Postpartum Haemorrhage

Overview

Postpartum Haemorrhage (PPH) is excessive bleeding from the genital tract following childbirth, typically within 24 hours (primary PPH) or up to 6 weeks (secondary PPH). It is the leading cause of maternal mortality worldwide, accounting for about 25% of maternal deaths, with higher rates in low- and middle-income countries. In Sri Lanka, PPH contributes to 12.7-25% of maternal deaths, with a national maternal mortality ratio (MMR) of around 30/100,000 live births, though improvements have been noted due to guideline implementation and training. Studies from teaching hospitals like the De Soysa Hospital for Women show a decline in PPH incidence from 5.96% in 2009 to 4.27% in 2011 post-guideline introduction, with mortality reduced to zero in managed cases. PPH leads to complications like shock, organ failure, and long-term issues such as anemia or Sheehan's syndrome. Management emphasizes prevention, rapid recognition, and multidisciplinary intervention. Sri Lankan guidelines from the Sri Lanka College of Obstetricians & Gynaecologists (SLCOG) and Family Health Bureau (FHB) align with WHO and FIGO recommendations, focusing on active third-stage management and tranexamic acid use. Key resources include the SLCOG Guideline on Management of Primary Post-Partum Haemorrhage (2020) available here, SLJOG Management of Primary Postpartum Haemorrhage (2022) available here, and National Guidelines for Maternal Care (FHB, 2013) available here.

Classification

PPH is classified by timing and severity:

• Primary PPH: Within 24 hours of delivery, blood loss ≥500 ml (vaginal) or ≥1000 ml (cesarean); major if >1000 ml (moderate 1001-2000 ml, severe >2000 ml).

• Secondary PPH: From 24 hours to 6 weeks postpartum, often due to infection or retained products.

• Etiological (Four T's): Tone (uterine atony, 70-80%), Trauma (lacerations, 20%), Tissue (retained placenta, 10%), Thrombin (coagulopathy, 1%).

In Sri Lanka, atonic PPH is most common (80%), followed by traumatic (15%).

Signs and Symptoms

Symptoms include heavy vaginal bleeding, signs of hypovolemic shock (tachycardia >100 bpm, hypotension <100 mmHg systolic, tachypnea, altered mental status), pallor, dizziness, and oliguria. Fundal height may rise with atony or internal bleeding. Shock index (heart rate/systolic BP) ≥1 indicates severity. In Sri Lanka, guidelines stress visual estimation underestimates loss by 30-50%, so clinical signs are crucial.

Causes and Pathophysiology

PPH results from failure of uterine contraction (atony), genital tract trauma, retained placental tissue, or clotting disorders. Pathophysiology involves hypovolemia leading to shock, acidosis, hypothermia, and coagulopathy (the "lethal triad"). In Sri Lanka, common causes include atony from grand multiparity or prolonged labor, trauma from instrumental delivery, and coagulopathy from dengue or preeclampsia.

Risk Factors

Antenatal: Anemia, previous PPH, grand multiparity (>4), fibroids, placenta previa/accreta, obesity, preeclampsia, multiple gestation. Intrapartum: Prolonged labor, instrumental delivery, cesarean, retained placenta, chorioamnionitis. In Sri Lanka, studies highlight grand multiparity and dengue as key risks; high-risk women should deliver in tertiary centers.

Diagnosis

Diagnosis is clinical: Measure blood loss (weigh pads/swabs), monitor vitals (MEOWS chart), assess Four T's. Labs: Full blood count, clotting profile, cross-match. Ultrasound for retained products. In Sri Lanka, FHB guidelines recommend immediate assessment and senior involvement if loss >1000 ml or shock signs.

Treatment

Multidisciplinary: Call team (obstetrician, anesthetist, hematologist). ABC resuscitation: Oxygen, IV access (two 14-16G cannulae), fluids (crystalloids up to 2L, then blood), tranexamic acid 1g IV within 3 hours. Address cause:

• Atonic: Uterotonics (oxytocin 5-10 IU IV + infusion 40 IU/500 ml at 125 ml/h), ergometrine 0.5 mg IV (repeat x3), misoprostol 800-1000 mcg rectal/sublingual, bimanual compression, balloon tamponade (Bakri or condom catheter).

• Traumatic: Repair lacerations under anesthesia.

• Tissue: Manual removal/exploration.

• Thrombin: Blood products (FFP, cryoprecipitate, platelets).

Surgical: Compression sutures, ligation, hysterectomy if refractory. In Sri Lanka, SLCOG emphasizes early tranexamic acid, balloon training, and massive transfusion protocol (4:4:1 RBC:FFP:platelets).

Prevention

Active third-stage management: Oxytocin 10 IU IM/IV, controlled cord traction, uterine massage. Antenatal anemia correction (Hb >10 g/dL), risk assessment. In Sri Lanka, FHB promotes universal active management; high-risk cases get IV access and blood saving.

Prognosis

With prompt treatment, mortality is low (<1% in managed cases); untreated, up to 10% fatal. Complications: Anemia, infection, PTSD. In Sri Lanka, post-guideline studies show reduced severe morbidity (e.g., hysterectomy from 0.9% to 0.2%). Debriefing is recommended to mitigate psychological impact.

Epidemiology

Globally, PPH affects 2-10% of deliveries. In Sri Lanka, incidence is 4-6%, causing 12-25% of maternal deaths, with declines noted (e.g., from 12.7% in 2008). Higher in rural areas; national surveillance via MDSR helps prevention.

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