and concealment) - volume replacement should usually be instigated early
- Smaller patients will need lower thresholds as such blood loss will reflect a greater percentage of their circulating volume.
Management
Much of the management is the same, regardless of the nature of the haemorrhage.
There will of course be some variations in ante and postpartum haemorrhage.
An A to E assessment process will help provide a structured approach.
This will include:
Consider these factors which will be related to the nature of bleeding.
There will of course be some variations in ante and postpartum haemorrhage.
An A to E assessment process will help provide a structured approach.
This will include:
- Get help early
- 15L NRB mask O2
- Left lateral position if antenatal - can consider leg raise
- Establish large bore access - x2 16g cannula
- Send bloods:
- Cross match 6 units PRBC
- FBC
- Coagulation profile
- Cross match 6 units PRBC
- Provide volume resuscitation
- Activate massive haemorrhage protocol if suspicion of need
- Crystalloid as temporising measure
- PRBC as soon as possible - O negative or type specific
- Warm all fluids
- Activate massive haemorrhage protocol if suspicion of need
Consider these factors which will be related to the nature of bleeding.
- Surgical management
- Delivery of the foetus in major APH is likely to be needed
- Specific surgical interventions may be need in PPH, including hysterectomy
- Delivery of the foetus in major APH is likely to be needed
- Pharmacological management
- There are number of uterotonic agents used for PPH
- Avoid uterine relaxants in PPH
- Tranexamic acid may play a role in major haemorrhage
- There are number of uterotonic agents used for PPH
Anaesthetic Management
This will be guided by the clinical scenario, including the condition of both the mother and foetus (if antepartum).
In general, if there is cardiovascular compromise, general anaesthesia will likely be the method of choice, because of the potential disastrous effect of neuraxial blockade on sympathetic tone (coagulopathy may also develop rapidly in these patients).
A stable induction will be essential.
Ketamine and etomidate have pharmacologically advantageous profiles for this, but skilled use of propofol and thiopentone may still allow relative CVS stability.
Additional intraoperative factors include:
In general, if there is cardiovascular compromise, general anaesthesia will likely be the method of choice, because of the potential disastrous effect of neuraxial blockade on sympathetic tone (coagulopathy may also develop rapidly in these patients).
A stable induction will be essential.
Ketamine and etomidate have pharmacologically advantageous profiles for this, but skilled use of propofol and thiopentone may still allow relative CVS stability.
Additional intraoperative factors include:
- Establishing invasive BP monitoring
- Employing cell-salvage (where time and facilities allow)
- Minimising uterine relaxation by avoiding excessive volatile anaesthetic agent doses.
Transfusion
The important principles in massive obstetric haemorrhage are to maintain adequate intravascular volume and oxygen carrying capacity.
Initial resuscitation with crystalloids can achieve the former, but RBC transfusion may be required, especially in massive haemorrhage.
Thresholds and triggers have been hard to define due to the variation in speed of bleeding, and the subsequent challenges of clinical detection and biochemical detection.
Even point of care testing of haemoglobin can be misleading in rapid haemorrhage.
As such, guidance is to combine clinical and biochemical assessment to guide transfusion practice.
Many aspects of major haemorrhage in other contexts therefore also apply:
Initial resuscitation with crystalloids can achieve the former, but RBC transfusion may be required, especially in massive haemorrhage.
Thresholds and triggers have been hard to define due to the variation in speed of bleeding, and the subsequent challenges of clinical detection and biochemical detection.
Even point of care testing of haemoglobin can be misleading in rapid haemorrhage.
As such, guidance is to combine clinical and biochemical assessment to guide transfusion practice.
Many aspects of major haemorrhage in other contexts therefore also apply:
- Group O negative blood if needing urgently
- The use of ‘major haemorrhage packs’ for appropriate blood product ratios
Antepartum Haemorrhage
As noted above, this is defined as bleeding in pregnancy at a gestation of greater than 24 weeks (i.e. once foetal viability has been reached).
It complicates approximately 3% of pregnancies.
There is a particular increase in perinatal morbidity and mortality, but also a risk to the mother.
The causes, as noted above, include:
The Royal College of Obstetricians and Gynaecologists (RCOG) have produced guidance on APH: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg63/
It complicates approximately 3% of pregnancies.
There is a particular increase in perinatal morbidity and mortality, but also a risk to the mother.
The causes, as noted above, include:
- Placental abruption (about ⅓)
- Placenta praevia (about ⅓)
- Other causes e.g. uterine rupture, vasa praevia (about ⅓)
The Royal College of Obstetricians and Gynaecologists (RCOG) have produced guidance on APH: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg63/
Management
A to E assessment as with other critically ill patients, and will be similar to the general measures
Specific points include:
Foetal assessment will form an important part of the overall assessment and subsequent management plan.
Assessment of foetal heart rate can provide information on whether there is foetal compromise and thus on the urgency of ongoing care.
Specific points include:
- Establish wide bore IV access (2 x 16g cannula)
- Send bloods - FBC, Coagulation
- Crossmatch blood - 6 units PRBC. Consider major haemorrhage protocols if indicated. Be aware of the potential for coagulopathy.
- Catheterise
Foetal assessment will form an important part of the overall assessment and subsequent management plan.
Assessment of foetal heart rate can provide information on whether there is foetal compromise and thus on the urgency of ongoing care.
Placental Abruption
This is where there is premature separation of the the placenta from the uterine wall.
It can occur at any time in the pregnancy and may be partial or complete.
Risk factors include:
This is a nice introductory video from the team at Osmosis: https://www.youtube.com/watch?v=2bPBNSgkPDo
It can occur at any time in the pregnancy and may be partial or complete.
Risk factors include:
- Previous abruption (biggest risk)
- Smoking
- Cocaine use
- Uterine distension e.g. polyhydramnios, multiple pregnancy
- Abdominal trauma e.g. RTC, domestic violence
- Hypertension
- Pre-eclampsia
This is a nice introductory video from the team at Osmosis: https://www.youtube.com/watch?v=2bPBNSgkPDo
Presentation
The presentation is one of abdominal pain +/- vaginal bleeding.
The presentation may be divided into:
In the revealed form, blood will drain out the cervix.
The volume of blood can still be totally unrelated to the total blood loss, but is more likely associated with a incomplete abruption.
The bleeding results in myometrial irritation and abdominal pain.
This abdominal pain is usually continuous, but the bleeding can also trigger uterine contractions and the onset of labour.
The uterus will often be tender, and can be described as feeling ‘woody’.
The clinical picture can be very variable, but important consideration include:
The presentation may be divided into:
- Revealed - bleeding occur PV (80%)
- Concealed - no bleeding PV (20%)
In the revealed form, blood will drain out the cervix.
The volume of blood can still be totally unrelated to the total blood loss, but is more likely associated with a incomplete abruption.
The bleeding results in myometrial irritation and abdominal pain.
This abdominal pain is usually continuous, but the bleeding can also trigger uterine contractions and the onset of labour.
The uterus will often be tender, and can be described as feeling ‘woody’.
The clinical picture can be very variable, but important consideration include:
- Hypovolemia -
- there may be significant hypovolemia resulting from this haemorrhage and the mother may be overtly shocked.
- Some mothers may have no hypovolaemia.
- there may be significant hypovolemia resulting from this haemorrhage and the mother may be overtly shocked.
- Foetal distress
- The disruption of placental blood flow can again be variable, resulting in varying degrees of foetal hypoxia and distress, or even death.
- The disruption of placental blood flow can again be variable, resulting in varying degrees of foetal hypoxia and distress, or even death.
Management
The initial management should be the focused A to E assessment and resuscitation as described for general obstetric haemorrhage.
Again, the wide variation in presentation means that there may be a range of subsequent management options.
If the abruption is minor, and the mother and foetus are unaffected, then the patient may be admitted for monitoring only.
In the case of more significant abruption, then there may be a few scenarios, though the management options will be guided by the obstetric team.
Treatment will primarily focus on maternal resuscitation and optimising care of the foetus, giving a few approaches:
Steroids may be given in cases where the foetus is still premature, and there may be efforts to delay delivery to allow optimal effect.
Labour may be induced in some patients if it hasn’t been triggered e.g. amniotomy.
Again, the wide variation in presentation means that there may be a range of subsequent management options.
If the abruption is minor, and the mother and foetus are unaffected, then the patient may be admitted for monitoring only.
In the case of more significant abruption, then there may be a few scenarios, though the management options will be guided by the obstetric team.
Treatment will primarily focus on maternal resuscitation and optimising care of the foetus, giving a few approaches:
- Uncompromised foetus - may aim for normal vaginal delivery
- Compromised foetus - emergency delivery by C-section
- Foetus already dead - vaginal delivery unless other implications
Steroids may be given in cases where the foetus is still premature, and there may be efforts to delay delivery to allow optimal effect.
Labour may be induced in some patients if it hasn’t been triggered e.g. amniotomy.
Anaesthetic Considerations
If the patient is labouring, epidural analgesia would likely be the analgesia option of choice.
This will allow good analgesia as well as hopefully providing easy access to anaesthesia if urgent surgical input required.
As in other cases of major obstetric, general anaesthesia may be the preferred technique in cases where there is maternal physiological disturbance (cardiovascular, coagulopathic).
Patients who have has placental abruption are at an increased risk of PPH.
Large amounts of blood in the uterus may impair uterine contraction.
Uterotonics should be used to help with appropriate uterine contraction and thus reduce haemorrhage.
This will allow good analgesia as well as hopefully providing easy access to anaesthesia if urgent surgical input required.
As in other cases of major obstetric, general anaesthesia may be the preferred technique in cases where there is maternal physiological disturbance (cardiovascular, coagulopathic).
Patients who have has placental abruption are at an increased risk of PPH.
Large amounts of blood in the uterus may impair uterine contraction.
Uterotonics should be used to help with appropriate uterine contraction and thus reduce haemorrhage.
Placenta Praevia
This refers to the pathological condition when the placenta is inserted into the lower segment of the uterus (either wholly or partly).
It is potential cause of both maternal and foetal morbidity and mortality and a cause of antepartum haemorrhage.
A low lying placenta is a common finding in early pregnancy (approx. 5%), but in the majority of cases this resolves with ongoing development of the lower segment of the uterus.
It is present in about 0.5% of pregnancies at term.
This is a very good introductory video from the team at Osmosis: https://www.youtube.com/watch?v=xnRIF8SDYf8
Risk factors:
There are 4 grades of placenta praevia:
Another approach to classification is:
It is potential cause of both maternal and foetal morbidity and mortality and a cause of antepartum haemorrhage.
A low lying placenta is a common finding in early pregnancy (approx. 5%), but in the majority of cases this resolves with ongoing development of the lower segment of the uterus.
It is present in about 0.5% of pregnancies at term.
This is a very good introductory video from the team at Osmosis: https://www.youtube.com/watch?v=xnRIF8SDYf8
Risk factors:
- Previous placenta praevia
- Previous c-section:
- 1 previous C-section - relative risk 2
- 2 previous C-sections - relative risk 4
- 3 previous C -sections - relative risk 22
- 1 previous C-section - relative risk 2
- Increased parity
- Increased maternal age
- Smoking
- Cocaine use
There are 4 grades of placenta praevia:
- Placenta is low lying
- Placenta abuts but does not cover the cervical os
- Placenta partially covers the cervical os
- Placenta completely covers the cervical os
Another approach to classification is:
- Major - the placenta covers the os
- Minor - the placenta doesn’t cover the os but is in the lower segment
Presentation
It is usually detected on routine ultrasound scan.
As noted, this is not that uncommon at 20 weeks, but the placental position will not improve on follow up scanning.
Painless vaginal bleeding is the most common presentation of problems.
This can often be brisk but brief in nature.
In some cases in can be associated with some pain if there concomitant abruption.
Although it is not associated with triggering labour in the same way as abruption, there is an increased risk of premature labour developing in the following days after a bleed (in about 25%).
Sometimes a small ‘sentinel bleed’ may occur before a significant APH.
Problems occur with the normal mechanics of delivery because of the position of the placenta.
As such it is common for there to be a high presenting part or abnormal lie of the foetus.
There is a high risk of patients with placenta praevia who have had a previous c-section of having placenta accreta.
These patients should be managed as such.
As noted, this is not that uncommon at 20 weeks, but the placental position will not improve on follow up scanning.
Painless vaginal bleeding is the most common presentation of problems.
This can often be brisk but brief in nature.
In some cases in can be associated with some pain if there concomitant abruption.
Although it is not associated with triggering labour in the same way as abruption, there is an increased risk of premature labour developing in the following days after a bleed (in about 25%).
Sometimes a small ‘sentinel bleed’ may occur before a significant APH.
Problems occur with the normal mechanics of delivery because of the position of the placenta.
As such it is common for there to be a high presenting part or abnormal lie of the foetus.
There is a high risk of patients with placenta praevia who have had a previous c-section of having placenta accreta.
These patients should be managed as such.
Management
Again, there can be a wide variety of clinical presentations, from stable but recognised placenta praevia, to significant APH.
Factors that can influence decision making include:
Stable placenta praevia
Patients with grade 1 or 2 (minor) placenta praevia may be able to deliver vaginally.
Patients with grade 3 or 3 (major) placenta praevia will likely need to deliver by C-section.
This will aim to be performed at 38 weeks gestation.
If there has been bleeding, or other risks are involved, then decisions for early delivery may be considered.
Patients with bleeding
In mild bleeding with both maternal and foetal stability, it is often the case that a process of active observation will continue until 37 weeks gestation, to optimise foetal development.
In moderate or severe bleeding, and with signs of maternal or foetal compromise, it is likely that urgent delivery is required (which will generally be through cesarean section) alongside resuscitation of the mother.
Resuscitative and anaesthetic measures will mostly be the same as for other cases of major obstetric haemorrhage as previously outlined.
Additional factors for consideration include:
Factors that can influence decision making include:
- Maternal stability
- Foetal stability
- Gestational age
Stable placenta praevia
Patients with grade 1 or 2 (minor) placenta praevia may be able to deliver vaginally.
Patients with grade 3 or 3 (major) placenta praevia will likely need to deliver by C-section.
This will aim to be performed at 38 weeks gestation.
If there has been bleeding, or other risks are involved, then decisions for early delivery may be considered.
Patients with bleeding
In mild bleeding with both maternal and foetal stability, it is often the case that a process of active observation will continue until 37 weeks gestation, to optimise foetal development.
In moderate or severe bleeding, and with signs of maternal or foetal compromise, it is likely that urgent delivery is required (which will generally be through cesarean section) alongside resuscitation of the mother.
Resuscitative and anaesthetic measures will mostly be the same as for other cases of major obstetric haemorrhage as previously outlined.
Additional factors for consideration include:
- Highly vascular lower segment can result in a greater intraoperative blood loss and a greater risk of PPH - appropriate use of uterotonics and post-operative monitoring is required.
- Complex surgical cases (e.g. a more adherent placenta state) may outlast a single shot spinal - consideration of a CSE technique may be appropriate.
Postpartum Haemorrhage
This is blood loss that occurs after delivery.
As some degree of bleeding with any delivery is ‘normal’, the thresholds are defined as:
Further sub categorisation can split the PPH into:
This is a good video from the Osmosis team:
https://www.youtube.com/watch?v=SEQPKTceWp4
The RCOG have produced this guideline on the condition: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/
There is also a summary video here: https://www.youtube.com/watch?v=BVzpPIqXXXo
As some degree of bleeding with any delivery is ‘normal’, the thresholds are defined as:
- >500ml in vaginal delivery
- >1000ml in cesarean section
- Or, bleeding causing maternal physiological disturbance
Further sub categorisation can split the PPH into:
- Early - within 24 hours of delivery (a.k.a. primary)
- Late - 24 hours to 12 weeks after delivery (a.k.a. secondary)
This is a good video from the Osmosis team:
https://www.youtube.com/watch?v=SEQPKTceWp4
The RCOG have produced this guideline on the condition: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/
There is also a summary video here: https://www.youtube.com/watch?v=BVzpPIqXXXo
Aetiology
There are several causes of PPH, best remembered by the mnemonic “The 4 T’s”:
Tone
This refers to uterine atony.
Normally the myometrium will contract down after delivery, reducing blood flow through the uterine arteries.
If this doesn’t occur, blood flow through these vessels can continue, leading to bleeding.
It is responsible for around 80% of PPHs.
Risk factors for uterine atony include:
Trauma
This refers to any trauma of the genital tract.
This may be from the delivery, or iatrogenic:
Tissue
This refers to retained tissue with the placenta that allows bleeding to continue.
This usually means the placenta, either wholly or fragments of it.
In rare cases, a morbidly adherent placenta may be the cause e.g. placenta accreta.
Thrombin
This refers to a physiological disturbance of haemostasis that is resulting in ongoing bleeding.
Whilst less commonly a cause of PPH by themselves, they may complicate other causes.
There are clearly many causes of this, but some are more common in obstetric practice:
- Tone
- Trauma
- Tissue
- Thrombin
Tone
This refers to uterine atony.
Normally the myometrium will contract down after delivery, reducing blood flow through the uterine arteries.
If this doesn’t occur, blood flow through these vessels can continue, leading to bleeding.
It is responsible for around 80% of PPHs.
Risk factors for uterine atony include:
- Uterine distension - twins, multiple pregnancies
- Uterine fatigue - prolonged labour
- Obstruction - full bladder, fibroid
- Medication - general anaesthetics, magnesium,
Trauma
This refers to any trauma of the genital tract.
This may be from the delivery, or iatrogenic:
- Trauma from baby - perineal tear, vaginal, cervical
- Cesarean section - bleeding from incision sites
- Instrumentation - forceps, episiotomy
Tissue
This refers to retained tissue with the placenta that allows bleeding to continue.
This usually means the placenta, either wholly or fragments of it.
In rare cases, a morbidly adherent placenta may be the cause e.g. placenta accreta.
Thrombin
This refers to a physiological disturbance of haemostasis that is resulting in ongoing bleeding.
Whilst less commonly a cause of PPH by themselves, they may complicate other causes.
There are clearly many causes of this, but some are more common in obstetric practice:
- Massive haemorrhage
- Pre-eclampsia
- Placental abruption
- Sepsis
- Genetic e.g. Von Willebrand disease
Management
The principles of management again follow those of obstetric haemorrhage already described.
In addition, there are some more specific treatment considerations for the different causes of PPH, and hence the usefulness of “the 4 T’s” in helping to guide management.
Tone
The management strategies can be consider in terms of medical and nonmedical interventions.
Medical interventions are primarily drugs that cause uterine contraction (uterotonics).
These are discussed in more detail elsewhere, but usually consist of a stepwise approach:
It is also important to identify and minimise the impact of other medications that are potentially having a relaxing effect on the uterine tone (mentioned above).
As an example, in a patient under general anaesthesia steps to reduce the relaxing effect of volatile anaesthetic agents are taken (using nitrous oxide, reducing MAC).
Nonmedical interventions are general procedures that aim to mechanically trigger uterine contraction, or reduce bleeding through their direct action.
They are often considered as second line to medical management, but in cases of significant bleeding must clearly be deployed in parallel whilst medical therapy takes effect.
This may be through compression e.g. intrauterine balloon, or other surgical interventions on the uterus:
Uterine massage is an easy, routine steps undertaken to try and aid uterine contraction.
Massage of the uterus can stimulate muscular contraction and can be done easily by midwifery staff early on in the management process.
Similarly, urinary catheterisation is a rapid, simple procedure that can aid uterine contraction, as well as being part of monitoring.
In general, further ‘surgical’ management will be to some degree dependent on the surgical expertise within the team that are present.
Bimanual compression refers to a more invasive procedure where the goal is to tamponade ongoing uterine bleeding with direct pressure.
Intrauterine balloon tamponade e.g. Bakri balloon, is recommended as the first line ‘surgical’ intervention.
The balloon ‘tamponade test’ describes whether the inflation of the balloon is effective in controlling haemorrhage.
If positive (i.e. it stops bleeding) it is reassuring that laparotomy is not required, whilst if it fails, progression to laparotomy is generally indicated.
This video provides a nice overview of the balloon: https://www.youtube.com/watch?v=hRBtRZxf6Kk
Haemostatic suturing is often the next step in surgical management.
This involves the use of a suture to generate general uterine compression and thus control bleeding.
This is often done at laparotomy (although one technique does not require this) and so may be more useful in cases of PPH at cesarean section.
This is a good video demonstrating a B-Lynch suture: https://www.youtube.com/watch?v=sskjFqJ17hk
Ligation or embolisation of uterine vessels may be another approach to gaining control of haemorrhage.
This may be ligation at laparotomy, or embolisation by radiological methods.
A staged approach has been described:
Hysterectomy may be required in some cases as a life saving procedure.
Examples of when it may be more likely needed include cases of a morbidly adherent placenta or uterine rupture.
Early decision making is often needed and the RCOG recommend 2 experienced clinicians being involved in the decision.
Trauma
Trauma to the genital tract which results in bleeding clearly requires intervention to help gain haemostasis.
This may entail transfer to theatre, with repair being dependent on the type of trauma present e.g. perineal repair.
Tissue
Any retained tissue may be contributing to ongoing bleeding, so the goal of management here is around its removal.
Again, this may well entail a transfer to theatre and anaesthesia to facilitate e.g. manual removal of placenta.
Thrombin
Thrombin abnormalities (i.e. coagulopathies) are more likely to be a development of other causes of PPH, but then form part of a vicious circle.
As such, the systematic approach to massive haemorrhage already described includes components to reduce this risk (maintaining normothermia, preventing acidosis, appropriate replacement of clotting factors and fibrinogen).
Some patients may be identifiable in advance as being at higher risk of bleeding due to coagulation abnormalities, and these risk factors should be mitigated where possible.
Consideration should be given to electively giving 0.5-1g Tranexamic acid IV during cesarean section for patients who are at high risk of PPH to promote haemostasis.
TXA should also be given to all woman with ongoing PPH.
The WOMAN trial: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext
Patients with pre-existing coagulopathies should be managed based on this.
Risk Reduction
Anticipating high risk patients and aiming to reduce their risk is also an important management factor.
Antenatal anaemia should be investigated and corrected where possible.
In addition, there are some more specific treatment considerations for the different causes of PPH, and hence the usefulness of “the 4 T’s” in helping to guide management.
Tone
The management strategies can be consider in terms of medical and nonmedical interventions.
Medical interventions are primarily drugs that cause uterine contraction (uterotonics).
These are discussed in more detail elsewhere, but usually consist of a stepwise approach:
- Oxytocin 5 units (may be repeated)
- Ergometrine 0.5mg
- Oxytocin infusion (40 units/500ml - 125ml/hr)
- Carboprost 0.25mg (max 8 doses at min 15 mins intervals)
- Misoprostol 800mcg sublingual
It is also important to identify and minimise the impact of other medications that are potentially having a relaxing effect on the uterine tone (mentioned above).
As an example, in a patient under general anaesthesia steps to reduce the relaxing effect of volatile anaesthetic agents are taken (using nitrous oxide, reducing MAC).
Nonmedical interventions are general procedures that aim to mechanically trigger uterine contraction, or reduce bleeding through their direct action.
They are often considered as second line to medical management, but in cases of significant bleeding must clearly be deployed in parallel whilst medical therapy takes effect.
This may be through compression e.g. intrauterine balloon, or other surgical interventions on the uterus:
- Uterine massage - ‘Rubbing up a contraction’
- Urinary catheter
- Bimanual compression
- Intrauterine balloon
- Haemostatic suturing
- Uterine artery ligation/embolisation
- Hysterectomy
Uterine massage is an easy, routine steps undertaken to try and aid uterine contraction.
Massage of the uterus can stimulate muscular contraction and can be done easily by midwifery staff early on in the management process.
Similarly, urinary catheterisation is a rapid, simple procedure that can aid uterine contraction, as well as being part of monitoring.
In general, further ‘surgical’ management will be to some degree dependent on the surgical expertise within the team that are present.
Bimanual compression refers to a more invasive procedure where the goal is to tamponade ongoing uterine bleeding with direct pressure.
Intrauterine balloon tamponade e.g. Bakri balloon, is recommended as the first line ‘surgical’ intervention.
The balloon ‘tamponade test’ describes whether the inflation of the balloon is effective in controlling haemorrhage.
If positive (i.e. it stops bleeding) it is reassuring that laparotomy is not required, whilst if it fails, progression to laparotomy is generally indicated.
This video provides a nice overview of the balloon: https://www.youtube.com/watch?v=hRBtRZxf6Kk
Haemostatic suturing is often the next step in surgical management.
This involves the use of a suture to generate general uterine compression and thus control bleeding.
This is often done at laparotomy (although one technique does not require this) and so may be more useful in cases of PPH at cesarean section.
This is a good video demonstrating a B-Lynch suture: https://www.youtube.com/watch?v=sskjFqJ17hk
Ligation or embolisation of uterine vessels may be another approach to gaining control of haemorrhage.
This may be ligation at laparotomy, or embolisation by radiological methods.
A staged approach has been described:
- One uterine artery
- Both uterine arteries
- Low uterine arteries
- One ovarian artery
- Both ovarian arteries
Hysterectomy may be required in some cases as a life saving procedure.
Examples of when it may be more likely needed include cases of a morbidly adherent placenta or uterine rupture.
Early decision making is often needed and the RCOG recommend 2 experienced clinicians being involved in the decision.
Trauma
Trauma to the genital tract which results in bleeding clearly requires intervention to help gain haemostasis.
This may entail transfer to theatre, with repair being dependent on the type of trauma present e.g. perineal repair.
Tissue
Any retained tissue may be contributing to ongoing bleeding, so the goal of management here is around its removal.
Again, this may well entail a transfer to theatre and anaesthesia to facilitate e.g. manual removal of placenta.
Thrombin
Thrombin abnormalities (i.e. coagulopathies) are more likely to be a development of other causes of PPH, but then form part of a vicious circle.
As such, the systematic approach to massive haemorrhage already described includes components to reduce this risk (maintaining normothermia, preventing acidosis, appropriate replacement of clotting factors and fibrinogen).
Some patients may be identifiable in advance as being at higher risk of bleeding due to coagulation abnormalities, and these risk factors should be mitigated where possible.
Consideration should be given to electively giving 0.5-1g Tranexamic acid IV during cesarean section for patients who are at high risk of PPH to promote haemostasis.
TXA should also be given to all woman with ongoing PPH.
The WOMAN trial: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext
Patients with pre-existing coagulopathies should be managed based on this.
Risk Reduction
Anticipating high risk patients and aiming to reduce their risk is also an important management factor.
Antenatal anaemia should be investigated and corrected where possible.
Links & References
- Banks, A. Norris, A. Massive haemorrhage in pregnancy. CEACCP. 2005. 5(6): 195-198. https://academic.oup.com/bjaed/article/5/6/195/331380
- Heazell, A. Clift, J (eds) Obstetrics for anaesthetists. Cambridge University Press. 2008.
- Plaat, F. Shonfeld, A. Major obstetric haemorrhage. CEACCP. 2015. 15(4): 190-193. https://academic.oup.com/bjaed/article/15/4/190/305952
- Payne, J. Placenta and placental problems. Patient.info. 2015. Available at: https://patient.info/doctor/placenta-and-placental-problems#nav-2
- The Royal College of Obstetricians and Gynaecologists (RCOG). Antepartum haemorrhage (Green-top guideline no. 63). 2014. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg63/
- Payne, J. Placenta praevia. Patient.info. 2015. Available at: https://patient.info/doctor/placenta-praevia
- Osmosis. Postpartum haemorrhage - causes, symptoms, treatment, pathology. Youtube. 2016. https://www.youtube.com/watch?v=SEQPKTceWp4
- The Royal College of Obstetricians and Gynaecologists (RCOG). Postpartum haemorrhage, prevention and management (Green-top guideline no. 52). 2016. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/
- Chandraharan, E. Krishna, A. Diagnosis and management of postpartum haemorrhage. BMJ. 2017.
