Primary Postpartum Haemorrhage (PPH)
Summary
Primary PPH is defined as the loss of >500ml of blood (vaginal delivery) or >1000ml (Caesarean) within the first 24 hours of birth. It remains a leading cause of maternal morbidity and mortality worldwide. Bleeding can be torrential (150ml/min) because the placental bed is highly vascular. The physiological mechanism of haemostasis is uterine contraction compressing the spiral arteries; failure of this (Atony) is the most common cause. Management follows a strict multidisciplinary drill involving mechanical, pharmacological, and surgical interventions. [1,2]
Key Facts
- Classification:
- Minor: 500-1000ml.
- Major: >1000ml.
- The 4 T's (Aetiology):
- Tone (70%): Uterine Atony (Overdistension - Twins/Poly, Prolonged labour, Grand multiparity).
- Trauma (20%): Lacerations (Perineal, Vaginal, Cervical), Uterine Rupture, Uterine Inversion.
- Tissue (10%): Retained Placenta or membranes (prevents contraction).
- Thrombin (1%): Coagulopathy (Pre-eclampsia, DIC, Haemophilia).
- Shock Index: Pulse / Systolic BP. Vital signs in young fit women are deceptive. BP is maintained until massive loss (>30% vol). Tachycardia is the earliest sign.
Clinical Pearls
Rub the Fundus: The first diagnostic AND therapeutic step. If it feels soft and boggy, it's Atony. Rub it hard to stimulate contraction. If it feels firm but bleeding continues, it's Trauma (tears).
Full Bladder: A full bladder is a common cause of atony (it pushes the uterus up and prevents contraction). Catheterise immediately.
Don't Forget the Clots: A uterus full of blood clots cannot contract. You must perform "Evacuation of Clots" (Manual compression) to allow the muscle to clamp down.
Incidence
- Affects 5-10% of deliveries.
- Risk is increasing (Older maternal age, C-section rates, Obesity).
Risk Factors
- Antenatal: Placenta Praevia, Fibroids, BMI >35, Previous PPH.
- Intrapartum: Prolonged labour (>12h), Induction, C-section, Forceps.
Physiological Haemostasis
Upon separation of the placenta, the interlacing muscle fibres of the myometrium contract powerfully, acting as "living ligatures" to constrict the spiral arterioles.
Pathological Failure
- Atony: Muscle fatigue or overstretching fails to close the vessels.
- DIC: Consumptive coagulopathy develops rapidly in massive haemorrhage, exacerbating the bleeding (Thrombin T).
Signs
- Abdomen: Palpate fundal height and tone.
- Perineum/Vagina: Inspect for tears using a speculum (good light essential).
- Placenta: Check completeness (missing cotyledons?).
Bedside
- Weigh Swabs: Visual estimation underestimates loss by 50%.
- Shock Index: Pulse > BP = Danger.
Lab
- FBC: Hb and Platelets.
- Coagulation Screen: PT, APTT, Fibrinogen (Clauss). Low Fibrinogen is an early predictor of severe PPH.
- Crossmatch: 4-6 Units. Activate Major Haemorrhage Protocol (O Negative).
Management Algorithm (RCOG Protocol)
MAJOR HAEMORRHAGE CALL (2222)
(Blood Loss > 1000ml)
↓
RESUSCITATION (A, B, C)
- Lie Flat + Oxygen (15L)
- 2 x Grey Cannulae (14G) + Bloods
- Fluids (Stat 2L Crystalloid/Colloid)
- Transfuse O Neg / Type Specific
↓
MECHANICAL / FIRST AID
- Call for help (Consultant, Senior Midwife, Anaesthetist)
- **Rub Uterus** (Massage)
- **Catheterise**
- **Bi-manual Compression**
↓
PHARMACOLOGICAL (Stepwise)
1. **Oxytocin** (Syntocinon): 5 IU Slow IV + Infusion
2. **Ergometrine**: 500mcg IM/IV (Warning: HTN)
3. **Carboprost**: 250mcg IM (Deep muscle) q15mins (Warning: Asthma)
4. **Misoprostol**: 800-1000mcg PR (Sublingual less effective in shock)
5. **Tranexamic Acid**: 1g IV (WOMAN Trial)
↓
SURGICAL (If bleeding persists)
- EUA (Examination Under Anaesthetic)
- Intrauterine Balloon (Bakri)
- B-Lynch Suture (Compression suture)
- Uterine Artery Embolisation
- **Hysterectomy** (Life saving)
1. Mechanical
- Bimanual Compression: One hand in vagina making a fist in anterior fornix, other hand on abdomen behind fundus. Squeeze uterus between hands. Hold until help arrives.
2. Pharmacological Details
- Oxytocin: First line. Rapid onset. Short half life.
- Ergometrine: Tetanic contraction. Contraindicated in Pre-eclampsia/Hypertension (causes stroke risk).
- Carboprost (Prostaglandin F2alpha): Very potent. Contraindicated in Asthma (causes bronchospasm). Side effect: Diarrhoea.
- Tranexamic Acid: Antifibrinolytic. Reduces death due to bleeding by 20-30% if given within 3 hours (WOMAN trial).
3. Surgical
- Bakri Balloon: Hydrostatic pressure stops capillary bleeding.
- B-Lynch: "Braces" for the uterus to mechanically compress it.
- Sheehan's Syndrome: Pituitary necrosis due to hypovolaemic shock. (Failure to lactate, amenorrhoea).
- Acute Kidney Injury: Tubules sensitive to hypotension.
- DIC: Disseminated Intravascular Coagulation.
- Most women recover fully with prompt management.
- Hysterectomy results in permanent infertility.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| GTG 52 | RCOG (2016) | Standard definition of PPH. 4 T's approach. Major Haemorrhage Protocol activation. |
| PPH Prevention | NICE | Active management of 3rd stage (Oxytocin IM) reduces PPH risk by 60%. |
Landmark Trials
1. WOMAN Trial (Lancet 2017)
- Findings: Tranexamic acid reduces death due to bleeding in women with PPH by ~30% if given within 3 hours. No increase in adverse events.
- Impact: TXA is now standard of care for PPH.
What is PPH?
It is heavy bleeding after giving birth. While some bleeding is normal, losing too much can make you very ill.
Why did it happen?
Usually, after the baby and placenta come out, the womb muscles clamp down tight to close the blood vessels. Sometimes (e.g., if you had a long labour or a big baby), the muscle is tired and "boggy" (Atony). It doesn't clamp down well.
How do you treat it?
We act very fast. We massage your tummy to wake up the womb muscle. We give you strong medicines to make it contract. We also put a drip in to replace the fluid you lost.
Primary Sources
- RCOG Green-top Guideline No. 52. Prevention and Management of Postpartum Haemorrhage. 2016.
- WOMAN Trial Collaborators. Effect of early tranexamic acid on mortality in women with post-partum haemorrhage. Lancet. 2017.
- Knight M, et al. MBRRACE-UK: Saving Lives, Improving Mothers' Care.
Common Exam Questions
- Contraindications: "Patient with Pre-eclampsia has PPH. Which drug to avoid?"
- Answer: Ergometrine (Causes severe hypertension/stroke).
- Pharmacology: "Patient with Asthma has PPH. Which drug to avoid?"
- Answer: Carboprost (Causes bronchospasm).
- Aetiology: "Most common cause of PPH?"
- Answer: Atony (Tone).
- Clinical: "Uterus is firm but bleeding continues. Diagnosis?"
- Answer: Trauma (Cervical/Vaginal tear).
Viva Points
- Active Management of 3rd Stage: 10 IU Oxytocin IM + Controlled Cord Traction. Reduces PPH risk significantly compared to Physiological management.
- Secondary PPH: Occurs 24h to 12 weeks post birth. Usually due to Infection (Endometritis) or Retained Tissue.
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