Postpartum Hemorrhage - Types, Causes, and Symptoms

Introduction

Postpartum hemorrhage (PPH) or postpartum bleeding is heavy bleeding that occurs after childbirth. It is a rare severe condition that usually happens within one day of giving birth, but sometimes it can happen up to 12 weeks after childbirth. Globally postpartum hemorrhage results in 44,000 to 86,000 deaths per year. However, women usually lose about 500 milliliters to 1000 milliliters of blood after childbirth. But in postpartum hemorrhage, the amount of blood loss will be much more than this, causing severe complications. In addition, postpartum hemorrhage causes a significant change in blood pressure and heart rate resulting in very low blood pressure leading to shock and death if not treated as early as possible.

What Is Postpartum Hemorrhage?

Postpartum hemorrhage or postpartum bleeding occurs when a woman loses more than 32 fluid ounces (vaginal delivery or cesarean section) or more than 500 milliliters of blood after vaginal delivery and 1000 milliliters of blood after cesarean section. Heavy blood loss results in symptoms including increased heart rate, restlessness, drop in blood pressure, and elevated breathing rate. Emergency medical management is given to patients with postpartum hemorrhage to avoid severe complications and death.

What Are the Types of Postpartum Hemorrhage?

1. Based on the onset of heavy bleeding after delivery, postpartum hemorrhage can be of two types.

• Primary Postpartum Hemorrhage - In this type, severe blood loss occurs 24 hours after childbirth.

• Secondary Postpartum Hemorrhage - It involves heavy blood loss in women within 24 hours to 12 weeks after delivery.

2. Based on the amount of blood loss after childbirth, postpartum hemorrhage can be of the following types.

• Minor - The amount of blood loss will be less than 1000 milliliters (one liter).

• Major - More than one liter of blood is lost after childbirth.

• Severe - There will be severe blood loss of more than two liters.

What Are the Causes of Postpartum Hemorrhage?

The most common cause of postpartum hemorrhage is poor uterine contraction. Other factors responsible for postpartum hemorrhage are uterine trauma, coagulopathy, and retained placental tissues.

• Uterine Atony - Uterine tone or uterine atony is the most common etiology for the incidence of postpartum hemorrhage (nearly 70 percent of cases). It is the inability of uterine tissues to contract adequately, leading to continuous bleeding. After childbirth, the uterine muscles may not contract enough to clamp the placental blood vessels, resulting in steady blood loss after delivery.

• Retained Placental Tissue - Retention of placental tissues and placental abnormalities lead to heavy bleeding after delivery and cause post-traumatic hemorrhage.

• Uterine Trauma - Injury to the vagina, uterus, cervix, and perineum (area between genitals and anus) during childbirth due to trauma from instruments like vacuum or forceps can cause bleeding, leading to postpartum hemorrhage.

• Thrombin - Women with coagulation disorders (coagulopathies) have impaired blood coagulation, and thus uncontrollable bleeding occurs in such cases after childbirth leading to postpartum hemorrhage.

What Are the Symptoms of Postpartum Hemorrhage?

• Heavy vaginal bleeding.

• Increased heart rate.

• Increased respiratory rate.

• Low blood pressure.

• Unconsciousness.

• Dizziness.

• Blurred vision.

• Postural hypotension (low blood pressure upon standing).

• Cold skin.

• Confusion.

• Weakness.

• Pale skin.

• Abdominal or pelvic pain.

• Vomiting.

• Reduced red blood cell count.

What Are the Risk Factors Associated with Postpartum Hemorrhage?

Certain factors are involved in the increased incidence of postpartum hemorrhage in women after childbirth.

They are :

• Placental abnormalities.

• Overstretched uterus.

• Prolonged labor.

• Perineal lacerations during delivery.

• Infection during labor.

• High blood pressure.

• Anemia.

• Clotting disorders.

• History of multiple deliveries.

• Obesity.

• Clotting disorders.

• Systemic infections.

• Having multiple babies (twins or triplets).

• Intrahepatic cholestasis (accumulation of bile in the liver) of pregnancy.

What Are the Diagnostic Tests Used for Postpartum Hemorrhage?

Diagnosis of postpartum hemorrhage is made through physical and visual examination, review of health history, and laboratory tests. In addition, the amount of blood lost after delivery is measured based on the volume of collected blood and soaked pads or sponges to diagnose postpartum hemorrhage. Other methods used in the diagnosis of postpartum hemorrhage are the following.

• Continuous monitoring of pulse rate.

• Blood tests to measure clotting factors.

• Red blood cell count.

• Hemoglobin levels.

• Ultrasound of the uterus.

• Serum iron levels.

How Can Postpartum Hemorrhage Be Prevented?

The most significant way to prevent postpartum hemorrhage is to identify and evaluate the potential risk factors for each woman before childbirth and take appropriate preventive measures. Individuals with placental problems like placental abruption (a serious condition where placenta separates from the uterus), placenta accreta (placenta grows deep into the wall of the uterus), placenta previa (the placenta blocks the cervix completely or partially), and retained placenta (placenta does not completely move out of the uterus after childbirth) are considered at high-risk for postpartum hemorrhage. Detailed medical history and associated symptoms must be recorded to rule out the chance of developing postpartum hemorrhage. Specific therapeutic agents can be used right after childbirth to prevent postpartum hemorrhage. For example, oxytocin is given during delivery to enhance uterine contractions and prevent heavy bleeding. However, the consumption of adequate iron supplements during pregnancy and resultant normal red blood cell levels can minimize the complications of postpartum hemorrhage.

How To Treat Postpartum Hemorrhage?

Emergency medical management is needed for postpartum hemorrhage. The first line of treatment involves stopping the source of bleeding to avoid further bleeding as early as possible and blood volume replacement.

Other treatment strategies used for the management of postpartum hemorrhage are:

• Uterine massage to enhance uterine contractions and reduce bleeding.

• Intravenous administration of oxytocin to stimulate contractions.

• Removal of retained placental tissues.

• Blood transfusion.

• Use of clot-stabilizing agents like Tranexamic acid to prevent excessive blood loss.

• Uterine artery embolization.

• Repair cervical, vaginal and uterine lacerations and tears to reduce blood loss.

• Use of a balloon or catheter to apply pressure on uterine walls to prevent bleeding.

• Tying off the ruptured blood vessels to reduce further bleeding and complications.

• In severe cases, a hysterectomy (surgical removal of the uterus) or laparotomy (a surgical procedure where the abdominal cavity is accessed through cuts made in the abdominal wall) is carried out to save the patient's life.

Conclusion

Postpartum hemorrhage is a serious emergency medical condition that occurs in women due to severe vaginal bleeding after delivery. Due to abnormal blood loss, there will be alterations in heartbeat and a drop in blood pressure resulting in complications. Poor uterine contractions, uterine trauma, coagulation disorders, placenta abnormalities, and retained placental tissue are the common etiological factors causing postpartum hemorrhage. Early detection and emergency medical management are necessary to avoid further bleeding and complications and to save lives.