Postpartum haemorrhage

1. INTRODUCTION

Postpartum haemorrhage (PPH) is one of the leading causes of maternal mortality worldwide, especially in developing countries. It occurs after childbirth and requires rapid recognition and management to prevent serious complications or death.

Normally, some bleeding occurs after delivery, but excessive bleeding becomes life-threatening if not controlled promptly.

2. DEFINITION

PPH is defined as:

Blood loss ≥ 500 mL after vaginal delivery

Blood loss ≥ 1000 mL after cesarean section

OR any amount of bleeding causing hemodynamic instability

It can occur:

Within 24 hours → Primary (early) PPH

After 24 hours up to 6 weeks → Secondary (late) PPH

3. CAUSES (The “4 Ts”)

The causes of PPH are commonly remembered by the 4 Ts:

1. Tone (Uterine Atony) – Most common cause

• Failure of uterus to contract after delivery

• Leads to continuous bleeding

• Accounts for ~70–80% of cases

Risk factors:

• Over distended uterus (twins, polyhydramnios)

• Prolonged labor

• Grand multiparity

2. Trauma

• Injury to birth canal:

• Cervical tears

• Vaginal tears

• Perineal tears

• Uterine rupture

3. Tissue (Retained Placenta)

• Placental fragments remain inside uterus

• Prevent proper contraction

Examples:

• Retained placenta

• Placenta accreta spectrum

4. Thrombin (Coagulation Disorders)

• Blood clotting problems

Examples:

• Disseminated intravascular coagulation (DIC)

• Severe preeclampsia

• Sepsis

4. CLINICAL MANIFESTATIONS

• Visible Signs

• Excessive vaginal bleeding

• Blood clots

• Soaking of pads rapidly

• General Symptoms

• Weakness

• Dizziness

• Palpitations

• Restlessness

• Signs of Shock (Severe cases)

• Tachycardia (↑ pulse)

• Hypotension (↓ BP)

• Cold, clammy skin

• Pallor

• Reduced urine output

5. TYPES Of PPH

6. Management Of PPH

• PPH is a medical emergency, and management should be immediate and systematic.

A. Initial Management (Emergency Steps)

1. Call for Help

• Activate emergency team

2. Assess ABCs

• Airway

• Breathing

• Circulation

3. Resuscitation

• Oxygen administration

• Two large-bore IV lines

• Rapid IV fluids (crystalloids)

• Blood transfusion if needed

B. Identify Cause (4 Ts Approach)

1. Tone → Uterine Atony

• Uterine massage

• Uterotonic drugs:

• Oxytocin (first-line)

• Misoprostol

• Ergometrine

2. Tissue

• Retained Placenta

• Manual removal of placenta

• Curettage if required

3. Trauma

• Tears

• Inspect birth canal

• Repair lacerations surgically

4. Thrombin

• Coagulopathy

• Correct clotting disorder

Give:

• Fresh frozen plasma (FFP)

• Platelets

• Cryoprecipitate

C. Advanced Management

If bleeding continues:

1. Mechanical Methods

• Uterine balloon tamponade (e.g., Bakri balloon)

2. Surgical Management

• Uterine artery ligation

• Internal iliac artery ligation

• Hysterectomy (last resort, life-saving)

D. Preventive Measures

• Active management of third stage of labor (AMTSL):

• Oxytocin after delivery

• Controlled cord traction

• Uterine massage

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🚀Here’s a short “exam trick” version for Postpartum haemorrhage — super quick points you can remember :

Definition: ≥500 mL (vaginal) or ≥1000 mL (C-section) blood loss.

Types: Primary (<24 hrs), Secondary (24 hrs–6 weeks).

Primary PPH: Third stage (before placenta), True PPH (after placenta).

Main Cause: Uterine atony (most common).

4 Ts Causes: Tone, Trauma, Tissue, Thrombin.

Symptoms: Heavy bleeding, dizziness, shock signs.

Secondary Causes: Retained products, infection, subinvolution.

Management: ABC + IV fluids + oxygen.

Drugs: Oxytocin (first-line), misoprostol, ergometrine.

Advanced: Balloon tamponade, surgery if severe.

Prevention: Active management of 3rd stage of labor.

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🚀Here’s a set of 07 MCQs on Portal Hypertension for practice :

1. PPH is defined as blood loss of:

A. ≥300 mL after delivery

B. ≥500 mL after vaginal delivery

C. ≥200 mL after delivery

D. ≥400 mL after cesarean

✅ Answer: B

2. Most common cause of PPH is:

A. Trauma

B. Retained placenta

C. Uterine atony

D. Coagulation disorder

✅ Answer: C

3. Primary PPH occurs within:

A. 6 hours

B. 12 hours

C. 24 hours

D. 48 hours

✅ Answer: C

4. Secondary PPH occurs:

A. Within 12 hours

B. Within 24 hours

C. After 24 hours up to 6 weeks

D. After 2 months

✅ Answer: C

5. Which of the following is NOT a cause of PPH (4 Ts)?

A. Tone

B. Trauma

C. Tissue

D. Temperature

✅ Answer: D

6. First-line drug in management of PPH:

A. Misoprostol

B. Oxytocin

C. Ergometrine

D. Antibiotics

✅ Answer: B

7. First step in management of uterine atony:

A. Surgery

B. Blood transfusion

C. Uterine massage

D. Antibiotics

✅ Answer: C