Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Postpartum Hemorrhage in Emergency Medicine Clinical Presentation

  • Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE  more...
 
Updated: Nov 08, 2015
 

History

The clinical history should be taken as a primary survey (ABCs) of the patient. This should include collecting an initial set of vital signs to guide the patient’s management, as the patient is positioned to begin the physical examination. Keep in mind, that if the bleeding is very brisk, the patient’s mental status may wane. As a result, this first set of questions should include queries about signs and symptoms that are most crucial in managing potential circulatory collapse, identifying the cause of postpartum hemorrhage (PPH), and selecting appropriate therapies.[10]

Severity of bleeding

Consider the following:

  • Is the placenta delivered?
  • What has been the duration of the third stage of labor?
  • How long has the bleeding been heavy?
  • Was initial postdelivery bleeding light, medium, or heavy?
  • Are symptoms of hypovolemia present such as dizziness/lightheadedness, changes in vision, palpitations, fatigue, orthostasis, syncope or presyncope?
  • If evaluating a patient with delayed postpartum hemorrhage, what has been the bleeding pattern since delivery?

Intervention guides

Obtain the following information:

  • Is there a history of transfusion? What was the reason for transfusion? Is there a history of a transfusion reaction?
  • Past medical history (particularly cardiovascular, pulmonary, or hematologic conditions)
  • Allergies

Predisposing factors and potential etiology

Obtain the following information:

  • History of postpartum hemorrhage
  • Gravity, parity, length of most recent pregnancy, history of multiple gestations
  • Number of fetuses for the most recent pregnancy
  • Pregnancy complications (polyhydramnios, infection, vaginal bleeding, placental abnormalities)
  • If the placental was delivered, was it spontaneous, or was manual delivery required?
  • Current and past history of vaginal delivery versus cesarean delivery
  • If cesarean delivery, was it planned in advance, decided upon after a failed vaginal delivery attempt, or performed emergently?
  • Other uterine surgeries such as myomectomy (transvaginal vs transabdominal), uterine septum removal
  • Personal or family history of bleeding disorder
  • Medications such as prescribed, over the counter, diet supplements, or vitamins (with particular attention to anticoagulants, platelet inhibitors, uterine relaxants, and antihypertensives)
  • Vaginal penetration since delivery (tampons, finger, other foreign object, vaginal intercourse)
  • Signs or symptoms of infection such as uterine pain or tenderness, fever, tachycardia, or foul vaginal discharge
  • Information helpful for continued management
  • When and where was the delivery?
  • Who assisted the delivery?
  • Where and with whom was prenatal care?
  • Healthy infant(s) delivered (any complications or concerns before, during, or after delivery)?
  • Past surgical history
Next

Physical

As mentioned earlier, patients with postpartum hemorrhage (PPH) should be managed like all emergency department resuscitation situations, with the history and physical examination occurring simultaneously while following acute life support algorithms.

The physical examination should focus on determining the cause of the bleeding. The patient may not have the typical hemodynamic changes of shock early in the course of the hemorrhage due to physiologic maternal hypervolemia.

Important organ systems to assess include the pulmonary system (evidence of pulmonary edema), the cardiovascular (heart murmur, tachycardia, strength of peripheral pulses), and neurological systems (mental status changes from hypovolemia).The skin should also be checked for petechiae or oozing from skin puncture sites, which could indicate a coagulopathy, or a mottled appearance, which can be indicative of severe hypovolemia.

Looking for occult postpartum hemorrhage—in the form of a pelvic, vaginal, uterine, or abdominal wall hematoma, or intra-abdominal or perihepatic bleeding—is always an important consideration when unstable hemodynamic findings are present without evidence of excessive vaginal blood loss.

Having a gynecologic examination bed is helpful but not necessary. The patient's pelvis can always be elevated on an inverted bedpan (thick-side toward the patient's feet) cushioned with towels and a sheet for comfort.

Ensure that good lighting and suction are available before beginning the following evaluations:

  • Abdominal examination: Pain and tenderness (concerning for retained placenta tissue, rupture, or endometritis), distension, boggy or grossly palpable uterus (at or above the umbilicus) is suggestive of atony. Palpation of an overdistended bladder may indicate a barrier to adequate uterine contraction.
  • Perineal examination: A brisk bleed should be visible at the introitus; identify any perineal lacerations.
  • Speculum examination: Gently suction blood, clots, and tissue fragments as needed to maintain the view of the vagina and cervix. Careful inspection of the cervix and vagina under good light may reveal the presence and extent of lacerations.
  • Bimanual examination: Bimanual palpation of the uterus may reveal bogginess, atony, uterine enlargement, or a large amount of accumulated blood. Palpation may also reveal hematomas in the vagina or pelvis. Assess if the cervical os is open or closed.
  • Placental examination: Examine the placenta for missing portions, which suggest the possibility of retained placental tissue.
Previous
Next

Causes

The 4Ts of postpartum hemorrhage (PPH) +1: tone, trauma, tissue, thrombosis, and traction. More than one of these can cause postpartum hemorrhage in any given patient.

Uterine atony

"Tone"

Atony is by far the most common cause of postpartum hemorrhage. Uterine contraction is essential for appropriate hemostasis, and disruption of this process can lead to significant bleeding. Uterine atony is the typical cause of postpartum hemorrhage that occurs in the first 4 hours after delivery.

Risk factors for atony include the following:

  • Overdistended uterus (eg, multiple gestation, fetal macrosomia, polyhydramnios)
  • Fatigued uterus (eg, augmented or prolonged labor, amnionitis, use of uterine tocolytics such as magnesium or calcium channel blockers)
  • Obstructed uterus (eg, retained placenta or fetal parts, placenta accreta, or an overly distended bladder)

Laceration or hematoma

"Trauma"

Trauma to the uterus, cervix, and/or vagina is the second most frequent cause of postpartum hemorrhage. Injury to these tissues during or after delivery can cause significant bleeding because of their increased vascularity during pregnancy. Vaginal trauma is most common with surgical or assisted vaginal deliveries. It also occurs more frequently with deliveries that involve a large fetus, manual exploration, instrumentation, a fetal hand presenting with the head, or spontaneously from friction between mucosal tissue and the fetus during delivery. Cervical lacerations are rarer now that forceps-assisted deliveries are less common. They are more likely to occur when delivery assistance is provided before the cervix is fully dilated.

Risk factors for trauma include the following:

  • Delivery of a large infant
  • Any instrumentation or intrauterine manipulation (eg, forceps, vacuum, manual removal of retained placental fragments)
  • Episiotomy

Retained placenta

"Tissue"

Retained placental tissue is most likely to occur with a placenta that has an accessory lobe, deliveries that are extremely preterm, or variants of placenta accreta. Retained or adherent placental tissue prevents adequate contraction of the uterus allowing for increased blood loss.

Risk factors for retained products of conception include the following:

  • Prior uterine surgery or procedures
  • Premature delivery
  • Difficult or prolonged placental delivery
  • Multilobed placenta
  • Signs of placental accreta by antepartum ultrasonography or MRI

Clotting disorder

"Thrombosis"

During the third stage of labor (after delivery of the fetus), hemostasis is most dependent on contraction and retraction of the myometrium. During this period, coagulation disorders are not often a contributing factor. However, hours to days after delivery, the deposition of fibrin (within the vessels in the area where the placenta adhered to the uterine wall and/or at cesarean delivery incision sites) plays a more prominent role. In this delayed period, coagulation abnormalities can cause postpartum hemorrhage alone or contribute to bleeding from other causes, most notably trauma. These abnormalities may be preexistent or acquired during pregnancy, delivery, or the postpartum period.

Potential causes include the following:

  • Platelet dysfunction: Thrombocytopenia may be related to preexisting disease, such as idiopathic thrombocytopenic purpura (ITP) or, less commonly, functional platelet abnormalities. Platelet dysfunction can also be acquired secondary to HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count).
  • Inherited coagulopathy: Preexisting abnormalities of the clotting system, as factor X deficiency or familial hypofibrinogenemia
  • Use of anticoagulants: This is an iatrogenic coagulopathy from the use of heparin, enoxaparin, aspirin, or postpartum warfarin.
  • Disseminated intravascular coagulation (DIC): This can occur, such as from sepsis, placental abruption, amniotic fluid embolism, HELLP syndrome, or intrauterine fetal demise.
  • Dilutional coagulopathy: Large blood loss, or large volume resuscitation with crystalloid and/or packed red blood cells (PRBCs), can cause a dilutional coagulopathy and worsen hemorrhage from other causes.
  • Physiologic factors: These factors may develop during the hemorrhage such as hypocalcemia, hypothermia, and acidemia.

Uterine inversion

"Traction": The traditional teaching is that uterine inversion occurs with an atonic uterus that has not separated well from the placenta as it is being delivered, or from excessive traction on the umbilical cord while placental delivery is being assisted. Studies have yet to demonstrate the typical mechanism for uterine inversion. However, clinical vigilance for inversion, secondary to these potential causes, is generally practiced. Inversion prevents the myometrium from contracting and retracting, and it is associated with life-threatening blood losses as well as profound hypotension from vagal activation.

Previous
 
 
Contributor Information and Disclosures
Author

Maame Yaa A B Yiadom, MD, MPH Staff Physician, Department of Emergency Medicine, Cooper University Hospital, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School

Maame Yaa A B Yiadom, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, National Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Daniela Carusi, MD, MSc Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director, Department of General Ambulatory Gynecology, Brigham and Women's Hospital

Daniela Carusi, MD, MSc is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, Massachusetts Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE Medical Director, Department of Emergency Medicine, Sentara Norfolk General Hospital; Associate Professor, Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Assaad J Sayah, MD, FACEP Chief, Department of Emergency Medicine; Senior Vice President, Primary and Emergency Care, Cambridge Health Alliance

Assaad J Sayah, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Special thanks to Dr. Donnie Bell for his assistance with the "Imaging" section for this topic.

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author, Michael P Wainscott, MD, to the development and writing of this article.

References
  1. Minino AM, Heron MP, Murphy SL, et al. National Vital Statistic Reports: Deaths 2004. US Department of Health and Human Services and the Centers for Disease Control and Prevention. August 21, 2007. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_19.pdf.

  2. World Health Organization. World Health Report 2005: Make Every Mother and Child Count. Available at http://www.who.int/whr/2005/whr2005_en.pdf. Accessed: September 10, 2008.

  3. USAID (United States Agency for International Development). Postpartum Hemorrhage Prevention. USAID Postpartum Hemorrhage Prevention Initiative (POPPHI). Available at http://www.pphprevention.org/briefs_newsletters.php. Accessed: September 9, 2008.

  4. PATH. Saving Mother's Lives: Initiative promotes proven strategy for preventing postpartum hemorrhage. PATH: Preventing Postpartum Hemorrhage. Available at http://www.path.org/projects/preventing_postpartum_hemorrhage.php. Accessed: September 9, 2008.

  5. Miller S, Lester F, Hensleigh P. Prevention and treatment of postpartum hemorrhage: new advances for low-resource settings. J Midwifery Womens Health. 2004 Jul-Aug. 49(4):283-92. [Medline]. [Full Text].

  6. Menitove JE, McElligott MC, Aster RH. Febrile transfusion reaction: what blood component should be given next?. Vox Sang. 1982. 42(6):318-21. [Medline].

  7. Shimada E, Tadokoro K, Watanabe Y, et al. Anaphylactic transfusion reactions in haptoglobin-deficient patients with IgE and IgG haptoglobin antibodies. Transfusion. 2002 Jun. 42(6):766-73. [Medline].

  8. Popovsky MA. Transfusion and lung Injury. Transfusion Clin Biol. 2001. 8:272-7.

  9. Kicklighter EJ, Klein HG. Hemolytic transfusion reactions. Linden JV, Bianco C, eds. Blood Safety and Surveillance. New York: Marcel Dekker; 2001. 47-70.

  10. Tintinalli JE, Kelen GD, Stapczynski JS. Gynecology and Obstetrics: Post Partum Hemorrhage. Emergency Medicine: A Comprehensive Study Guide. 6th. New York: McGraw Hill; 2004. 682.

  11. Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2014 Feb 13. 2:CD003249. [Medline].

  12. Sentilhes L, Lasocki S, Ducloy-Bouthors AS, et al. Tranexamic acid for the prevention and treatment of postpartum haemorrhage. Br J Anaesth. 2015 Apr. 114 (4):576-87. [Medline].

  13. Ducloy-Bouthors AS, Jude B, Duhamel A, et al, for the EXADELI Study Group. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011. 15 (2):R117. [Medline].

  14. Fox S. Preparing for ob/gyn emergencies: ACOG issues tips. February 20, 2014. Available at http://www.medscape.com/viewarticle/820913. Accessed: February 25, 2014.

  15. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014 Mar. 123(3):722-5. [Medline].

  16. Soriano D, Dulitzki M, Schiff E, Barkai G, Mashiach S, Seidman DS. A prospective cohort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage. Br J Obstet Gynaecol. 1996 Nov. 103(11):1068-73. [Medline].

  17. Winikoff B, Dabash R, Durocher J, Darwish E, Nguyen TN, Leon W, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial. Lancet. 2010 Jan 16. 375(9710):210-6. [Medline].

  18. Martin E, Legendre G, Bouet PE, Cheve MT, Multon O, Sentilhes L. Maternal outcomes after uterine balloon tamponade for postpartum hemorrhage. Acta Obstet Gynecol Scand. 2015 Apr. 94 (4):399-404. [Medline].

  19. Howard TF, Grobman WA. The relationship between timing of postpartum hemorrhage interventions and adverse outcomes. Am J Obstet Gynecol. 2015 Aug. 213 (2):239.e1-3. [Medline].

  20. Sparrow AH, Schwemmer SS, Thompson KH. Radiosensitivity studies with woody plants. III. Predictions of limits of probable acute and chronic LD50 values from lognormal distributions of interphase chromosome volumes in gymnosperms. Radiat Res. 1976 Feb. 65(2):315-26. [Medline].

  21. [Guideline] American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); (ACOG practice bulletin; no. 76). 2006 Oct. 10 p. [Full Text].

  22. [Guideline] World Health Organization (WHO). WHO recommendations for the prevention of postpartum haemorrhage. Geneva, Switzerland: World Health Organization (WHO). 2007. 116 p. [Full Text].

  23. Baskett TF. Complications of the third stage of labour. Essential Management of Obstetrical Emergencies. 3rd ed. Bristol, England: Clinical Press; 1999. 196-201.

  24. Bobrowski RA, Jones TB. A thrombogenic uterine pack for postpartum hemorrhage. Obstet Gynecol. 1995 May. 85(5 Pt 2):836-7. [Medline].

  25. Boulleret C, Chahid T, Gallot D, et al. Hypogastric arterial selective and superselective embolization for severe postpartum hemorrhage: a retrospective review of 36 cases. Cardiovasc Intervent Radiol. 2004 Jul-Aug. 27(4):344-8. [Medline].

  26. Bouwmeester FW, Jonkhoff AR, Verheijen RH, van Geijn HP. Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII. Obstet Gynecol. 2003 Jun. 101(6):1174-6. [Medline].

  27. Carr PL, Ricciotti HA, Freund K, Kahan S. Postpartum hemorrhage. Ob/gyn and Women's Health: In a Page. Blackwell Publishing; 2003. 132.

  28. Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ. 2003 Feb 21. 52(2):1-8. [Medline]. [Full Text].

  29. Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol. 1991 Jan. 77(1):69-76. [Medline].

  30. Cunningham FG, et al. Obstetrical hemorrhage. William's Obstetrics. 21st ed. 2001. 619-669.

  31. Cunningham FG, MacDonald PC, Gant NF, et al. Abnormalities of the third stage of labor. William's Obstetrics. 1993. 615-20.

  32. Dildy GA 3rd. Postpartum hemorrhage: new management options. Clin Obstet Gynecol. 2002 Jun. 45(2):330-44. [Medline].

  33. Druelinger L. Postpartum emergencies. Emerg Med Clin North Am. 1994 Feb. 12(1):219-37. [Medline].

  34. Gilbert WM, Moore TR, Resnik R, Doemeny J, Chin H, Bookstein JJ. Angiographic embolization in the management of hemorrhagic complications of pregnancy. Am J Obstet Gynecol. 1992 Feb. 166(2):493-7. [Medline].

  35. Gilstrap LC 3rd, Ramin SM. Postpartum hemorrhage. Clin Obstet Gynecol. 1994 Dec. 37(4):824-30. [Medline].

  36. Goldberg CC, Kallen MA, McCurdy CM, Miller HS. Effect of intrapartum use of oxytocin on estimated blood loss and hematocrit change at vaginal delivery. Am J Perinatol. 1996 Aug. 13(6):373-6. [Medline].

  37. Hofmeyr GJ, Ferreira S, Nikodem VC, et al. Misoprostol for treating postpartum haemorrhage: a randomized controlled trial [ISRCTN72263357]. BMC Pregnancy Childbirth. 2004 Aug 6. 4(1):16.

  38. Mendelson MH. Postpartum emergencies. Harwood-Nuss AL, ed. The Clinical Practice of Emergency Medicine. 3rd ed. 2000. 331-3.

  39. Michalakes CJ, Pundt MR, Kerryann BB. Obstetrics and disorders of pregnancy. Aghababian RV, ed. Emergency Medicine: The Core Curriculum. 1998. 598-600.

  40. Nordstrom L, Fogelstam K, Fridman G, Larsson A, Rydhstroem H. Routine oxytocin in the third stage of labour: a placebo controlled randomised trial. Br J Obstet Gynaecol. 1997 Jul. 104(7):781-6. [Medline].

  41. O'Brien P, El-Refaey H, Gordon A, Geary M, Rodeck CH. Rectally administered misoprostol for the treatment of postpartum hemorrhage unresponsive to oxytocin and ergometrine: a descriptive study. Obstet Gynecol. 1998 Aug. 92(2):212-4. [Medline].

  42. Petrovic O, Zupanic M, Rukavina B, Vlastelic I, Cuk D. Placenta accreta: postpartum diagnosis and a potentially new mode of management using real-time ultrasonography. J Clin Ultrasound. 1994 Mar-Apr. 22(3):204-8. [Medline].

  43. Pierre F, Mesnard L, Body G. For a systematic policy of iv oxytocin inducted placenta deliveries in a unit where a fairly active management of third stage of labour is yet applied: results of a controlled trial. Eur J Obstet Gynecol Reprod Biol. 1992. 43:131-135.

  44. Prendiville WJ. The prevention of post partum haemorrhage: optimising routine management of the third stage of labour. Eur J Obstet Gynecol Reprod Biol. 1996 Oct. 69(1):19-24. [Medline].

  45. Roberts WE. Emergent obstetric management of postpartum hemorrhage. Obstet Gynecol Clin North Am. 1995 Jun. 22(2):283-302. [Medline].

  46. Sherer DM, Abulafia O, Anyaegbunam AM. Intra- and early postpartum ultrasonography: a review. Part II. Obstet Gynecol Surv. 1998 Mar. 53(3):181-90. [Medline].

  47. Varner M. Postpartum hemorrhage. Crit Care Clin. 1991 Oct. 7(4):883-97. [Medline].

  48. Wittich AC, Salminen ER, Hardin EL, Desantis RA. Uterine packing in the combined management of obstetrical hemorrhage. Mil Med. 1996 Mar. 161(3):180-2. [Medline].

  49. World Health Organization. Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and The World Bank. World Health Organization. 2007. Available at http://www.who.int/whosis/mme_2005.pdf.

  50. Zahn CM, Yeomans ER. Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol. 1990 Sep. 33(3):422-31. [Medline].

  51. Valent AM, Newman T, Chen A, Thompson A, DeFranco E. Gestational age-specific neonatal morbidity among pregnancies complicated by advanced maternal age: a population-based retrospective cohort study. J Matern Fetal Neonatal Med. 2015 Jun 9. 1-6. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.