Key Points

1. Stabilize and Transfer if necessary
2. Quantify blood loss and monitor vital signs for hypovolemia
3. Infuse crystalloids and blood products immediately
4. Identify and treat the cause

Synopsis

Postpartum Hemorrhage (PPH) is divided into primary or early PPH and secondary or delayed PPH. With primary PPH, the onset is within the first 24 hours after delivery. In contrast, delayed PPH occurs from 24 hours to 12 weeks postpartum. Both consider the quantity of bleeding and the signs and symptoms of hypovolemia. The American College of Obstetricians and Gynecologists (ACOG) defines PPH as the cumulative blood loss of 1000mL or more or signs/symptoms of hypovolemia, regardless of the route of delivery. Additional guidelines come from the California Maternal Quality Care Collaboratives staging system and the Advanced Trauma Life Support classification of hemorrhage.

Etiology

Top 6 causes of PPH include SITTTT:

• Subinvolution of the placenta
• Infection 
• Tone: Uterine atony
• Trauma: Lacerations
• Thrombin: Coagulopathy or platelet dysfunction
• Tissue: Retained products of conception, accreta spectrum disorders

Management

1. Unstable: stabilize or transfer to a venue capable of surgical intervention
2. Stable: evaluation can proceed
   1. History: obstetric, route of birth, complications, coagulopathy
   2. Medications: anticoagulants, platelet inhibitors, uterine relaxants
   3. Labs: platelet count, prothrombin time, activated partial thrombin time, CBC
      1. hCG to evaluate choriocarcinoma, retained POCs, or new pregnancy
      2. A fibrinogen level less than 200mg/dL is an excellent predictor of severe PPH and needs multiple units of blood and blood products to a goal fibrinogen level of above 300mg/dL
   4. Imaging: ultrasound of pelvis
      1. Vascularity is key for retained products of conception (POCs)
      2. Lack of vascularity consistent with a blood clot
      3. Hypoechoic tortuous vessels seen along the inner third of the myometrium are suspicious for subinvolution of the placenta
3. Treatment: all patients should receive a crystalloid infusion until blood products are available. Tranexamic acid can reduce the risk of death due to bleeding.
4. Atony: uterotonics, balloon tamponade, uterine artery embolization, laparotomy
5. Lacerations: evaluate and repair
6. Retained POCs: dilation and curettage
7. Subinvolution of the placental site: administer uterotonic agents such as Methergine, Hemabate, and Oxytocin. Also, consider Tranexamic Acid and surgical D&C
8. Endometritis: broad-spectrum antibiotics