Maternal hemorrhage remains the leading cause of maternal mortality worldwide.
Management can range from observation and management with medications to ultimately a hysterectomy to resolve it. Besides shoulder dystocia and eclampsia, maternal hemorrhage is one of the biggest emergencies in OBGYN requiring all hands on deck and quick response and management.
It can occur not only during or after a delivery but also before or even in the 1st trimester. For example, an ectopic pregnancy (or pregnancy outside the uterus--most commonly in the fallopian tube) can rupture causing blood in the abdomen that can lead to extensive blood loss and even death if the patient is not quickly taken to the OR for emergent surgery to remove the pregnancy, evacuate the blood, and replace all the volume the patient has lost.
Bleeding can also occur during pregnancy which can lead to prompt delivery such as placental abruption or separation of the placenta from its normally implanted site in the uterus. Also, other abnormalities of the placenta such as a placenta previa (or placenta over the cervix) can lead to abrupt bleeding which needs to be immediately evaluated to ensure reassurance of fetal well being and check maternal labs with close monitoring. Whereas a placenta abruption is usually PAINFUL vaginal bleeding, a placenta previa is usually PAINLESS vaginal bleeding. You are required to have a c-section with a placenta previa since the placenta is over the cervix; and if you attempted a vaginal delivery, you would hemorrhage. This is a high risk pregnancy and needs close monitoring and immediate presentation to the hospital if bleeding occurs.
The most common hemorrhages OBGYNs face is that during delivery and following. Certain risk factors can be associated with hemorrhage at the time of delivery or postpartum (following delivery) and you should be aware of these.
Risk factors include: history of prior uterine surgery, more than 4 previous deliveries, multiple gestation (twins/triplets/etc), large fibroids, infection during labor (chorioamnionitis), use of magnesium sulfate (which is used in pre-eclampsia or high blood pressure during pregnancy), prolonged use of pitocin (contraction medicine), placenta previa/accreta/increta/percreta), low blood count (hematocrit less than 30), bleeding at admission, blood clotting disorders, history of postpartum hemorrhage, abnormal vital signs (low BP, fast heart rate). When any of these factors are noted, team members should be prepared in case a hemorrhage occurs.
So what is a postpartum hemorrhage? iI is greater than 500cc blood loss at time of a vaginal delivery or 1000cc at time of c-section.
What causes a postpartum hemorrhage?
There are primary causes and secondary causes. Primary causes occur within 24 hours of a delivery and can include things such a uterine atony (failure of the uterus to contract down), vaginal/cervical/perineal lacerations (or tears), retained placenta or placenta adhered to uterus (accreta), growing into the muscle of uterus (increta), or growing through the uterus (percreta). A placenta accreta, increta, or percreta are usually diagnosed prior to delivery and requires a cesarean hysterectomy (c-section followed by removal of the uterus).
Secondary causes occur 24 hours after up to 12 weeks following a delivery. Some causes can include subinvolution of the placental site (where the area from where placenta separates does not contract down and continues to bleed), retained products of conception (etc placenta), infection, blood clotting disorders.
How do you handle a hemorrhage? You have to act quickly and efficiently and it's important to have a good team available to help you. When evaluating bleeding, I always think of the 4 Ts mnemonic to make sure nothing is missed- Tone, Trauma, Tissue, Thrombin. Theres too much to write in how to actually manage a postpartum hemorrhage but the goal is to ultimately stop bleeding. While I am attempting to do this, I make sure I'm frequently assessing the patient's vital signs, monitoring labs, weighing blood loss and keeping up with how much blood loss has occurred, and have available IV access (usually 2 IV sites) in case the patient needs blood/fluids/etc. There have been cases when I can simply clear a blood clot out and the bleeding stops, administer multiple medications, or remove the patient's uterus to ultimately stop the bleeding. A hysterectomy is usually the last resort and all measures have been exhausted or the patient is unstable and unless the uterus is removed, they could bleed out.
I have had some scary postpartum hemorrhage events but honestly I would say the scariest is when it is a DELAYED postpartum hemorrhage. I have had on two separate occasions when a patient has come into the ER and I had no idea how much blood loss has occurred prior to her arrival or my evaluation of her. When labs are obtained, usually the blood loss is not reflected until a couple of hours later when the body has equilibrated. I have been taught, and it has become very evident to me, that OBGYNs and doctors in general tend to underestimate blood loss. So in my cases of delayed postpartum hemorrhages, the women required prompt surgery and multiple blood products to replace what they had already lost. One moment vitals can be stable and labs normal and within an hour, a woman's life can be at risk due to bleeding. It is very important to know what amount of bleeding is normal following a delivery and what is not. Bleeding like a period which starts to lighten up as the days go on=NORMAL. Bright red vaginal bleeding that doesn't stop, feeling dizzy/lightheaded/weak, soaking 1 pad per hour, or abrupt vaginal bleeding after days of not bleeding=NOT NORMAL.
In summary, maternal hemorrhage is one of the most serious topics of OBGYN. Physicians/nurses should be able to appropriately recognize the severity of it along with the importance of educating patients on how to recognize when it is getting out of hand and seek help.
Hope this provided some insight on a topic near and dear to my heart.
Thanks y'all!
Dr. Riley
----------------------------------------------------------------------------------
References:
ACOG PB #183 Postpartum Hemorrhage:
https://www.acog.org/Clinical%20Guidance%20and%20Publications/Practice%20Bulletins/Committee%20on%20Practice%20Bulletins%20Obstetrics/Postpartum%20Hemorrhage.aspxectopic pic: https://www.google.com/search?q=ectopic+pregnancy&rlz=1C5CHFA_enUS733US733&source=lnms&tbm=isch&sa=X&ved=0ahUKEwi-6MGs_LHgAhXLz4MKHQ7ZDDMQ_AUIDigB&biw=1453&bih=718#imgrc=jcrnQc574LpFSM:
retained POC pic: https://www.google.com/search?rlz=1C5CHFA_enUS733US733&biw=1453&bih=669&tbm=isch&sa=1&ei=04lgXOXAI6Kp_QbV_Ju4Ag&q=retained+products+on+ultrasound+after+delivery&oq=retained+products+on+ultrasound+after+delivery&gs_l=img.3...22934.25626..25979...0.0..0.108.1398.14j1......1....1..gws-wiz-img.szGupO1vU_I#imgrc=P4jtgdfYKI4sXM:
Comments