13.3 Postpartum Haemorrhage (PPH) Causes & Management

Postpartum Haemorrhage (PPH) Causes & Management

1. Definition and Classification of Postpartum Haemorrhage

Postpartum Haemorrhage (PPH) remains the leading cause of maternal mortality worldwide and a high-frequency topic in the UPSC CMS examination.

Definitions

• Primary PPH: Excessive blood loss occurring within 24 hours of childbirth.
  • Vaginal Delivery: Cumulative blood loss ≥ 500 mL (or any blood loss causing hemodynamic instability).
  • Cesarean Section: Cumulative blood loss ≥ 1000 mL.
  • Severe PPH: Cumulative blood loss ≥ 1000 mL regardless of delivery route.
• Secondary (Late) PPH: Excessive vaginal bleeding occurring between 24 hours and 12 weeks postpartum (most commonly between days 8–14 postpartum due to retained placental tissue or uterine infection).

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2. Etiology: The 4 Ts Framework

The primary causes of PPH are systematically categorized using the 4 Ts framework:

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3. Medical Management Protocol for Atonic PPH

When atonic PPH is identified, immediate simultaneous resuscitation and therapeutic intervention must be initiated:

Step 1: Immediate Resuscitation & Diagnostic Checks

• Call for emergency obstetric assistance.
• Airway, Breathing, Circulation (ABC): Administer high-flow oxygen (10–15 L/min).
• Establish two large-bore IV lines (16G or 18G). Draw blood for CBC, blood group & crossmatch, coagulation profile, and serum electrolytes.
• Rapid infusion of warmed crystalloids (Ringer's Lactate or Normal Saline).
• Perform bimanual uterine compression (one fist in anterior vaginal fornix, other hand on abdominal wall compressing posterior uterine wall).
• Insert Foley catheter to empty bladder (a full bladder inhibits uterine contraction).
• Inspect birth canal thoroughly with speculum to rule out traumatic lacerations.

Step 2: Uterotonic Pharmacotherapy

1. Oxytocin (First-Line):
   • Dose: 10–40 IU in 1000 mL Normal Saline or Ringer's Lactate IV infusion at 125–250 mL/hr (or 10 IU IM).
   • Caution: Never give as a rapid IV bolus (causes severe hypotension, arrhythmias, and cardiac collapse).
2. Tranexamic Acid (TXA):
   • Dose: 1 gram IV over 10 minutes within 3 hours of birth (WOMAN trial protocol). Repeat 1g IV after 30 minutes if bleeding continues or restarts within 24 hours.
3. Methylergometrine / Ergometrine:
   • Dose: 0.2 mg IM or slow IV.
   • Action: Causes sustained tetanic uterine contractions.
   • Absolute Contraindications: Hypertension, Preeclampsia, Eclampsia, Heart Disease (causes severe vasoconstriction and hypertensive crisis).
4. Carboprost Tromethamine (15-methyl PGF2α):
   • Dose: 0.25 mg (250 mcg) deep IM every 15 to 90 minutes (maximum 8 doses = 2 mg).
   • Absolute Contraindications: Asthma or active reactive airway disease (causes severe bronchospasm). Relative contraindication: hepatic or cardiac disease.
5. Misoprostol (PGE1 synthetic analog):
   • Dose: 600–800 mcg sublingually, orally, or rectally.
   • Advantage: Thermostable, no refrigeration needed; valuable in low-resource settings.

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4. Mechanical & Surgical Interventions for Refractory PPH

If bleeding persists despite full uterotonic therapy and TXA:

1. Intrauterine Balloon Tamponade (IBT):
   • Insertion of a Bakri balloon, condom catheter, or Foley catheter bundle into the uterine cavity, inflated with 300–500 mL of warm sterile saline. Provides internal mechanical pressure against uterine walls. Effective in ~85% of cases.
2. Surgical Uterine Compression Sutures:
   • B-Lynch Suture: Continuous brace suture wrapping around the uterus from anterior to posterior wall, compressing the uterine corpus.
   • Hayman / Cho Modification Sutures: Vertical transfixing sutures.
3. Surgical Vessel Ligation (Stepwise Devascularization):
   • Bilateral Uterine Artery Ligation (O'Leary stitches).
   • Bilateral Utero-Ovarian Artery Ligation.
   • Bilateral Internal Iliac (Hypogastric) Artery Ligation: Ligates the anterior division of internal iliac artery; reduces pelvic pulse pressure by ~85% without sacrificing pelvic tissue viability.
4. Uterine Artery Embolization (UAE): Performed by interventional radiology if patient is hemodynamically stable.
5. Subtotal or Total Emergency Peripartum Hysterectomy: Ultimate life-saving procedure when all conservative surgical interventions fail.

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5. Management of Acute Uterine Inversion

Uterine inversion is a life-threatening obstetric emergency where the fundus turns inside out into the uterine cavity or through the cervix/vagina.

Etiology & Presentation

• Causes: Mismanaged third stage—applying strong fundal pressure or cord traction on an unseparated placenta when the uterus is atonic.
• Clinical Presentation: Profuse vaginal bleeding accompanied by severe neurogenic and hemorrhagic shock. The shock is disproportionately greater than visible blood loss due to parasympathetic vagal stimulation from traction on pelvic peritoneum and ovaries.

Management Steps

1. Stop all uterotonic agents immediately (they prevent manual reduction by causing cervical ring spasm).
2. Johnson's Maneuver: Grasp the inverted fundus with the palm in the vagina and push it upwards through the cervical ring toward the umbilicus, returning the fundus to its anatomical position.
3. Placental Removal: Remove placenta ONLY AFTER successful manual replacement of the uterus. (Removing placenta first increases fatal hemorrhage).
4. If manual replacement fails: O'Sullivan's Hydrostatic Method (instilling warm saline into vagina via douche nozzle to create hydrostatic pressure) or surgical correction (Huntington or Haultain operation).
5. Give IV uterotonics immediately AFTER uterine replacement to prevent re-inversion.