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Show Notes
1. Definition and Recognition
- Definition: The standard definition of PPH is a cumulative blood loss of ≥ 1000 mL, or any blood loss accompanied by signs and symptoms of hypovolemia within 24 hours following delivery, regardless of whether the delivery was vaginal or cesarean.
- Classification: PPH is considered "primary" (or immediate) if it happens within the first 24 hours, and "secondary" (or delayed) if it happens between 24 hours and 12 weeks after delivery. Primary PPH is vastly more common and clinically severe.
- Clinical Presentation: PPH often occurs suddenly, without warning, and in the absence of traditional risk factors. Because healthy pregnant patients can tolerate up to 15-20% blood volume loss with minimal symptoms, the sudden onset of tachycardia, tachypnea, and delayed capillary refill are crucial early warning signs of intravascular depletion.
2. The 80% Culprit: Uterine Atony
- Prevalence: Uterine atony is the single most important concept in PPH, accounting for approximately 80% of all cases.
- Pathophysiology: Under normal circumstances, the uterus contracts immediately after the placenta is delivered, which constricts the spiral arteries and stops bleeding. Atony occurs when this vital muscular contraction fails to happen.
- Diagnosis: The clinical diagnosis of atony is primarily physical; instead of feeling a firm, contracted uterus, the clinician will palpate a soft, pliable, and "boggy" uterus.
3. Other Critical Causes (The Remaining 20%)
- Retained Placenta: Retained placental tissue mechanically prevents the uterus from contracting fully. It is imperative that every placenta is carefully inspected after expulsion to detect any missing cotyledons.
- Genital Tract Lacerations: Tears in the cervix, vagina, or perineum can cause steady, life-threatening blood loss, and should be suspected if bleeding is excessive despite a firm, contracted uterus.
- Abnormal Placentation: Conditions like placenta accreta, increta, and percreta occur when the placenta abnormally attaches to or invades the uterine wall. Risk factors dramatically increase with prior cesarean sections and placenta previa.
- Coagulopathy & Rare Events: Acquired or congenital blood clotting defects can lead to a vicious cycle of bleeding. Other exceedingly rare but catastrophic causes include uterine inversion (where the uterus turns inside out) and uterine rupture.
4. Immediate Management & Interventions PPH is an unequivocal emergency requiring the immediate mobilization of all available resources.
- Initial Resuscitation: Providers must quickly establish two large-bore intravenous (IV) lines, begin crystalloid infusions, cross-match blood, and assess clotting. The mainstay of blood replacement is packed red blood cells (PRBCs), though a 1:1:1 ratio of PRBCs, fresh frozen plasma, and platelets is recommended for severe hemorrhage.
- Bimanual Uterine Massage: This is a crucial, immediate manipulative therapy that is often successful in stimulating uterine contraction while other treatments are prepared.
- Uterotonic Medications: Medical management includes agents designed to force the uterus to contract, such as IV/IM Oxytocin, Methylergonovine (avoided in hypertensive patients), Misoprostol, Dinoprostone, and 15-methyl PGF2a