PPH - obstetrician’s trial by fire

The medical community is currently shattered by the untimely demise of a dear colleague. The events leading to this incident are well chronicled in the media, leading to increased awareness about the trigger event “Postpartum Hemorrhage" (PPH), a life threatening complication that can occur during the process of childbirth.

PPH has always been a leading cause of maternal deaths worldwide.

Incidence of PPH is reported as 2 - 4 % after vaginal delivery and 6% after cesarean section.

With the improvements in healthcare systems, the incidence rate has been brought down drastically over the years, so much that it's a rare cause of maternal deaths in the western world. Even urban India has matched the western standards, while rural healthcare is catching up well. At the same time, there is no denying that the occurrence of PPH can be poorly predicted, even by the best of the obstetricians.

What is the definition of PPH?

PPH is a rare but a serious condition, when a woman has excessive bleeding after giving birth.

Medical textbook defines it as “excessive loss (vaginal delivery : >/= 500ml; C- section : >/= 1000ml) immediately or until. 12 weeks after delivery”.

According to ACOG, “Irrespective of the route of delivery, if the blood loss > 1000ml, it is considered as PPH”. There are a couple of definitions and nuances which are out of scope of this article.

Primary PPH : excessive bleeding withing 24 hrs of childbirth

secondary PPH : Excessive bleeding after 24 hours of childbirth, upto 6 weeks.

What exactly happens in PPH that is different from the blood loss normally seen during the delivery process?

There are 4 main causes (4T’s) that can cause significant Postpartum Hemorrhage.

1. Tone : decreased tone of the uterus (about 50 % cases)

Immediately after the baby is born, the uterus starts contracting. This process enables the uterus to go back to its pre-pregnancy size (which takes about 40 days), however a more significant outcome is restricting the post delivery blood loss. As the uterine muscles contract, they compress the blood vessels of the uterus,causing a natural tamponade effect and stopping blood loss. However if the uterus fails to contract and remains flaccid, this natural mechanism is lost that can cause PPH.

2. Trauma : lacerations/cervical tear / vaginal injury /uterine rupture

Signs of uterine rupture may not be visible immediately and hence is an obstetric emergency.

3. Tissue : Failure of expulsion of placental tissue can lead to significant blood loss and PPH.

4. Thrombin : certain genetic conditions e.g. Von Willebrand disorder or underlying health conditions (cancer, Intrahepatic cholestasis of pregnancy) can cause deficiency of clotting factors, especially thrombin. As the clotting mechanism fails, there is significant loss of blood aka PPH.

Risk factors of PPH:

maternal 

during labour process

placental

multiple pregnancies

labour time : quick labour (<3 hrs) or prolonged labour (both affect the tone of the uterus)

placenta previa

nutritional deficiency and anemia

assisted vaginal delivery vacuum / forceps (vaginal injury)

incomplete/ non expulsion of placenta post delivery.

fibroids/ anatomical defects in uterus

cesarean section delivery (less likely)

placenta adhering to uterine tissue ; placenta accreta

high blood pressure during pregnancy

malpresentation. 

PPH during previous pregnancy

general anaesthesia during labour

overdistended uterus eg: twin pregnancy/excessive amniotic fluid

medications to induce to labour or to prevent preterm labour (very rare cause)

fibroids/ anatomical defects in uterus

Signs and symptoms of PPH

1. Heavy bleeding from vagina that doesn’t slow or stop
2. Signs suggestive of hypovolemic shock - drop in blood pressure, cold & clammy limbs, excessive sweating, dizziness, confused mental state, pale skin, very fast heart rate.
3. Severe nausea and vomiting
4. Blood clot (hematoma) around the vagina.

How to confirm the diagnosis of PPH?

1. Vitals : low Blood pressure, tachycardia
2. Getting an estimate of blood loss, which the doctors and nurses measure with fair accuracy
3. Tests : Hemoglobin i.e.Hb and Hematocrit value (which falls significantly and quickly after blood loss)
4. Blood clotting tests e.g. bleeding time, clotting time, clotting factor tests and assays.
5. Pelvic examination
6. USG

Treatment of PPH

Treatment is determined by the causative factors

1. Supportive therapy is initiated at the earliest no matter what may be the cause of PPH. It includes :
2. Fluids : to prevent further fall in blood pressure
3. transfusion of blood, platelets and plasma : to maintain the BP, Hb, provide adequate clotting factors and platelets. This also helps in preventing a serious condition called DIC. (Disseminated Intravascular Coagulation)
4. Providing supportive Oxygen. If the patient appears to be in comatose situation, mechanical ventilation may be needed.
5. Specific measures:
6. Uterine massaging
7. Removing remnants of placenta from the uterus
8. Embolization of blood vessels that supply the uterus
9. Surgical procedure to suture the uterus or removal of uterus (obstetric hysterectomy) as a last resort.

Preventive measures

1. Regular health check ups during the 9 months of pregnancy. This cannot be emphasised enough.
2. Adequate nutrition during pregnancy including supplements for Iron to ensure healthy Hb levels.
3. Compliance of treatment in case one is diagnosed with a medical condition during the pregnancy.
4. Avoiding self diagnosis/ self medication via the internet.
   

With all the knowledge an obstetrician possesses, PPH remains a literal trial by fire as no doctor wants the happy occasion of arrival of the bundle of joy to be affected by any negative outcomes. And in case if such an eventuality occurs, your doctor is as devastated as is the family.

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