Massive Postpartum Haemorrhage

Massive postpartum haemorrhage is blood loss of 2000 mL or more, loss of half the blood volume within 3 hours, or bleeding at more than 150 mL per minute, or continuing instability despite initial treatment. It results from uterine atony, trauma, retained placenta, accreta spectrum, rupture or coagulopathy, often in combination. It is a life-threatening emergency that needs a team approach, rapid transfusion and early surgery.

• Risk factors: placenta praevia or accreta spectrum, abruption, uterine rupture, previous caesarean section, multiple pregnancy, severe preeclampsia, sepsis.
• Mortality rises with delay in transfusion and surgery.
• A massive transfusion pack and a stepwise plan save lives.

Women have profuse bleeding, severe pallor, confusion, cold clammy skin, rapid weak pulse, low blood pressure, falling urine output and loss of consciousness. Bleeding may be concealed.

• Pulse above 120 per minute with systolic pressure below 90 mmHg.
• Cool peripheries and prolonged capillary refill above 3 seconds.
• Differential diagnosis: uterine atony, genital tract trauma, uterine rupture, inversion, accreta spectrum, coagulopathy, amniotic fluid embolism.
• Complications: shock, DIC, acute kidney injury, acute respiratory distress syndrome, cardiac arrest, hypothermia, hysterectomy, Sheehan syndrome, maternal death.

The approach is concurrent resuscitation, examination and testing with no delay for results.

• Pulse, blood pressure, respiratory rate, oxygen saturation, urine output, temperature, shock index above 1.
• Haemoglobin (may be normal early), platelets, fibrinogen, prothrombin time, activated partial thromboplastin time, lactate, arterial or venous gas, calcium, potassium, creatinine, group and cross-match 6 units.
• Examination for uterine tone, genital tract tears, retained tissue, inversion and rupture.
• Ultrasound or CT only if the woman is stable enough.

The principle is to activate the massive haemorrhage plan, resuscitate with blood products in fixed ratios, stop the bleeding by escalating steps and correct coagulopathy, acidosis, hypothermia and hypocalcaemia.

• Supportive: call obstetric consultant, anaesthetist, haematologist, blood bank and theatre; two large-bore cannulae; warm Ringer's lactate 1 to 2 litres while blood is prepared; oxygen 10 to 15 L/minute; urinary catheter; warming blanket; aortic compression (a firm closed fist over the abdominal aorta above the umbilicus until the femoral pulse disappears) or a non pneumatic anti-shock garment while preparing; cell salvage in theatre.
• Pharmacological: O negative blood until cross-matched blood arrives; massive transfusion pack of 4 units packed red cells, 4 units fresh frozen plasma and one adult dose of platelets, repeated as needed; fibrinogen concentrate 2 to 4 g or cryoprecipitate 10 units for fibrinogen below 2 g/L; calcium gluconate 1 g IV after every 4 units of blood; tranexamic acid 1 g IV over 10 minutes (repeat once after 30 minutes); oxytocin 10 IU IM or 5 IU slow IV, then infusion of 40 IU in 1 litre at 250 mL per hour; ergometrine 0.2 mg IM, carboprost 250 micrograms IM every 15 minutes (maximum 8 doses) and misoprostol 800 micrograms sublingual if no contraindication; noradrenaline 0.05 micrograms/kg/minute IV titrated for mean arterial pressure above 65 mmHg after volume replacement; targets: haemoglobin 7 to 9 g/dL, platelets above 50 x 10^9/L, fibrinogen above 2 g/L, INR below 1.5, temperature above 36 degrees Celsius, pH above 7.2.
• Procedures: balloon tamponade (300 to 500 mL sodium chloride 0.9 percent); compression sutures; stepwise devascularisation; embolisation; pelvic packing and a planned relook; hysterectomy early rather than late for rupture, accreta spectrum or atony after drugs and balloon fail.
• Special groups: women who decline transfusion need cell salvage, tranexamic acid, early surgery, IV iron (ferric carboxymaltose 15 mg/kg, maximum 1000 mg per dose) and erythropoietin 300 units/kg subcutaneous daily.
• Red flags: loss above 2000 mL, systolic blood pressure below 80 mmHg, lactate above 4 mmol/L, fibrinogen below 1.5 g/L, core temperature below 35 degrees Celsius, cardiac arrest.
• Follow-up: intensive care for 24 to 48 hours; haemoglobin, clotting and electrolytes every 4 to 6 hours; ferrous sulphate 200 mg oral 8-hourly for 3 months; debrief with the woman; review at 6 weeks for Sheehan syndrome symptoms (failure to lactate, amenorrhoea).