Brief Didactic:
Postpartum Hemorrhage (PPH): A postpartum hemorrhage (PPH)is defined as either a 10%
decrease in hematocrit between admission and the postpartum time period or the need for a blood
transfusion. (ACOG 1998) The average blood loss at vaginal delivery and cesarean have been
reported as 500mL and 1000mL respectively, but the estimated blood loss (EBL) at delivery is
often significantly underestimated, often by as much as 50%, so you have to take into account
both the estimated blood loss and the patient’s clinical picture. Also, remember that the
hematocrit does not drop immediately in response to hemorrhage and will not equilibrate until
nearly 12 hours later. So, the bottom line is, treat the patient not the labs. While there are
definite risk factors associated with PPH, many of, such as obesity, placenta previa, placental
abruption, etc, cannot be prevented. Because of this it is imperative that you recognize risk
factors and are prepared should a PPH occur.
Incidence: The incidence of PPH differs based on the type of delivery. PPH occurs after
approximately 4% of vaginal deliveries and around 6% of cesarean deliveries and for women
who have had a previous PPH, the risk of recurrence is as high as 10%. (Hall, 1985; Bonnar,
2000)
Clinical Picture: Blood loss may be obvious at either vaginal or cesarean delivery. At times,
though, it may be masked by amniotic fluid. As blood loss continues, however, the patient will
become tachycardic and then hypotensive. She may also complain of shortness of breath, chest
pain, or have an altered level of consciousness.
Risk Factors: There are multiple risk factors for a patient developing a postpartum hemorrhage.
Some of these include the following:
Previous postpartum hemorrhage
Multiple pregnancy
Preeclampsia
Prolonged second or third stage of labor
Episiotomy
Obesity
Placenta abruption/previa
Chorioamnionitis
Birthweight > 4000gms
Coagulopathy
(Adapted from Bukowski, 2001)
Causes: While there are multiple possible etiologies for PPH, the most common causes are
uterine atony, retained placental tissue, and vaginal or perineal lacerations. Because of this, your
initial treatment will be directed at ruling these out and treatment them should they be present.
Prevention: Active management of the third stage of labor, which includes early cord clamping,
oxytocin after delivery of the baby, and controlled cord traction, will prevent around 60% of
PPH. (Bukowski, 2001) In addition to this, recognizing possible risk factors for PPH will allow
you to have the proper personnel and equipment available should it occur.
Treatment: The treatment of PPH should include efforts to both stabilize the mother and
correct the underlying cause. The initial steps that should be taken are:
Call for help (staff/anesthesia)
IV access/fluid bolus (crystalloid)
O2 by facemask
Monitors (ensure you have someone to check BP/pulse)
Place a foley catheter (when stabilized) to monitor urine output
Determine cause Think of risk factors
Check uterine tone
Manually explore uterus for
retained products.
Examine for lacerations
See the Figure 1 and Table 1 at the end for a treatment algorithm common medications that are
used for treatment.
Use of Blood Products: The use of blood products in patients who experience a significant
postpartum hemorrhage can be life-saving. Patients who refuse blood transfusions, such as
Jehovah’s witnesses, are at increased risk for maternal mortality from postpartum hemorrhage,
with one study reporting a 44-fold increase in the risk of death from hemorrhage in this
population. (Singla, 2002) However, because a transfusion involves some risk to the patient in
terms of viral infection and transfusion reactions, treatment should be carefully considered and
the appropriate products ordered. The most commonly used blood products on labor and
delivery include packed red blood cells (PRBC), platelets, fresh-frozen plasma (FFP), and
cryoprecipitate.
Packed red blood cells (PRBCs): Most patients who suffer a significant hemorrhage will first
receive a transfusion of PRBCs. They are indicated when a patient is hemodynamically unstable
due to hemorrhage, especially if the hemoglobin level falls to less than 8 or 9 gm/dL. (Strong,
1997) While red blood cells are critical to transport oxygen to tissues in the body, care must be
taken to monitor the patient for pulmonary edema when multiple transfusions are required. In
general, you can expect the patient’s hemoglobin and hematocrit to increase by 3% and 1gm/dL
per unit transfused.
Platelets: Platelets should be transfused when there is evidence of hemorrhage as a result of
either thrombocytopenia or platelet dysfunction. It may also be given in the face of massive
transfusion of PRBC’s and abnormal bleeding as a dilutional thrombocytopenia can occur in this
situation. While a patient is considered thrombocytopenic if their platelet count falls below
100,000/mm3, there is generally no problem with surgery (i.e. cesarean section) as long as the
level does not fall to below 50,000/mm3. When a patient has a platelet count of less than
20,000/mm3, then they should be prophylactically transfused to prevent spontaneous bleeding. A
single unit of platelets will increase the patient’s platelet count by approximately 7500/mm3.
Fresh-frozen plasma (FFP): This is extracted from whole blood and contains both significant
amounts of fibrinogen as well as multiple clotting factors. This is given when disseminated
intravascular coagulation (DIC), vitamin K deficiency, or clotting factor deficiencies related to
liver disease (and therefore vitamin K dependant clotting factors) are present. It can be expected
to increase the patient’s fibrinogen level by 10-15 mg/dL per unit transfused. The goal of
treatment with FFP in the presence of DIC or hypofibrinogenemia is a fibrinogen level of at least
100 mg/dL.
It is important to think ahead when you encounter a significant postpartum hemorrhage as it
takes at least 30 minutes for this blood product to be thawed and made available in most blood
banks.
(Of note, this is the only blood product with clotting factors V, XI, and XII.)
Cryoprecipitate (Cryo): This blood product is a fraction of FFP that is rich in factors VII, XIII
and fibrinogen, as well as von Willebrand’s factor. Because of the small amount of volume of
each unit as compared to FFP (40mL vs 250mL) it is a more efficient way to raise the patient’s
fibrinogen level. (This may be important in a patient with DIC with pulmonary edema secondary
to fluid overload from multiple transfusions of PRBCs where you need to increase the fibrinogen
level, but need to give as little additional volume as possible.) One unit of cryoprecipitate will
increase the patient’s fibrinogen level by 10-15 mg/dL. In general, cryoprecipitate is given
specifically for the treatment of von Willebrand’s disease, factor VII deficiency, or
hypofibrinogenemia.
See Table 2 for a comparison of all the different blood products
Complications of Blood Transfusions: While the transfusion of blood products is often lifesaving in obstetrics, there are risks involved and these are important to discuss with patients
when they are required.
Adverse reactions: Adverse reactions that may occur with the transfusion of blood products
generally either involve acute reactions or transmission of infectious agents to the recipient.
Acute hemolytic transfusion reaction: This is most commonly a result of a clerical error
resulting in the transfusion of incompatible blood products. It usually presents with a fever,
which may be accompanied by nausea, emesis, dypsnea, back pain, and discomfort at the
infusion site. It may progress to shock, disseminated intravascular coagulation (DIC), or acute
renal failure. The incidence of this type of reaction is, however, only 1:25,000. The risk of a
fatal acute hemolytic reaction is much less at 1:600,000. (Menitove, 2000) If there is any
suspicion of a hemolytic reaction, then the transfusion should be stopped and the blood product
returned to the blood bank with a description of the possible reaction. Supportive care of the
patient is indicated as well.
Febrile non-hemolytic transfusion reaction: This type of reaction occurs approximately in
1:5,000-1:10,000 transfusions. (Menitove, 2000) When this occurs, the patient will generally
experience a headache, shaking chills, or a fever within an hour of the transfusion beginning. If
this occurs, then the transfusion should be stopped and the blood product sent back to the
laboratory for testing. A hemolytic reaction should be ruled out by demonstrating no evidence of
hemolysis (i.e. absence of hemoglobinemia, hemoglobinuria, and a negative direct antiglobulin
test). Patients should receive acetaminophen for the fever and given supportive care.
Anaphylactic reaction: Anaphylactic reactions, which are characterized by urticaria,
angioedema dypsnea, nausea or abdominal cramping, and even shock, occur approximately
1:150,000 units of blood transfused. (Menitove, 2000) When this occurs, you should again, stop
the infusion and send the products to the laboratory. Treatment of the patient involves stabilizing
the airway and administering antihistamines and epinephrine as needed.
Infections: Although all blood products are screened prior to administration to patients, the
possibility of acquiring an infection, usually viral, still exists. Current estimates of these risks
can be found in Table 3 below.
FIGURE 1: TREATMENT ALGORITHM FOR POSTPARTUM HEMORRHAGE
CONSIDER PPH RISK FACTORS
ACTIVE MANAGEMENT OF 3RD STAGE OF LABOR
POSTPARTUM HEMORRHAGE OCCURS
-
Call for help (staff/anesthesia)
Obtain IV access
Start IV fluids (crystalloid) – 1L BOLUS
O2 by facemask (10L)
Check vital signs (BP/Pulse/Pulse oximetry)
Place a foley catheter to monitor urine output
Send labs (CBC, PT/PTT/Fibrinogen)
Blood products (PRBC, FFP, Cryoprecipitate)
DETERMINE ETIOLOGY OF HEMORRHAGE
Palpate Uterus
Not palpable
Check for and Treat
Uterine Inversion if present
Not Firm
Firm
Treat Uterine Atony
Check for lacerations
- Uterine massage
- Medications
(See Table 1)
- Surgery or Uterine
artery embolization
(if stable enough)
“-“
“+”
Repair lacerations
Check for retained
placental fragments
“-“
“+”
Coagulopathy?
“-“
Surgical
Treatment
- Manual removal
- D&C if needed
“+”
- Consider placenta
accreta, increta, percreta
Treat
Coagulopathy
Table 1: Medications for Postpartum Hemorrhage
MEDICATION
Methylergonovine
(Methergine)
Prostaglandin F-2alpha
(Hemabate)
Misoprostol
(Cytotech, PGE-1)
DOSE
0.2mg IM
OR
into myometrium Q2-4
hours
250ug IM
OR
into myometrium Q15
minutes
(up to 8 doses)
600ug-1000 mcg per rectum
x 1 dose
CONTRAINDICATIONS
Hypertension,
preeclampsia, asthma,
Raynaud’s syndrome
Asthma, renal disorders,
pulmonary hypertension
Known hypersensitivity to
NSAIDs, active GI bleeding
Table 2: Common blood products
Blood product
Contains
Indications
Volume
(mL)
Packed red
blood cells
Red cells, some
plasma
Increase red cell
mass
300
Platelets
Platelets, some
plasma, few
RBC/WBC
Plasma,
clotting factors
Hemorrhage from
thrombocytopenia
50
Fresh frozen
plasma
Cryoprecipitate
Fibrinogen,
factors V, VIII,
XIII, von
Willebrand’s
factor
Treatment of
coagulation
disorders
Hemophilia A, von
Willebrand’s
disease,
hypofibrinogenemia
250
40
Effect
Increase Hct
3%/unit
Increase Hgb
1gm/unit
Increase platelet
count by
7500mm3/unit
Increase total
fibrinogen 1015mg/dL/unit
Increase total
fibrinogen 10-15
mg/dL/unit
Table 3: Incidence of viral infection after transfusion (per unit infused)
INFECTION
Hepatitis B
Hepatitis C
HIV 1-2
HTLV
RISK
1:63,000 – 1:233,000
1:120,000
1:676,000
1:640,000
*Modified from Menitove, 2000
References:
Bonnar J. Massive obstetric haemorrhage. Baillieres Best Pract Res Clin Obstet Gynaecol,
2000; 14:1-18.
Bukowski R, Hankins, GDV. Managing postpartum hemorrhage. Contemporary OB/GYN 2001
Sept; 46:92-102.
Hall MH, Halliwell R, Carr-Hill R. Concomitant and repeated happening of complications of the
third stage of labor. Br J Obstet Gynaecol 1985; 92:732-738.
Menitove JE. In Cecil Textbook of Medicine, 21st ed, Goldman (ed), W.B. Saunders Co, 2000.
Singla AK, Lapinski RH, Berkowitz RL, Saphier CJ. Are women who are Jehovah's Witnesses
at risk of maternal death? Am J Obstet Gynecol. 2001 Oct;185(4):893-5.
Silver R, Depp R, Sabbagha RE, Dooley SL. Placenta previa: aggressive expectant management.
Am J Obstet Gynecol 1984; 150:15.
(*Didactic reprinted with permission from A Practical Manual to Labor and Delivery, © Shad Deering, 2009)