Primary Post-Partum Haemorrhage

Original Author: Nandhaa Pazhaniappan
Last Updated: 23rd December 2016
Revisions: 12

Primary post-partum haemorrhage is the loss of >500 ml of blood per-vagina within 24 hours of delivery. It can be classified into two main types:

  • Minor PPH – 500-1000ml of blood loss
  • Major PPH – >1000ml of blood loss

It is a major cause of obstetric morbidity and mortality worldwide.

In this article, we shall examine the risk factors, clinical features and management of a primary post-partum haemorrhage.


Aetiology and Risk Factors:

The causes for primary post-partum haemorrhage can be broadly categorised by the 4 T’stone, tissue, trauma and thrombin.

Tone

‘Tone’ refers to uterine atony, which is the most common cause of primary post-partum haemorrhage. This is where the uterus fails to contract adequately following delivery, due to a lack of tone in the uterine muscle.

The risk factors for uterine atony include:

  • Maternal profile: Age >40, BMI > 35, Asian ethnicity.
  • Uterine over-distension – multiple pregnancy, polyhydramnios, fetal macrosomia.
  • Labourinduction, prolonged (>12 hours).
  • Placental problems – placenta praevia, placental abruption, previous PPH.

Tissue

‘Tissue’ refers to retention of placental tissue – which prevents the uterus from contracting. It is the second most common cause of 1° PPH

Trauma

This refers to damage sustained to the reproductive tract during delivery (e.g. vaginal tears, cervical tears). Risk factors include:

  • Instrumental vaginal deliveries (forceps or ventouse)
  • Episiotomy
  • C-section

Thrombin

‘Thrombin’ refers to coagulopathies and vascular abnormalities which increase the risk of primary post-partum haemorrhage:

  • Vascular – Placental abruption, hypertension, pre-eclampsia.
  • Coagulopathies – von Willebrand’s disease, haemophilia A/B, ITP or acquired coagulopathy i.e. DIC, HELLP.
Fig 1 - Placenta praevia, where the placenta is inserted into the lower uterine segment. It is an important risk factor for post-partum haemorrhage.

Fig 1 – Placenta praevia, where the placenta is inserted into the lower uterine segment. It is an important risk factor for post-partum haemorrhage.


Clinical Features

The main feature of a post-partum haemorrhage is bleeding from the vagina.

If there is substantial blood loss, the patient may complain of dizziness, palpitations, and shortness of breath.

On Examination:

  • General examination may reveal haemodynamic instability with tachypnoea, prolonged capillary refill time, tachycardia, and hypotension.
  • Abdominal examination may show signs of uterine rupture i.e. palpation of fetal parts as it moves into the abdomen from the uterus.
  • Speculum examination may reveal sites of local trauma causing bleeding.
  • Examine the placenta to ensure that the placenta is complete (a missing cotyledon or ragged membranes could both cause a PPH).
Fig 2 - A complete placenta. In the assessment of post-partum haemorrhage, the placenta should be examined.

Fig 2 – A complete placenta. In the assessment of post-partum haemorrhage, the placenta should be examined.


Investigations

The initial laboratory tests in primary post-partum haemorrhage include:

  • Full blood count
  • Cross match 4-6 units of blood
  • Coagulation profile
  • Urea and Electrolytes
  • Liver function tests

Management

The management of primary post-partum haemorrhage should include the simultaneous delivery of TRIM:

  • Teamwork (Immediate Management)
  • Resuscitation (Immediate Management)
  • Investigations and Monitoring (Immediate Management)
  • Measures to arrest bleeding (Definitive Management)

Immediate Management

  • Teamwork – Involve appropriate colleagues for minor and major PPH, including the midwife in charge and midwives, obstetricians, anaesthetists, blood bank, clinical haematologist and porters. Communication between the team, and diligent documentation is vital.
  • Investigations and Monitoring – Investigations as above. Monitoring should include RR, O2 sats, HR, BP, temperature every 15 mins. Consider catheterisation and insertion of a central venous line.

Resuscitation

Resuscitate the patient via an A-E approach:

  • Airway
    • Protect airway (may lose it with reduced levels of consciousness).
  • Breathing
    • 15L of 100% oxygen through non-rebreathe mask. 
  • Circulation:
    • Assess circulatory compromise (Cap refill, HR, BP, ECG)
    • Insert two large bore (14G) cannulas and take blood samples (see below)
      • Start circulatory resuscitation. Give cross-matched blood as soon as it is available, until then give up to 2L of warmed crystalloid and 1-2L of warmed colloids, then transfuse O negative or uncross matched group specific blood.
    • Additional blood productions i.e. factor VIIa in Haemophilia A, and if major haemorrhage protocol activated may need to supplement fresh frozen plasma, platelets, fibrinogen. (Discussion with blood bank)
  • Disability
    • Monitor patient’s Glasgow coma score (GCS).
  • Exposure
    • Expose patient to identify bleeding sources.

Definitive Management

The definitive treatment for primary post-partum haemorrhage is largely dependent on the underlying cause:

Uterine Atony

  • Bimanual compression to stimulate uterine contraction – insert a gloved hand into the vagina, then form a fist insider the anterior fornix to compress the anterior uterine wall and the other hand applies pressure on the abdomen at the posterior aspect of the uterus (ensure the bladder is emptied by catheterisation).
  • Pharmacological measures (Table 1) – act to increase uterine myometrial contraction.
  • Surgical measures – intrauterine balloon tamponade, haemostatic suture around uterus (e.g. B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (as a last resort).
Fig 3 - Management of PPH; (a) Bimanual compression, (b) Balloon tamponade.

Fig 3 – Management of PPH; (a) Bimanual compression, (b) Balloon tamponade.

Trauma

Primary repair of laceration, if uterine rupture: laparotomy and repair or hysterectomy.

Tissue

Administer IV Oxytocin, manual removal of placenta with regional or general anaesthetic, and prophylactic antibiotics in theatre. Start IV Oxytocin infusion after removal.

Thrombin

Correct any coagulation abnormalities with blood products under the advice of the haematology team.

Table 1 – Drugs used in Primary Post-Partum Haemorrhage
Drug Mechanism of Action Side Effects Contraindications
Syntocinon Synthetic oxytocin, act on oxytocin receptors in the myometrium Nausea, vomiting, headache, rapid infusion à hypotension Hypertonic uterus, severe CVS disease
Ergometrine Multiple receptor sites action Hypertension, nausea, bradycardia Hypertension, eclampsia, vascular disease
Carboprost Prostaglandin analogue Bronchospasm, pulmonary oedema, HTN, cardiovascular collapse Cardiac disease, pulmonary disease i.e. asthma, untreated PID
Misoprostol Prostaglandin analogue Diarrhoea

Prevention

Active management of the 3rd stage of labour routinely reduces PPH risk by 60%:

  • Women delivering vaginally should be administered 5-10 units of IM Oxytocin prophylactically.
  • Women delivering via C-section should be administered 5 units of IV Oxytocin

Quiz

Question 1 / 3
How is a post-partum haemorrhage defined?

Quiz

Question 2 / 3
Which of the following is a risk factor for uterine atony?

Quiz

Question 3 / 3
All of the following drugs are used in the management of primary PPH. Which one is a oxytocin analogue?

Results

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