Postpartum Bleeding – Causes, Symptoms, Treatment

Postpartum Bleeding or postpartum hemorrhage (PPH) is often defined as the loss of more than 500 ml or 1,000 ml of blood within the first 24 hours following childbirth. Some have added the requirement that there also be signs or symptoms of low blood volume for the condition to exist.^[rx] Signs and symptoms may initially include: an increased heart rate, feeling faint upon standing, and an increased breathing rate.^[rx] As more blood is lost, the woman may feel cold, blood pressure may drop, and she may become restless or unconscious.^[rx] The condition can occur up to six weeks following delivery.^[rx]

Postpartum hemorrhage (PPH) has been traditionally defined as greater than 500 mL estimated blood loss in a vaginal delivery or greater than 1000 mL estimated blood loss at the time of cesarean delivery. This was redefined in 2017 by the American College of Obstetrics and Gynecology as cumulative blood loss greater than 1000 mL with signs and symptoms hypovolemia within 24 hours of the birth process, regardless of the route of delivery.  While this was change was made with the knowledge that blood loss at the time of delivery is routinely underestimated, blood loss at the time of vaginal delivery greater than 500 mL should be considered abnormal with the potential need for intervention. Primary postpartum hemorrhage is bleeding that occurs in the first 24 hours after delivery, while secondary postpartum hemorrhage is characterized as bleeding that occurs 24 hours to 12 weeks postpartum.[rx][rx][rx]

Stage of Postpartum Bleeding

It describes 4 stages of obstetrical hemorrhage after childbirth and its application reduces maternal mortality.^[47]

• Stage 0: normal – treated with fundal massage and oxytocin.
• Stage 1: more than normal bleeding – establish large-bore intravenous access, assemble personnel, increase oxytocin, consider use of methergine, perform fundal massage, prepare 2 units of packed red blood cells.
• Stage 2: bleeding continues – check coagulation status, assemble response team, move to operating room, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider: uterine artery embolization, dilatation and curettage, and laparotomy with uterine compression stitches or hysterectomy.
• Stage 3: bleeding continues – activate massive transfusion protocol, mobilize additional personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy.

Pathophysiology

Risk factors for postpartum hemorrhage are dependent on the etiology of the hemorrhage. Risk factors for uterine atony include high maternal parity, chorioamnionitis, prolonged use of oxytocin, general anesthesia, and conditions that cause increased distention of the uterus such as multiple gestation, polyhydramnios, fetal macrosomia, and uterine fibroids. Risk factors that can lead to uterine inversion include excessive umbilical cord traction, short umbilical cord, and fundal implantation of the placenta. Genital tract trauma risk factors include operative vaginal delivery and precipitous delivery. Retained placenta and abnormal placentation are more common if an incomplete placenta is noted at delivery, a succenturiate lobe of the placenta is present, or if the patient has a history of previous uterine surgery.  Coagulation abnormalities are more common in patients presenting with fetal death in utero, placental abruption, sepsis, disseminated intravascular coagulopathy (DIC), and in those with a history of an inherited coagulation defect.

The California PPH toolkit states that those patients who are bleeding on presentation to labor and delivery, those with history PPH, hematocrit less than 30%, history of bleeding diathesis or coagulation deficit, morbidly adherent placenta, or with hypotension or tachycardia on presentation to labor and delivery should be considered high risk for PPH on admission.[rx][rx][rx][rx]

Causes of Postpartum Bleeding

Primary causes – of postpartum hemorrhage include uterine atony, genital tract lacerations, retained placenta, uterine inversion, abnormal placentation, and coagulation disorders. Uterine atony, or lack of effective contraction of the uterus, is the most common cause of postpartum hemorrhage.

Secondary causes – of postpartum hemorrhage include retained products of conception, infection, subinvolution of the placental site, and inherited coagulation deficits.[rx][rx][rx][rx]

The causes for primary post-partum haemorrhage can be broadly categorised by the 4 T’s – tone, 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.
• Labour – induction, 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.

Conditions that affect the uterus

• Uterine atony – This is the most common cause of PPH. It happens when the muscles in your uterus don’t contract (tighten) well after birth. Uterine contractions after birth help stop bleeding from the place in the uterus where the placenta breaks away. You may have uterine atony if your uterus is stretched or enlarged (also called distended) from giving birth to twins or a large baby (more than 8 pounds, 13 ounces). It also can happen if you’ve already had several children, you’re in labor for a long time or you have too much amniotic fluid. Amniotic fluid is the fluid that surrounds your baby in the womb.
• Uterine inversion – This is a rare condition when the uterus turns inside out after birth.
• Uterine rupture – This is when the uterus tears during labor. It happens rarely. It may happen if you have a scar in the uterus from having a c-section in the past or if you’ve had other kinds of surgery on the uterus.

Conditions that affect the placenta

• Placental abruption – This is when the placenta separates early from the wall of the uterus before birth. It can separate partially or completely.
• Placenta accreta – placenta increta or placenta percreta. These conditions happen when the placenta grows into the wall of the uterus too deeply and cannot separate.
• Placenta previa – This is when the placenta lies very low in the uterus and covers all or part of the cervix. The cervix is the opening to the uterus that sits at the top of the vagina.
• Retained placenta –This happens if you don’t pass the placenta within 30 to 60 minutes after you give birth. Even if you pass the placenta soon after birth, your provider checks the placenta to make sure it’s not missing any tissue. If tissue is missing and is not removed from the uterus right away, it may cause bleeding.

Conditions during labor and birth

• Having a c-section
• Getting general anesthesia – This is medicine that puts you to sleep so you don’t feel pain during surgery. If you have an emergency c-section, you may need general anesthesia.
• Taking medicines to induce labor –  Providers often use a medicine called Pitocin to induce labor. Pitocin is the man-made form of oxytocin, a hormone your body makes to start contractions.
• Taking medicines to stop contractions during preterm labor – If you have preterm labor, your provider may give you medicines called tocolytics to slow or stop contractions.
• Tearing (also called lacerations) – This may happen if the tissues in your vagina or cervix are cut or torn during birth. The cervix is the opening to the uterus that sits at the top of the vagina. You may have tearing if you give birth to a large baby, your baby is born through the birth canal too quickly or you have an episiotomy that tears. An episiotomy is a cut made at the opening of the vagina to help let the baby out. Tearing also can happen if your provider uses tools, like forceps or a vacuum, to help move your baby through the birth canal during birth. Forceps look like big tongs. A vacuum is a soft plastic cup that attaches to your baby’s head. It uses suction to gently pull your baby as you push during birth.
• Having quick labor or being in labor a long time – Labor is different for every woman. If you’re giving birth for the first time, labor usually takes about 14 hours. If you’ve given birth before, it usually takes about 6 hours.  Augmented labor may also increase risk of PPH.  Augmentation of labor means medications or other means are used to make more contractions of the uterus during labor.

Other conditions

• Blood conditions, like von Willebrand disease or disseminated intravascular coagulation (also called DIC) – These conditions can increase your risk of forming a hematoma. A hematoma happens when a blood vessel breaks causing a blood clot to form in tissue, an organ or another part of the body. After giving birth, some women develop a hematoma in the vaginal area or the vulva (the female genitalia outside of the body). Von Willebrand’s disease is a bleeding disorder that makes it hard for a person to stop bleeding. DIC causes blood clots to form in small blood vessels and can lead to serious bleeding. Certain pregnancy and childbirth complications (like placenta accreta), surgery, sepsis (blood infection) and cancer can cause DIC.
• Infection, like chorioamnionitis – This is an infection of the placenta and amniotic fluid.
• Intrahepatic cholestasis of pregnancy (also called ICP) – This is the most common liver condition that happens during pregnancy.
• Obesity – Being obese means you have an excess amount of body fat. If you’re obese, your body mass index (also called BMI) is 30 or higher. BMI is a measure of body fat based on your height and weight. To find out your BMI, go to www.cdc.gov/bmi.
• Preeclampsia or gestational hypertension – These are types of high blood pressure that only pregnant women can get. Preeclampsia is a condition that can happen after the 20th week of pregnancy or right after pregnancy. It’s when a pregnant woman has high blood pressure and signs that some of her organs, like her kidneys and liver, may not be working properly. Signs of preeclampsia include having protein in the urine, changes in vision and severe headache.  Gestational hypertension is high blood pressure that starts after 20 weeks of pregnancy and goes away after you give birth. Some women with gestational hypertension have preeclampsia later in pregnancy.
• Uterine infection – (known as endometritis) risk factors include Caesarean section, premature rupture of membranes and long labour.
• Retained placental fragments or tissue
• Abnormal involution of the placental site (inadequate closure and sloughing of the spiral arteries at the placental attachment site).
• Trophoblastic disease (very rare).

Some women are at greater risk for postpartum hemorrhage than others. Conditions that may increase the risk for postpartum hemorrhage include the following:

• Placental abruption. The early detachment of the placenta from the uterus.
• Placenta previa. The placenta covers or is near the cervical opening.
• Overdistended uterus. Excessive enlargement of the uterus due to too much amniotic fluid or a large baby, especially with birthweight over 4,000 grams (8.8 pounds).
• Multiple pregnancy. More than one placenta and overdistention of the uterus.
• Gestational hypertension or preeclampsia. High blood pressure of pregnancy.
• Having many previous births
• Prolonged labor
• Infection
• Obesity
• Medications to induce labor
• Medications to stop contractions (for preterm labor)
• Use of forceps or vacuum-assisted delivery\General anesthesia

Postpartum hemorrhage may also be due to other factors including the following:

• Tear in the cervix or vaginal tissues
• Tear in a uterine blood vessel
• Bleeding into a concealed tissue area or space in the pelvis which develops into a hematoma, usually in the vulva or vaginal area
• Blood clotting disorders, such as disseminated intravascular coagulation
• Placenta accreta. The placenta is abnormally attached to the inside of the uterus (a condition that occurs in one in 2,500 births and is more common if the placenta is attached over a prior cesarean scar).
• Placenta increta. The placental tissues invade the muscle of the uterus.
• Placenta percreta. The placental tissues go all the way into the uterine muscle and may break through (rupture).

Symptoms of Postpartum Bleeding

• Symptoms generally include heavy bleeding from the vagina that doesn’t slow or stop over time.^[rx] Initially there may be an increased heart rate, feeling faint upon standing, and an increased respiratory rate. As more blood is lost, the woman may feel cold, blood pressure may drop, and she may become unconscious.^[rx]
• Signs and symptoms of circulatory shock may also include blurry vision, cold and clammy skin, confusion, and feeling sleepy or weak.^[rx][rx]
• Uncontrolled bleeding
• Decreased blood pressure
• Increased heart rate
• Decrease in the red blood cell count
• Swelling and pain in the vagina and nearby area if bleeding is from a hematoma

Diagnosis of Postpartum Bleeding

History and Physical

Patients present with acute bleeding post-partum.

• The general examination – may reveal hemodynamic 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).

Evaluation

• Initial evaluation of the patient should include a rapid assessment of the patient’s status and risk factors. In postpartum women, signs or symptoms of blood loss such as tachycardia and hypotension may be masked, so if these signs are present, there should be a concern for considerable blood volume loss (greater than 25% of total blood volume). Continuous assessment of vital signs and on-going estimation of total blood loss is an important factor in ensuring safe care of the patient with PPH.
• An exam of the patient at the time of hemorrhage can help to identify the probable cause of bleeding focused on any specific risks factors the patient may have. A rapid assessment of the entire genital tract for lacerations, hematomas, or signs of uterine rupture should be performed.  Possible manual exam and extraction for any retained placental tissue or assessment by bedside ultrasound may be a part of the evaluation. A soft, “boggy” or non-contracted uterus is the common finding with uterine atony. Uterine inversion presents as round bulge or mass with palpation of the fundal wall in the cervix or lower uterine segment and is often associated with excessive traction on the umbilical cord or abnormally adherent placenta. Widespread bleeding, such as from venipuncture sites, is a sign of disseminated intravascular coagulation (DIC).
• Laboratory studies can be ordered in a PPH to help evaluate and manage the patient, although interventions such as medication or blood product administration should not be withheld pending the results of such studies. Type and screen or crossmatch may be ordered to prepare for possible blood transfusion. Complete blood count to assess hemoglobin, hematocrit, and platelets can be evaluated at intervals although lab values often lag behind the clinical presentation. Coagulation studies and fibrinogen will be useful in the patient where DIC is suspected.

Treatment of Postpartum Bleeding

• Antibiotics – usually a combination of ampicillin (clindamycin if penicillin-allergic) and metronidazole. Gentamicin should be added to the above combination in cases of endometritis (tender uterus) or overt sepsis.
• Uterotonics – examples include syntocinon (oxytocin), syntometrine (oxytocin+ergometrine), carboprost (prostaglandin F2) and misoprostol (Prostaglandin E1).
• Oxytocin – A hormone naturally produced by the posterior pituitary works rapidly to cause uterine contraction with no contraindications and minimal side effects.
• Methylergonovine – Semi-synthetic ergot alkaloid.  Works rapidly for sustained uterine contraction.  Contraindicated in patients with hypertension.
• Carboprost – Synthetic prostaglandin analog of PGF Contraindicated in severe hepatic, renal, and cardiovascular disease, may cause bronchospasm in asthmatics.
• Misoprostol – Prostaglandin E1 analog. More delayed onset than the above medications.
• Carbetocin – compared with oxytocin produced a reduction in women who needed uterine massage and further uterotonic drugs for women having caesarean sections. There was no difference in rates of PPH in women having caesarean sections or women having vaginal deliveries when given carbetocin. Carbetocin appears to cause less adverse effects. More research is needed to find the cost effectiveness of using carbetocin.^[rx]
• Tranexamic acid – a clot stabilizing medication, may also be used to reduce bleeding and blood transfusions in low-risk women, however evidence as of 2015 was not strong. A 2017 trial found that it decreased the risk of death from bleeding from 1.9% to 1.5% in women with postpartum bleeding.^[rx] The benefit was greater when the medication was given within three hours.^[rx]
• Methylergometrine  – In some countries, such as Japan, methylergometrine and other herbal remedies are given following the delivery of the placenta to prevent severe bleeding more than a day after the birth. However, there is not enough evidence to suggest that these methods are effective.^[30]

Resuscitate the patient via an A-E approach:

• Airway
• • Protect the airway (may lose it with reduced levels of consciousness).
• Breathing
• • 15L of 100% oxygen through a 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 hemorrhage protocol activated may need to supplement fresh frozen plasma, platelets, fibrinogen. (Discussion with blood bank)

• Disability
  • Monitor the patient’s Glasgow coma score (GCS).

• Exposure
  • Expose patients to identify bleeding sources.

The treatment and management of postpartum hemorrhage are focused on resuscitation of the patient while identifying and treating the specific cause. [rx]

• Maintaining hemodynamic stability – of the patient is important to ensure continued perfusion to vital organs. Ample intravenous (IV) access should be obtained. Careful direct assessment of cumulative blood loss is important, and a focus should be on early initiation of protocols for the release of blood products and massive transfusion protocols.
• Rapid identification – of the cause of postpartum hemorrhage and initiating treatment should be done simultaneously. Transfer to an operating suite with anesthesia assistance may be indicated for help with a difficult laceration repair, to correct uterine inversion, to help provide analgesia if needed for removal of retained products, or if surgical exploration is indicated.
• If the postpartum hemorrhage is due to uterine atony – treatment modalities include medical management with uterotonic agents, uterine tamponade, pelvic artery embolization, and surgical management.
• Medical management with uterotonic and pharmacologic agents – is typically the first step if uterine atony is identified. While oxytocin is given routinely by most institutions at the time of delivery (see prevention), additional uterotonic medications may be given with bimanual massage in an initial response to hemorrhage. Uterotonic agents include oxytocin, ergot alkaloids, and prostaglandins. Commonly used uterotonic include:
• If bimanual massage and uterotonic medications – are not sufficient to control hemorrhage, uterine tamponade may be considered. An intrauterine balloon tamponade system can be used, typically by filling an intrauterine balloon with 250 to 500 mL of normal saline. If there is not an intrauterine balloon readily available, the uterus may be packed with gauze, or multiple large Foley catheters may be placed concurrently. It is important to keep an accurate count of anything placed in the uterus to prevent retained foreign bodies.
• Uterine artery embolization – may be considered in a stable patient with persistent bleeding. Fluoroscopy is used to identify and occlude bleeding vessels. While the unstable patient is not a candidate for this modality, it has the benefit of uterine conservation and possible future fertility.

Surgery

Surgery may be used if medical management fails or in case of cervical lacerations or tear or uterine rupture.

• Methods used may include uterine artery ligation, ovarian artery ligation, internal iliac artery ligation, selective arterial embolization, B-lynch suture, and hysterectomy. Bleeding caused by traumatic causes should be management by surgical repair. When there is bleeding due to uterine rupture a repair can be performed but most of the time a hysterectomy is needed.
• There is currently no reliable evidence from randomised clinical trials about the effectiveness or risks of mechanical and surgical methods of treating postpartum bleeding.^[rx]
• Exploratory laparotomy is typically indicated in the setting where less invasive measures for postpartum hemorrhage have failed or if the suspected reason for postpartum hemorrhage such as morbidly adherent placenta, demands it. A midline vertical abdominal incision should be considered to maximize exposure; however, if the patient had a cesarean delivery, the existing incision may be utilized. Vascular ligation sutures may be attempted to decrease pulse pressure at the uterus.
• Bilateral uterine artery ligation (O’Leary sutures) sutures may be placed as well as bilateral utero-ovarian ligament ligation sutures. Ligation of the internal iliac arteries may also be performed however as this entails a retroperitoneal approach, it is rarely used.
• Uterine compression sutures may also be used as a treatment for atony. The B-Lynch suture technique, the most commonly performed of the compression sutures, physically compresses the uterus looping from the cervix to the fundus.
• The definitive treatment for postpartum hemorrhage is a hysterectomy. A peripartum hysterectomy is associated not only with permanent sterility but also increased surgical risk with higher risk of bladder and ureteral injury. Supracervical hysterectomy may be performed alternately as a faster surgery with potentially fewer complicated risks.

Medical devices

• The World Health Organization recommends the use of a device called the non-pneumatic anti-shock garment (NASG) for use in delivery activities outside of a hospital setting, the aim being to improve shock in a mother with obstetrical bleeding long enough to reach a hospital.^[rx] External aortic compression devices (EACD) may also be used.^[rx][rx]
• Uterine balloon tamponade can improve postpartum bleeding.^[rx] Inflating a Sengstaken–Blakemore tube in the uterus successfully treats atonic postpartum hemorrhage refractory to medical management in approximately 80% of cases.^[rx] Such procedure is relatively simple, inexpensive and has low surgical morbidity.^[rx] A Bakri balloon is a balloon tamponade specifically constructed for uterine postpartum hemorrhage.^[rx]
• While effective, commercially available devices may be expensive for settings in which postpartum hemorrhage is most common. Low-cost devices, such as the ESM-UBT have been shown to be effective without the need for operative intervention.^[rx][rx][rx]

Strength of Evidence for Interventions To Manage PPH

The strength of evidence for interventions is summarized below:

• Pharmacologic interventions – The strength of evidence is insufficient for all outcomes of each agent studied (oxytocin and other uterotonics, misoprostol, tranexamic acid, carboprost tromethamine, thrombomodulin, and rFVIIa) for PPH management because of the study sizes and lack of studies addressing each agent.
• Transfusion for supportive management of PPH – While three fair-quality studies addressed transfusion, two of them were so confounded that we could not confidently ascertain their outcomes; thus, strength of evidence for all outcomes in insufficient.
• Uterine balloon tamponade – The strength of evidence for the success of uterine balloon tamponade in controlling bleeding is insufficient.
• Uterine artery embolization – The strength of evidence for embolization controlling bleeding without additional procedures or surgeries is low because of a lack of comparative studies and small sample sizes in studies providing data to assess success of the intervention.
• Uterine compression sutures – The strength of evidence is insufficient for the success of uterine compression sutures.
• Uterine and other pelvic vessel ligation – The strength of evidence is low for ligation controlling bleeding without further surgeries or procedures.
• Hysterectomy – The strength of evidence is insufficient for all outcomes of hysterectomy.
• Combined interventions – The strength of evidence is insufficient for all outcomes.

As noted, we identified few studies of medications meeting our review criteria. However, a number of studies of misoprostol and oxytocin have been conducted in developing countries. Four recent systematic reviews of interventions for PPH, including two Cochrane reviews, assessed uterotonics, including misoprostol. We summarize these reviews fully in the Findings in Relation to What Is Already Known section in the full report and provide a brief summary here.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.
• Before your visit, write down questions you want answered.
• Bring someone with you to help you ask questions and remember what your provider tells you.
• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
• Ask if your condition can be treated in other ways.
• Know why a test or procedure is recommended and what the results could mean.
• Know what to expect if you do not take the medicine or have the test or procedure.
• If you have a follow-up appointment, write down the date, time, and purpose for that visit.
• Know how you can contact your provider if you have questions.

References