Postpartum Hemorrhage: Causes, Types and Management

Postpartum hemorrhage is considered an important topic for the NEET PG exam. It is a common cause of maternal morbidity and mortality and is considered one of the leading causes of maternal death worldwide. As a result, it is a frequently asked topic from Obstetrics and Gynecology in medical exams and is likely to be covered in the NEET PG exam as well. 

Therefore, a comprehensive understanding of postpartum hemorrhage is crucial for effective NEET PG exam preparations.

Read this blog further to get an overview of the causes, prevention, and management of postpartum hemorrhage.

Overview

Postpartum Hemorrhage (PPH) is defined as excessive bleeding in genital tract following the delivery of a baby. It is considered a significant medical emergency and can lead to severe maternal morbidity and mortality if not properly managed.

Causes of PPH

​​There are various causes of PPH, including the 4T - 

• Atonic uterus (MC): Normal contraction of uterus postpartum compresses vessels by acting as living ligatures
• Trauma (cervical, uterine, vaginal injuries) 
• Thrombin deficiency (coagulation defect) 
• Retained Tissue (placental bits) 

PPH Definition 

• Any bleed > 500 ml in Normal delivery or 1000 ml in CS in PPH 

• If > 2000 ml of blood loss: Severe PPH 
• 1000-2000 ml is moderate PPH 
• Any bleed which reduces Hb by 1gm % is PPH

Prevention of PPH

• Oxytocin 5-10 IU / IM or IV drip
• Control cord Traction    

Active management of 3^rd stage of labor

• Massage of uterus 

Mx of PPH  

• DOC: oxytocin 10-20 IU by IV drip 
• Methyl ergometrine: IV / IM 0.2mg; it is C/l in Pre - Eclamptic toxemia, HTN, twins (before delivery of 2nd baby), Rh -ve pregnancy, heart disease (MR, MS, VSD) 
• Carboprost (PGF2 α): 250ug IM only (upto 8 injections in 24 hours) 
• Misoprostol (PGE1): Orally 200 - 400 ugm or rectal 600-800 ug 
• Activated factor VII
• Prophylactically: Uterine artery Embolization and intra - aortic balloon (In cases like placenta accrete where there is risk of severe PPH) 
• BRACE Sutures 

• B. Lynch sutures
• Hayman sutures

• Uterine artery ligation
• Internal iliac artery ligation: Anterior division ligature is done - sluggish blood flow, so promotes thrombosis (Reduces Pulse pressure)
• Obstetric Hysterectomy

• Dinoprostone is not given/regular drug used to control PPH (so if all other drugs given along with dinoprostone in management of PPH exception mark dinoprostone)

Types of PPH 

There are several types of PPH, including -

• Primary PPH: PPH within 24 hours of delivery; mostly because of atonic uterus
• Secondary PPH: PPH after 24 hours of delivery up to 12 weeks of delivery; It is mostly due to retained placental bits. 
• Retained placental bits: Curettage (S/E of curettage is Asherman's syndrome) 

REMOVAL OF PLACENTA 

• Removal of placenta: Best method is controlled cord traction / Brandt Andrews method. 
• Forcible separation by squeezing fundus and pulling placenta: Crede's Method (obsolete): It causes lot of retained bits of placenta and that are managed by curettage: If overly done it results in Asherman's Syndrome 
• If no delivery of placenta > 30 min (retained placenta): Manual removal of placenta (MRP) under general anesthesia 

INVERSION OF UTERUS 

• If the placenta is pulled with force without giving counter traction: Acute inversion of placenta occurs
• Hemorrhagic shock: M/C cause of death
• Neurogenic shock

PPH Management 

PPH management involves: 

• Reposition of uterus manually or Hydrostatic method 

• Last part goes first inside 
• Reposition is done under general Anesthesia / Terbutaline (to relax uterus)
• Once reposition is done Oxytocin is administered 

Previous Year Questions

Q. A Primigravida underwent a normal vaginal delivery by an Intern. Patient had minimal bleeding but an out of proportion shock and eventually she died. What is the likely cause of death?

A. Inversion

B. Amniotic Fluid Embolism

C. PPH

D. Uterine Rupture

Q. A pregnant lady was given an oxytocin bolus for induction of labor by the nurse instead of an infusion. What will be the side effects of giving oxytocin bolus?

A. Hyperglycemia

B. Hypoglycemia

C. Hypotension

D. Maternal seizures

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