Post-Partum Haemorrhage (PPH)

1. Definition and Significance

• Post-partum haemorrhage (PPH) is a major cause of maternal morbidity and mortality worldwide. It is defined as:

• Primary PPH: Blood loss from the genital tract of 500 mL or more within the first 24 hours of birth.
• Major PPH: Blood loss of 1000 mL or more (this includes minor PPH: 500-1000mL and major PPH: >1000mL).
• Secondary PPH: Abnormal or excessive bleeding from the genital tract between 24 hours and 12 weeks postnatally.

• Crucially, the clinical impact is more important than the measured volume. A blood loss of 500mL may be well-tolerated by a healthy woman but can be catastrophic for an anaemic or haemodynamically compromised woman. Therefore, any blood loss that causes haemodynamic instability (e.g., tachycardia, hypotension) should be treated as a major PPH regardless of the measured volume.

2. Causes (The “4 T’s”)

A rapid, structured approach to identifying the cause is essential.

1. Tone (Atonic Uterus): ~70% of cases. The uterus fails to contract adequately after delivery.
2. Trauma: Tears to the cervix, vagina, or perineum; uterine rupture.
3. Tissue (Retained Products of Conception): Retained placenta or placental fragments.
4. Thrombin (Coagulopathy): Pre-existing (e.g., von Willebrand’s) or acquired (e.g., placental abruption, HELLP syndrome, amniotic fluid embolism) coagulation disorders.

3. Stepwise Management: A Structured Approach

Management is simultaneous, not sequential. It follows a “Call for Help, Assess, Resuscitate, Arrest Bleeding” approach, as outlined in major guidelines like MBRRACE-UK and RCOG.

Step 1: Immediate Response & Communication

• SHOUT FOR HELP: Alert the senior obstetrician, anaesthetist, midwives, and haematology team.
• Commence the PPH protocol in your unit.

Step 2: Resuscitation (ABC) and Monitoring

• Airway & Breathing: Administer high-flow oxygen (10-15 L/min via a non-rebreath mask).
• Circulation:
  • Obtain large-bore IV access (x2 cannulae, 14G or 16G).
  • Commence a rapid fluid infusion with crystalloids (e.g., 1-2 litres).
  • Transfuse O-negative blood immediately if the patient is shocked, without waiting for cross-match. Switch to cross-matched blood as soon as possible.
  • Follow Major Haemorrhage Protocol (MHP) if ongoing major bleeding.
• Monitoring: Continuous pulse, BP, SpO₂. Insert a Foley catheter to monitor urine output (aim >30mL/hr).

Step 3: Identify the Cause and Arrest the Bleeding

A. Initial Measures (Simultaneous Examination)

• Rub up a contraction: Massage the uterus bimanually.
• Empty the bladder: Catheterise.
• Examine for Trauma: Systematic inspection of the vagina, cervix, and perineum for lacerations. Repair under good light and analgesia.
• Examine for Retained Tissue: Examine the placenta for completeness. If retained, prepare for manual removal of placenta under regional or general anaesthesia.

B. Medical Management (Uterotonics)
First-line uterotonics should be administered simultaneously or in rapid succession for an atonic uterus.

1. First-line: Oxytocin (e.g., Syntocinon®)
   • Dose: 5 IU by slow IV injection or 40 IU in 500 mL crystalloid infused at 125 mL/hr.
2. Second-line: Ergometrine or Syntometrine®
   • Dose: Ergometrine 0.5 mg IM/IV or Syntometrine (1 ampoule = 5 IU oxytocin + 0.5 mg ergometrine) IM.
   • Contraindications: Hypertension, pre-eclampsia, cardiac disease.
3. Third-line: Carboprost (Hemabate™)
   • Dose: 0.25 mg IM, can be repeated every 15 minutes up to a maximum of 8 doses (2 mg).
   • Contraindications: Asthma, active cardiac or pulmonary disease.
4. Fourth-line: Misoprostol
   • Dose: 600-800 mcg rectally.
   • RCOG: Useful in low-resource settings or when other drugs are unavailable, but less practical than oxytocin. It serves as an adjunct.

C. Investigations and Haemostatic Support

• Send blood for FBC, U&Es, Clotting Screen, and Cross-match (4-6 units).
• Point-of-care tests like Viscoelastic Haemostatic Assays (TEG/ROTEM) can guide targeted transfusion of blood products (RBCs, FFP, Platelets, Cryoprecipitate/Fibrinogen).
• Tranexamic Acid: Administer 1g IV over 10 minutes as soon as possible (within 3 hours of birth), followed by a second 1g dose if bleeding continues after 30 minutes or restarts within 24 hours. (Based on strong evidence from the WOMAN trial).

D. Surgical & Radiological Interventions
If bleeding persists despite medical management, escalate immediately.

1. Intrauterine Balloon Tamponade (IUBT): (e.g., Bakri Balloon)
   • First-line surgical intervention. Effective in ~80-90% of cases for atonic PPH.
   • The balloon is inserted into the uterine cavity and filled with saline to provide mechanical pressure.
2. Compression Sutures: (e.g., B-Lynch suture)
   • A suture technique that physically compresses the uterus. Often used in conjunction with IUBT.
3. Vascular Embolisation:
   • Interventional Radiology: If the patient is stable enough for transfer to an angiography suite, selective arterial embolisation can be highly effective.
4. Laparotomy:
   • Systematic devascularisation: Bilateral uterine artery ligation, then internal iliac artery ligation.
   • Hysterectomy: The definitive, life-saving procedure when all other measures have failed. It should be performed without delay in a catastrophic haemorrhage. Two senior consultants should make the decision.

4. Key Points from Guidelines

•  Emphasises the emergency department’s role in recognising and initiating resuscitation for secondary PPH. Stresses the importance of early senior involvement and activation of the major haemorrhage protocol..
• Provides an evidence-based, systematic summary of causes and treatments, highlighting the efficacy of TXA and the step-up approach to uterotonics and interventions.
• NICE Guidelines (NG201): Focuses on risk assessment, prevention (active management of the third stage), and the bundle of care for immediate response. Recommends quantitative blood loss measurement where possible.
• RCOG Green-top Guidelines (No. 52): This is the most comprehensive guideline for obstetricians in the UK. It provides the definitive framework for the stepwise management of PPH, including detailed algorithms for medical and surgical interventions.

Summary: The management of PPH requires a calm, systematic, and multidisciplinary team approach. The key is to act fast: resuscitate simultaneously while diagnosing the cause, escalate uterotonic therapy rapidly, and have a low threshold for moving to mechanical and surgical interventions to save the mother’s life.