Postpartum hemorrhage: Difference between revisions
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*Laboratory findings consistent with the diagnosis of postpartum hemorrhage include a decreased concentration of [[hemoglobin]] and [[hematocrit]]. However, it may not be useful in clinical settings because of the relatively late reflection of rapid blood loss. Thus, the management of postpartum hemorrhage should be started without waiting for the decreased concentration of [[hemoglobin]] and [[hematocrit]].<ref name="pmid21332452">{{cite journal |vauthors=Rath WH |title=Postpartum hemorrhage--update on problems of definitions and diagnosis |journal=Acta Obstet Gynecol Scand |volume=90 |issue=5 |pages=421–8 |date=May 2011 |pmid=21332452 |doi=10.1111/j.1600-0412.2011.01107.x |url=}}</ref> | *Laboratory findings consistent with the diagnosis of postpartum hemorrhage include a decreased concentration of [[hemoglobin]] and [[hematocrit]]. However, it may not be useful in clinical settings because of the relatively late reflection of rapid blood loss. Thus, the management of postpartum hemorrhage should be started without waiting for the decreased concentration of [[hemoglobin]] and [[hematocrit]].<ref name="pmid21332452">{{cite journal |vauthors=Rath WH |title=Postpartum hemorrhage--update on problems of definitions and diagnosis |journal=Acta Obstet Gynecol Scand |volume=90 |issue=5 |pages=421–8 |date=May 2011 |pmid=21332452 |doi=10.1111/j.1600-0412.2011.01107.x |url=}}</ref> | ||
===Electrocardiogram=== | |||
An [[ECG]] may be helpful in the detection of [[myocardial infarction]], which might occur during severe postpartum hemorrhage. Findings on an [[ECG]] suggestive of [[myocardial infarction]] include [[T wave]] inversion, [[ST interval|ST-segment]] elevation, and [[Q waves]].<ref name="pmid14695721">{{cite journal |vauthors=Karpati PC, Rossignol M, Pirot M, Cholley B, Vicaut E, Henry P, Kévorkian JP, Schurando P, Peynet J, Jacob D, Payen D, Mebazaa A |title=High incidence of myocardial ischemia during postpartum hemorrhage |journal=Anesthesiology |volume=100 |issue=1 |pages=30–6; discussion 5A |date=January 2004 |pmid=14695721 |doi=10.1097/00000542-200401000-00009 |url=}}</ref> | |||
===X-ray=== | |||
There are no [[x-ray]] findings associated with postpartum hemorrhage. | |||
===Ultrasound=== | |||
[[Ultrasound]] may be helpful in the diagnosis of the underlying [[etiology]] of postpartum hemorrhage.<ref name="pmid27578054">{{cite journal |vauthors=Oba T, Hasegawa J, Sekizawa A |title=Postpartum ultrasound: postpartum assessment using ultrasonography |journal=J Matern Fetal Neonatal Med |volume=30 |issue=14 |pages=1726–1729 |date=July 2017 |pmid=27578054 |doi=10.1080/14767058.2016.1223034 |url=}}</ref> | |||
*Findings on ultrasound suggestive of retained [[placenta]] include [[echogenicity|echogenic]] mass in the [[uterus|uterine]] cavity, the diameter of the uterine cavity >90 percentile, and endometrial vascularity (on colour Doppler imaging). | |||
*Findings on ultrasound during pregnancy suggestive of [[placenta accreta|morbidly adherent placenta]] include nonvisible retro-placental clear zone and persistent blood flow from the [[myometrium]] into the [[placenta]] (on [[Doppler sonography]]). | |||
*Findings on ultrasound suggestive of [[uterine rupture]] include [[pelvic]] echo-free space which suggests free fluid within the [[pelvis]]. | |||
*Findings on ultrasound suggestive of [[uterine inversion]] include the collapse of the [[fundus (uterus)|fundus]] into the uterine cavity and an inverted [[fundus (uterus)|fundus]] (hyperechoic) surrounded by the uterine wall (hypoechoic) on the axial view (target sign). | |||
===CT scan=== | |||
Revision as of 17:42, 16 May 2021
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adnan Ezici, M.D[2]
Synonyms and keywords:
Overview
Historical Perspective
- In 1953, du Vigneaud et al. and Tuppy were the first to discover the aminoacid sequence of oxytocin and its biochemical synthesis.[1]
- In 1962, the use of prophylactic uterotonic agent, early cord clamping, and controlled cord traction were defined by Spencer for the active management of the third stage of labor (AMTSL).[2]
- The reduction of postpartum hemorrhage by the active management of the third stage of labor (AMTSL) compared to the physiological (expectant) management was established by Prendiville et al. in 1988 following a randomized controlled trial.[3]
- In 1997, the B-Lynch surgical technique was developed by B-Lynch et al. to treat postpartum hemorrhage.[4]
- In 2005, first placebo-controlled study of misoprostol was conducted by Derman et al. for the prevention of postpartum hemorrhage.[5]
- In 2007, the use of misoprostol in the absence of oxytocin was recommended by World Health Organization (WHO) for the prevention of postpartum hemorrhage.[1]
Classification
Postpartum hemorrhage is classified according to the duration between the delivery and hemorrhage into 2 groups: primary and secondary.[6]
- If the postpartum hemorrhage begins within the first 24 hours after birth, it is classified as primary postpartum hemorrhage.
- If the postpartum hemorrhage occurs between 24 hours and 12 weeks after birth, it is classified as secondary postpartum hemorrhage.
Pathophysiology
The pathophysiology of postpartum hemorrhage depends on the underlying etiology:
- Inadequate contractions following the delivery (uterine atony)[7]
- Trauma in either vulva, vagina, or cervix during the delivery (obstetrical lacerations)[8]
- Placenta accreta, increta, percreta, or incomplete delivery of placenta (retained placental tissue)[6]
- Massive activation of the coagulation system and subsequent consumption of the coagulation factors (disseminated intravascular coagulation), platelet disorders (thrombocytopenia caused by preeclampsia, HELLP syndrome, ITP, TTP, acute fatty liver of pregnancy and HUS, and also qualitative platelet disorders), von Willebrand disease (vWD), hemophilia A, and hemophilia B (maternal coagulation disorders) [9]
Causes
The most common cause of postpartum hemorrhage is uterine atony. Less common causes of postpartum hemorrhage include obstetrical lacerations, retained placental tissue, and maternal coagulation disorders.[6]
- The 4 T's (tone, trauma, tissue, and thrombin) can be used for summarizing the causes of postpartum hemorrhage.
Differential Diagnosis
It is important to differentiate the underlying etiology of postpartum hemorrhage for deciding the treatment.
- A detailed physical examination is crucial to detect the anatomical source (uterine, cervical, vaginal, perineal, etc.) of the bleeding.[10]
- The duration between the delivery and hemorrhage should be considered to decide whether the postpartum hemorrhage is primary or secondary.[10]
- Primary postpartum hemorrhage may be caused by uterine atony, obstetrical lacerations, retained placental tissue, placenta accreta spectrum (lacenta accreta, increta, and percreta), uterine inversion, inherited coagulation defects, and disseminated intravascular coagulation (DIC)
- Secondary postpartum hemorrhage may be caused by infection, retained products of conception (RPOC), subinvolution of placental sites (SPSs), and inherited coagulation defects (e.g., von Willebrand disease).
Epidemiology and Demographics
- The incidence of postpartum hemorrhage is approximately 4,000-6,000 per 100,000 individuals with a case-fatality rate of 7.5%.[11][12]
- Individuals living in rural areas are more likely to face postpartum hemorrhage than individuals living in urban areas.[11]
- Postpartum hemorrhage commonly affects individuals 15-54 years of age.[13]
- Approximately 25% of maternal deaths are due to postpartum hemorrhage, which is the leading cause of maternal deaths.[14]
- Postpartum hemorrhage usually results in death in individuals of the non-Hispanic black race. Non-Hispanic white individuals are less likely to die due to postpartum hemorrhage.[13]
Risk Factors
Common risk factors in the development of postpartum hemorrhage include the prolonged third stage of labor, preeclampsia, Asian race, and previous postpartum hemorrhage. Risk factors in the development of postpartum hemorrhage further differentiate depending on the cause.[11]
- Common risk factors in the development of uterine atony include uterine overdistention (e.g., polyhydramnios, multiple pregnancy, fetal macrosomia), prolonged labor, the application of oxytocin, chorioamnionitis, and the application of inhaled anesthetic agents.
- Common risk factors in the development of obstetrical lacerations include episiotomy, cesarean delivery, assisted delivery, genital tract lacerations, and uterine rupture.
- Common risk factors in the development of disseminated intravascular coagulation include placental abruption, amniotic fluid embolism, intrauterine fetal demise, and sepsis.
Screening
There is insufficient evidence to recommend routine screening for postpartum hemorrhage.
Natural History, Complications, and Prognosis
- Common early complications of postpartum hemorrhage include hypovolemic shock, disseminated intravascular coagulation (DIC), hepatic failure, acute renal failure, transfusion-related acute lung injury (TRALI), transfusion-associated volume overload, acute respiratory distress syndrome (ARDS), and death.[6]
- Common late complications of postpartum hemorrhage include Sheehan syndrome and infertility.
Diagnosis
Diagnostic Study of Choice
The diagnosis of postpartum hemorrhage is based on the amount of blood loss and clinical presentation of the patient, which include either blood loss ≥1000 mL (regardless of the form of the delivery) or the presence of tachycardia and hypotension in a patient with blood loss.[6]
- Blood loss could be measured by two different methods include visual and quantitative.
- Although quantitative method is better for the accuracy of the blood loss, there is no significant difference between these methods for the clinical outcomes.
- Postpartum hemorrhage is traditionally described as blood loss > 500 mL after a vaginal delivery or blood loss > 1000 mL after a cesarean delivery.
- Obstetric shock index (heart rate divided by systolic blood pressure) might be helpful to establish the severity of bleeding and the requirement of blood transfusion. [15][16]
- In a patient with obstetric shock index > 1, blood transfusion and further resuscitation attempts should be considered.
History and Symptoms
The hallmark of postpartum hemorrhage is hypovolemia. Common symptoms of postpartum hemorrhage include:[17]
These symptoms indicate the loss of approximately 25% of the total blood volume, therefore, it is important to detect the blood loss before these symptoms of hypovolemia appear.[10]
Physical Examination
Physical examination may provide the underlying etiology of postpartum hemorrhage.[10]
- The presence of a soft, large and boggy uterus on physical examination is highly suggestive of uterine atony.[18]
- Inspection of the lower genital tract is crucial for the identification of cervical, vaginal, perineal, or rectovaginal lacerations.[6]
- Following the delivery of the placenta, an inspection of the placenta should be carefully done. An incomplete placenta on inspection is highly suggestive of retained placental tissue. However, a complete placenta on inspection does not exclude the retained placental tissue due to the probability of retained succenturiate lobe of the placenta within the uterine cavity.[10]
Laboratory Findings
Laboratory values that should be obtained on admission to delivery include complete blood count, basic metabolic panel, blood type/cross-matching, fibrinogen, PT, and aPTT.[6]
- Laboratory findings consistent with the diagnosis of postpartum hemorrhage include a decreased concentration of hemoglobin and hematocrit. However, it may not be useful in clinical settings because of the relatively late reflection of rapid blood loss. Thus, the management of postpartum hemorrhage should be started without waiting for the decreased concentration of hemoglobin and hematocrit.[19]
Electrocardiogram
An ECG may be helpful in the detection of myocardial infarction, which might occur during severe postpartum hemorrhage. Findings on an ECG suggestive of myocardial infarction include T wave inversion, ST-segment elevation, and Q waves.[20]
X-ray
There are no x-ray findings associated with postpartum hemorrhage.
Ultrasound
Ultrasound may be helpful in the diagnosis of the underlying etiology of postpartum hemorrhage.[21]
- Findings on ultrasound suggestive of retained placenta include echogenic mass in the uterine cavity, the diameter of the uterine cavity >90 percentile, and endometrial vascularity (on colour Doppler imaging).
- Findings on ultrasound during pregnancy suggestive of morbidly adherent placenta include nonvisible retro-placental clear zone and persistent blood flow from the myometrium into the placenta (on Doppler sonography).
- Findings on ultrasound suggestive of uterine rupture include pelvic echo-free space which suggests free fluid within the pelvis.
- Findings on ultrasound suggestive of uterine inversion include the collapse of the fundus into the uterine cavity and an inverted fundus (hyperechoic) surrounded by the uterine wall (hypoechoic) on the axial view (target sign).
CT scan
References
- ↑ 1.0 1.1 Prata N, Bell S, Weidert K (2013). "Prevention of postpartum hemorrhage in low-resource settings: current perspectives". Int J Womens Health. 5: 737–52. doi:10.2147/IJWH.S51661. PMC 3833941. PMID 24259988.
- ↑ Hofmeyr GJ, Mshweshwe NT, Gülmezoglu AM (January 2015). "Controlled cord traction for the third stage of labor". Cochrane Database Syst Rev. 1: CD008020. doi:10.1002/14651858.CD008020.pub2. PMC 6464177. PMID 25631379.
- ↑ Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM (November 1988). "The Bristol third stage trial: active versus physiological management of third stage of labour". BMJ. 297 (6659): 1295–300. doi:10.1136/bmj.297.6659.1295. PMC 1834913. PMID 3144366.
- ↑ El-Hamamy E, Wright A, B-Lynch C (May 2009). "The B-Lynch suture technique for postpartum haemorrhage: a decade of experience and outcome". J Obstet Gynaecol. 29 (4): 278–83. doi:10.1080/01443610902797645. PMID 19835492.
- ↑ Derman RJ, Kodkany BS, Goudar SS, Geller SE, Naik VA, Bellad MB, Patted SS, Patel A, Edlavitch SA, Hartwell T, Chakraborty H, Moss N (October 2006). "Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial". Lancet. 368 (9543): 1248–53. doi:10.1016/S0140-6736(06)69522-6. PMID 17027730.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Bienstock JL, Eke AC, Hueppchen NA (2021). "Postpartum Hemorrhage". N Engl J Med. 384 (17): 1635–1645. doi:10.1056/NEJMra1513247. PMID 33913640 Check
|pmid=value (help). - ↑ Breathnach F, Geary M (2009). "Uterine atony: definition, prevention, nonsurgical management, and uterine tamponade". Semin Perinatol. 33 (2): 82–7. doi:10.1053/j.semperi.2008.12.001. PMID 19324236.
- ↑ "ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery". Obstet Gynecol. 132 (3): e87–e102. September 2018. doi:10.1097/AOG.0000000000002841. PMID 30134424.
- ↑ Silver RM, Major H (March 2010). "Maternal coagulation disorders and postpartum hemorrhage". Clin Obstet Gynecol. 53 (1): 252–64. doi:10.1097/GRF.0b013e3181cef930. PMID 20142661.
- ↑ 10.0 10.1 10.2 10.3 10.4 "ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage". Obstet Gynecol. 108 (4): 1039–47. October 2006. doi:10.1097/00006250-200610000-00046. PMID 17012482.
- ↑ 11.0 11.1 11.2 Oyelese Y, Ananth CV (March 2010). "Postpartum hemorrhage: epidemiology, risk factors, and causes". Clin Obstet Gynecol. 53 (1): 147–56. doi:10.1097/GRF.0b013e3181cc406d. PMID 20142652.
- ↑ Shirazee HH, Saha SK, Das I, Mondal T, Samanta S, Sarkar M (October 2010). "Postpartum haemorrhage: a cause of maternal morbidity". J Indian Med Assoc. 108 (10): 663–6. PMID 21510550.
- ↑ 13.0 13.1 Gyamfi-Bannerman C, Srinivas SK, Wright JD, Goffman D, Siddiq Z, D'Alton ME; et al. (2018). "Postpartum hemorrhage outcomes and race". Am J Obstet Gynecol. 219 (2): 185.e1–185.e10. doi:10.1016/j.ajog.2018.04.052. PMID 29752934. Review in: Evid Based Nurs. 2019 Apr;22(2):57
- ↑ Fukami T, Koga H, Goto M, Ando M, Matsuoka S, Tohyama A, Yamamoto H, Nakamura S, Koyanagi T, To Y, Kondo H, Eguchi F, Tsujioka H (2019). "Incidence and risk factors for postpartum hemorrhage among transvaginal deliveries at a tertiary perinatal medical facility in Japan". PLoS One. 14 (1): e0208873. doi:10.1371/journal.pone.0208873. PMC 6326562. PMID 30625154.
- ↑ Le Bas A, Chandraharan E, Addei A, Arulkumaran S (March 2014). "Use of the "obstetric shock index" as an adjunct in identifying significant blood loss in patients with massive postpartum hemorrhage". Int J Gynaecol Obstet. 124 (3): 253–5. doi:10.1016/j.ijgo.2013.08.020. PMID 24373705.
- ↑ Chandraharan E, Krishna A (September 2017). "Diagnosis and management of postpartum haemorrhage". BMJ. 358: j3875. doi:10.1136/bmj.j3875. PMID 28954732.
- ↑ Wormer KC, Jamil RT, Bryant SB. PMID 29763164. Missing or empty
|title=(help) - ↑ Quiñones JN, Uxer JB, Gogle J, Scorza WE, Smulian JC (March 2010). "Clinical evaluation during postpartum hemorrhage". Clin Obstet Gynecol. 53 (1): 157–64. doi:10.1097/GRF.0b013e3181cd5d36. PMID 20142653.
- ↑ Rath WH (May 2011). "Postpartum hemorrhage--update on problems of definitions and diagnosis". Acta Obstet Gynecol Scand. 90 (5): 421–8. doi:10.1111/j.1600-0412.2011.01107.x. PMID 21332452.
- ↑ Karpati PC, Rossignol M, Pirot M, Cholley B, Vicaut E, Henry P, Kévorkian JP, Schurando P, Peynet J, Jacob D, Payen D, Mebazaa A (January 2004). "High incidence of myocardial ischemia during postpartum hemorrhage". Anesthesiology. 100 (1): 30–6, discussion 5A. doi:10.1097/00000542-200401000-00009. PMID 14695721.
- ↑ Oba T, Hasegawa J, Sekizawa A (July 2017). "Postpartum ultrasound: postpartum assessment using ultrasonography". J Matern Fetal Neonatal Med. 30 (14): 1726–1729. doi:10.1080/14767058.2016.1223034. PMID 27578054.