🩸 Postpartum Hemorrhage (PPH)

🔷 INTRODUCTION

Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality, especially in developing countries. It refers to excessive bleeding following childbirth, and anesthesiologists play a central role in its resuscitation, surgical management, and anesthesia planning.


🔷 DEFINITION

Type

Definition

Primary PPH

Blood loss ≥500 mL after vaginal delivery or ≥1000 mL after cesarean delivery within first 24 hours

Secondary PPH

Excessive bleeding after 24 hours up to 12 weeks postpartum(M.C.C=Retained Placenta Tissue)

🔸 Severe PPH: Blood loss >1500 mL or requiring blood transfusion
🔸 Massive PPH: Blood loss >2500 mL or >5 units of PRBCs


🔷 ETIOLOGY – THE 4 Ts

Cause

Mechanism

Examples

Tone (70–80%)

Uterine atony (most common)

Overdistended uterus, multiple gestation, prolonged labor, chorioamnionitis

Trauma (10–15%)

Genital tract injury

Lacerations, uterine rupture, inversion

Tissue (5–10%)

Retained placental tissue

Placenta accreta, retained cotyledons

Thrombin (1%)

Coagulopathy

DIC, HELLP, abruption, severe preeclampsia


🔷 RISK FACTORS

  • Uterine atony: Overdistension, polyhydramnios, multiple gestation
  • Prolonged or rapid labor
  • Operative delivery: Forceps, vacuum, cesarean
  • Chorioamnionitis
  • High parity
  • Coagulation disorders
  • Placental abnormalities: Previa, accreta spectrum
  • Previous PPH


🔷 CLINICAL FEATURES

  • Vaginal bleeding – brisk, continuous
  • Uterine fundus – soft, “boggy” in atony
  • Signs of hypovolemia: Tachycardia, hypotension, pallor, delayed cap refill
  • Altered sensorium in late stages
  • Shock may precede visible bleeding in concealed hemorrhage


🔷 INITIAL ASSESSMENT

🔸 ABCDE approach
🔸 Estimate blood loss visually + via quantification
🔸 Two large-bore IV lines, blood sampling
🔸 Crossmatch 4–6 units PRBCs
🔸 Initiate massive transfusion protocol (MTP) if necessary


🔷 MANAGEMENT: STEPWISE APPROACH

1️⃣ Uterine Massage

First-line for uterine atony; stimulate uterine contraction

2️⃣ Pharmacologic Management – Uterotonics

Drug

Dose

Contraindications

Oxytocin

10 U I.M F/B 10–40 U in 1L NS/RL @200-500ml/hr

None (first-line)

Ergometrine

0.2 mg IM/IV q15min (max 5 doses)

HTN, preeclampsia

Carboprost (15-methyl PGF2α)

250 mcg IM q15–90 min (max 2 mg)

Asthma

Misoprostol

600–1000 mcg PR or SL

Caution in CV disease


3️⃣ Surgical Interventions

  • Uterine tamponade (Bakri balloon)
  • Uterine artery ligation
  • B-Lynch compression suture
  • Uterine artery embolization
  • Hysterectomy (life-saving)


4️⃣ Hemostatic Measures

  • Transfuse PRBCs, FFP, platelets, cryoprecipitate
  • Maintain:
    • Hb > 8 g/dL
    • INR < 1.5
    • Platelets > 75,000/mm³
    • Fibrinogen > 200 mg/dL
  • Tranexamic acid (TXA): 1 g IV over 10 mins; repeat in 30 min if needed


🔷 ANESTHETIC CONSIDERATIONS IN PPH

📌 Goals

  • Restore circulating volume
  • Maintain perfusion and oxygenation
  • Facilitate surgical intervention
  • Minimize coagulopathy and acidosis


💉 Anesthesia Choice

Status

Preferred technique

Hemodynamically stable

Regional (caution if coagulopathy suspected)

Hemodynamically unstable

General anesthesia with RSI and secure airway

🚫 Avoid spinal/epidural if:

  • Coagulopathy
  • Hypovolemia
  • Severe acidosis


🧪 Monitoring

  • Continuous ECG, pulse ox, NIBP
  • Arterial line for beat-to-beat BP & ABG
  • Central venous access for fluid/blood delivery
  • Urinary catheter for U/O monitoring
  • Temperature monitoring to avoid hypothermia (worsens coagulopathy)


🩸 Fluids and Transfusion

  • Crystalloids: RL/NS up to 2L initially
  • Colloids: Use judiciously
  • Blood products (Massive Transfusion Protocol):
    • PRBC:FFP:Platelet = 1:1:1
    • Cryoprecipitate for fibrinogen <200
    • TXA as antifibrinolytic


⚠️ Special Concerns

  • Hypothermia → warm fluids, blankets
  • Acidosis → affects drug efficacy & coagulation
  • Hypocalcemia → from massive transfusion (citrate toxicity)
  • Airway edema in pregnancy → prepare for difficult airway
  • Maintain left uterine displacement to avoid aortocaval compression


🔷 POSTOPERATIVE CARE

  • ICU monitoring if massive transfusion or organ dysfunction
  • Continue uterotonics and monitor bleeding
  • Monitor for:
    • DIC
    • ARDS
    • Renal failure
    • Sepsis
  • Psychological support for traumatic birth


🔷 VIVA QUESTIONS

  1. What are the 4 Ts of PPH?
  2. What are the contraindications for ergometrine?
  3. When do you switch to hysterectomy in PPH?
  4. How do you monitor adequacy of resuscitation?
  5. What’s the role of TXA in PPH?


🔷 MCQ PEARLS

Question

Answer

Most common cause of PPH

Uterine atony

First-line uterotonic

Oxytocin

Contraindicated uterotonic in asthma

Carboprost

Role of TXA in PPH

Antifibrinolytic

PPH blood loss thresholds

>500 mL (vaginal), >1000 mL (cesarean)

Indication for hysterectomy

Failed conservative and surgical measures