6.3 Postpartum Hemorrhage, Puerperal Infections & Maternal Mortality

Postpartum Hemorrhage (PPH)

Postpartum hemorrhage remains one of the top causes of maternal morbidity and mortality worldwide. Prompt recognition and an organized, multidisciplinary response are essential for survival.

Definition

The traditional definition of PPH was >500 mL blood loss for vaginal delivery and >1000 mL for cesarean. The modern, unified definition by ACOG is cumulative blood loss ≥1000 mL, OR bleeding associated with signs or symptoms of hypovolemia (tachycardia, hypotension, oliguria), occurring within 24 hours of the birth process, regardless of the route of delivery.

Etiology: The "4 Ts"

The causes of PPH can be systematically categorized into the "4 Ts":

1. Tone (70-80%): Uterine atony. The uterus fails to contract adequately to compress the placental site blood vessels. Risk factors include overdistention (macrosomia, multiples, polyhydramnios), prolonged labor, rapid labor, and chorioamnionitis.
2. Trauma (20%): Lacerations of the cervix, vagina, or perineum; uterine rupture; or uterine inversion. Suspect trauma if bleeding persists despite a firm, contracted uterus.
3. Tissue (10%): Retained products of conception (placenta, membranes) or abnormal placentation (placenta accreta spectrum).
4. Thrombin (<1%): Coagulopathies (e.g., von Willebrand disease, DIC, HELLP syndrome).

Management of PPH

Management requires simultaneous resuscitation and identification/treatment of the underlying cause.

1. Initial Resuscitation and Assessment:

• Call for help and activate a massive transfusion protocol if necessary.
• Establish two large-bore IVs, administer oxygen, and give crystalloid fluids.
• Perform continuous fundal massage.
• Inspect the lower genital tract for lacerations and explore the uterine cavity for retained placental tissue.

2. Medical Management of Uterine Atony (Uterotonics): If uterine atony is the cause, stepwise administration of uterotonic medications is initiated:

• Oxytocin (Pitocin): First-line agent. Given IV (continuous infusion) or IM. Never give as an IV push (can cause profound hypotension).
• Methylergonovine (Methergine): Ergot alkaloid given IM. Contraindicated in hypertension/preeclampsia due to the risk of severe vasospasm and stroke.
• Carboprost Tromethamine (Hemabate): 15-methyl prostaglandin F2-alpha given IM. Contraindicated in asthma due to the risk of bronchospasm. Common side effect is profound diarrhea.
• Misoprostol (Cytotec): Prostaglandin E1 given rectally, sublingually, or orally. Has a favorable side effect profile.
• Tranexamic Acid (TXA): An antifibrinolytic agent. The WOMAN trial demonstrated reduced mortality when 1g IV TXA is administered within 3 hours of bleeding onset.

3. Surgical and Procedural Interventions: If medical therapy fails, proceed to invasive measures:

• Intrauterine Balloon Tamponade (e.g., Bakri balloon): Inflated with sterile fluid to apply direct pressure to the uterine walls.
• Uterine Artery Embolization (UAE): Performed by interventional radiology if the patient is stable enough.
• Laparotomy: Surgical options include uterine compression sutures (B-lynch suture), sequential vessel ligation (uterine arteries, then internal iliac/hypogastric arteries), and ultimately, peripartum hysterectomy as a life-saving measure.

Puerperal Infections

Puerperal morbidity is traditionally defined as a temperature ≥38.0°C (100.4°F) on any two of the first 10 days postpartum, excluding the first 24 hours.

Endometritis

Postpartum endometritis is an infection of the decidua (endometrium). It is the most common cause of puerperal fever.

• Risk Factors: Cesarean delivery (highest risk, especially after labor or membrane rupture), chorioamnionitis, prolonged rupture of membranes, multiple cervical exams.
• Microbiology: Typically a polymicrobial infection involving ascending vaginal flora (aerobes like Group B Strep and E. coli, and anaerobes like Bacteroides and Peptostreptococcus).
• Diagnosis: Clinical diagnosis based on fever, uterine tenderness, purulent/foul-smelling lochia, and maternal tachycardia.
• Treatment: Broad-spectrum intravenous antibiotics are required until the patient is afebrile and asymptomatic for 24 hours. The gold standard regimen is Clindamycin and Gentamicin. If enterococcus is suspected or the patient fails to respond, Ampicillin is added.

Other Postpartum Infections

• Surgical Site Infections (SSI): Occur at the cesarean incision or episiotomy site. Presents with erythema, induration, purulent drainage. Management involves opening the wound, draining, debridement, and antibiotics.
• Mastitis: Infection of the breast parenchyma, most commonly caused by Staphylococcus aureus. Presents with unilateral breast pain, localized erythema, and fever. Treatment includes oral antibiotics (Dicloxacillin or Cephalexin) and continued breastfeeding/pumping to empty the breast.
• Septic Pelvic Thrombophlebitis (SPT): A rare complication where an infected thrombosis forms in the pelvic veins (usually the ovarian vein). Suspect SPT in a postpartum patient with persistent spiking fevers despite broad-spectrum antibiotics and no other localizing signs. CT scan may show a thrombosed vein. Treated with continued antibiotics and therapeutic anticoagulation (heparin).

Maternal Mortality

Maternal death is defined by the WHO as the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management. The primary direct causes globally are severe bleeding (mostly postpartum hemorrhage), infections (usually post-delivery), hypertensive disorders of pregnancy (preeclampsia/eclampsia), and unsafe abortion. Prevention relies on skilled attendance at birth, access to emergency obstetric care, and robust postpartum follow-up.