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.
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.
There are 4 main causes (4T’s) that can cause significant Postpartum Hemorrhage.
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.
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
Treatment is determined by the causative factors
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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