Key Facts

Postpartum haemorrhage is the leading cause of maternal mortality worldwide and remains a significant cause of morbidity in the UK. Early recognition and a systematic stepwise approach to management are crucial.

Epidemiology

• Primary PPH (within 24 hours): complicates 5-10% of deliveries
• Minor PPH (500-1000 mL): ~5%
• Major PPH (>1000 mL): ~1-3%
• Secondary PPH (24 hours - 12 weeks): ~1%
• Leading cause of maternal death globally; approximately 1 per 100,000 maternities in the UK

Aetiology (4 T's)

• Tone (70%): uterine atony - overdistended uterus (macrosomia, polyhydramnios, multiple pregnancy), prolonged labour, oxytocin use, chorioamnionitis, grand multiparity
• Trauma (20%): perineal tears, cervical tears, uterine rupture, episiotomy extension
• Tissue (10%): retained placenta, retained products, placenta accreta
• Thrombin (<1%): coagulopathy (DIC, pre-eclampsia, HELLP, inherited bleeding disorders, anticoagulant therapy)

Pathophysiology

• After placental separation, myometrial contraction compresses spiral arteries (living ligatures)
• Failure of uterine contraction (atony) leaves vessels open, causing rapid haemorrhage
• Blood loss can be rapid (up to 500 mL/min from the placental bed)
• Concealed haemorrhage (haematoma formation) may mask true blood loss

Primary PPH

• Visible vaginal bleeding (may be underestimated by 30-50%)
• Boggy, poorly contracted uterus on palpation (atony)
• Tachycardia, hypotension, pallor (signs of hypovolaemia)
• Continuous trickle of blood despite contracted uterus (suggests trauma or retained tissue)

Secondary PPH

• Abnormal vaginal bleeding >24 hours postpartum
• Offensive lochia (infection)
• Uterine tenderness
• Fever

Red Flags

• Blood loss >1000 mL
• Haemodynamic instability (tachycardia >120, systolic BP <90 mmHg)
• Altered consciousness
• Inability to achieve a contracted uterus
• Ongoing bleeding despite uterotonics
• Signs of DIC (oozing from IV sites, widespread petechiae)

Bedside

• ABCDE assessment
• Weigh swabs and measure blood in suction (quantitative blood loss)
• Bimanual uterine assessment
• Inspect placenta for completeness
• Systematic inspection of genital tract for tears
• Urinary catheter (hourly urine output)

Bloods

• FBC (haemoglobin, platelet count)
• Coagulation screen (PT, APTT, fibrinogen)
• Crossmatch (4-6 units for massive PPH)
• U&Es, LFTs
• ABG/VBG (lactate, base excess)
• Point-of-care testing: ROTEM/TEG if available

Imaging

• Ultrasound: retained products, uterine inversion, broad ligament haematoma
• CT angiography if considering embolisation

Special Tests

• Kleihauer test if RhD-negative
• Blood bank: activate massive transfusion protocol if needed

Non-pharmacological

• Call for help early (obstetric emergency team)
• ABCDE approach with simultaneous resuscitation
• Two large-bore IV cannulae (14G)
• Uterine massage (rubbing up a contraction)
• Empty bladder (catheterise)
• Bimanual uterine compression if severe
• Keep patient warm (prevent hypothermia)

Pharmacological

• First-line: Oxytocin 10 IU slow IV or 40 IU in 500 mL saline infusion
• Second-line: Ergometrine 500mcg IM/IV (avoid in hypertension/pre-eclampsia)
• Third-line: Carboprost (Hemabate) 250mcg IM every 15 min (max 8 doses; avoid in asthma)
• Misoprostol 800mcg sublingual/rectal (if other agents unavailable)
• Tranexamic acid 1g IV (give within 3 hours - WOMAN trial: reduced death from bleeding by 19%)
• Blood products: packed red cells, FFP, platelets, cryoprecipitate (target fibrinogen >2 g/L)
• Massive transfusion protocol: 1:1:1 ratio of RBC:FFP:platelets

Surgical/Interventional

• Intrauterine balloon tamponade (Bakri balloon, Rusch catheter)
• B-Lynch compression suture (uterine compression suture)
• Uterine artery ligation (bilateral)
• Internal iliac artery ligation
• Uterine artery embolisation (interventional radiology if available and patient stable)
• Peripartum hysterectomy (life-saving last resort)
• Manual removal of placenta under regional/GA if retained

Referral Criteria

• All major PPH requires consultant obstetrician attendance
• Interventional radiology for uterine artery embolisation
• Haematology for massive transfusion/DIC
• ITU for haemodynamic instability
• Debrief and psychological support post-event

• Active management of third stage reduces PPH by 60%
• Maternal mortality from PPH in UK: approximately 1 per 100,000 maternities
• Tranexamic acid within 3 hours: reduces death from bleeding by 19% (WOMAN trial)
• Hysterectomy rate for massive PPH: ~1 per 2,000 deliveries
• Sheehan syndrome (postpartum hypopituitarism): rare long-term complication of massive PPH
• Recurrence risk: 8-15% in subsequent pregnancies
• Psychological impact: PTSD, postnatal depression, fear of subsequent pregnancy

4 T's of PPH

WOMAN Trial Summary

Massive Transfusion Targets