وصف
Postpartum hemorrhage (PPH) is severe bleeding after giving birth. It's a serious and dangerous condition. PPH usually occurs within 24 hours of childbirth, but it can happen up to 12 weeks postpartum. When the bleeding is caught early and treated quickly, it leads to more successful outcomes.
Postpartum hemorrhage is when the total blood loss is greater than 32 fluid ounces after delivery, regardless of whether it’s a vaginal delivery or a Cesarean section, or C-section, or when bleeding is severe enough to cause symptoms of too much blood loss or a significant change in heart rate or blood pressure.
ملخص
- Postpartum hemorrhage (PPH) is defined as blood loss exceeding 500 ml after vaginal delivery or 1000 ml after cesarean section. The World Health Organization (WHO) broadens this to include any blood loss over 500 ml within 24 hours of delivery, or a decline in hematocrit/hemoglobin levels. Hemodynamic instability due to any amount of blood loss also constitutes PPH.
- Cardiac output and hemoglobin levels vary among pregnant women, meaning a seemingly small blood loss can be significant in some cases, especially those with pre-eclampsia or anemia. Individualized assessment, considering a patient's obstetric history, is crucial beyond just adhering to a fixed definition.
- PPH is a major contributor to maternal mortality, accounting for a substantial percentage of such deaths globally, including in India. The condition can be fatal within hours, emphasizing the importance of early recognition and intervention during the "golden hour" – the first 60 minutes after PPH is identified.
- Beyond mortality, PPH can lead to significant morbidity, including anemia, fatigue, postpartum depression, Sheehan's syndrome (hypopituitarism), and complications from blood transfusions. Disseminated intravascular coagulation (DIC) and organ ischemia are also potential consequences.
- The causes of PPH are often remembered using the "4 Ts": tone (uterine atony), trauma (lacerations, hematomas), tissue (retained placental fragments), and thrombin (coagulation disorders). Uterine atony is the most common cause, but trauma, particularly lacerations and hematomas, should also be considered.
- PPH is classified as primary (within the first 24 hours postpartum, mainly due to uterine atony) or secondary (after 24 hours and within six weeks postpartum, often due to retained products of conception or infection). Active Management of Third Stage of Labor (AMTSL) is vital to decrease the incidents of PPH.
- AMTSL involves administering oxytocin immediately after delivery (excluding the possibility of twins), controlled cord traction with counter-traction, and uterine massage. Oxytocin is preferred, but alternatives like ergometrine/methergine or misoprostol can be used.
- Ergometrine/methergine are contraindicated in patients with heart disease, pre-eclampsia, eclampsia, or high blood pressure. Mesoprostol's side effects include shivering and pyrexia. Carbetocin offers heat stability and ease of use but is more expensive. Obstetric emergency drug box containing cannulas, syringes and other basic supplies, blood collection tubes, and other supplies is also necessary.
- Preparation for PPH includes having an obstetric emergency drug box with IV cannulas, blood collection tubes, syringes, and other essential supplies, along with an inspection kit for trauma assessment. Timely checking of crash carts for expired medications is essential.
- Risk factors for PPH include previous PPH, augmented labor, chorioamnionitis, macrosomia, overdistended uterus, multiple gestation, pre-eclampsia, primiparity, and prolonged labor. Women with risk factors should be triaged to appropriate care centers.
- Resuscitation efforts prioritize airway, breathing, and circulation (ABC). Two large-bore IV access lines, oxygen administration, and crystalloid infusion (3 times the blood loss volume) are necessary. Blood should be reserved early, especially in high-risk cases.
- Estimating blood loss can be done visually, but it often leads to underestimation. Gravimetric methods (weighing blood-soaked materials) and quantifying with calibrated underbuttock drapes provide more accurate measurements. Visual estimation guidelines provide a rough estimate based on saturation levels of pads and the extent of blood spillage.
- PPH severity is classified into stages based on blood loss volume and signs/symptoms, ranging from mild (Class 1) to severe (Class 4). Management strategies depend on the stage and involve a combination of uterotonics, fluid resuscitation, and potentially surgical interventions.
- Initial management of atonic PPH includes placing the patient flat, uterine massage, bladder emptying, oxygen administration, and uterotonics. Tranexamic acid, administered within three hours of birth, can reduce PPH incidence.
- If uterotonics are ineffective, bimanual compression of the uterus and aortic compression can be employed. Non-pneumatic anti-shock garments (NASG) can stabilize patients during transport. In severe cases, uterine packing can be a temporary measure before transfer to a higher-level facility.
- Referral decisions should be based on the patient's condition, available resources, and adherence to modified early obstetric warning scoring system (MEOWS). Thorough documentation and continuous monitoring are essential during transport.
- Intrauterine balloon tamponade can be used if medical management fails, particularly after vaginal delivery. Surgical management, ranging from conservative compression sutures to hysterectomy, may be necessary. B-Lynch sutures, H-Min sutures or multiple suture methods can be used.
- Massive Transfusion Protocol (MTP) should be initiated for significant blood loss, involving a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets. Surgical options range from uterine artery ligation and ovarian artery ligation to hysterectomy.
- After all of the procedures, it is very important to follow-up the patient and also evaluate that they do not have any complications because of the postpartum hemorrhage.
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