Postpartum Haemorrhage

Also known as: PPH, Postpartum hemorrhage

Excessive bleeding following childbirth: traditionally defined as blood loss ≥500mL after vaginal delivery or ≥1000mL after cesarean section, though clinical significance depends more on rate of loss and the patient's hemodynamic response than absolute volume (notoriously difficult to estimate accurately). Leading cause of maternal mortality globally, particularly in resource-limited settings.

Classified by timing:

Primary PPH: within 24 hours of delivery: majority of cases
Secondary PPH: 24 hours to 6 weeks postpartum: typically retained products of conception or endometritis

Causes — the "4 Ts":

Tone: uterine atony (most common, ~70-80% of PPH)
Tissue: retained placenta/placental fragments, abnormal placentation (accreta spectrum)
Trauma: genital tract lacerations, uterine rupture, uterine inversion
Thrombin: coagulopathy (pre-existing or acquired: DIC from abruption/amniotic fluid embolism/severe pre-eclampsia)

Visible bleeding from genital tract, often significant and rapid: but note internal/concealed bleeding is possible (broad ligament hematoma, uterine rupture with intra-abdominal bleeding)
Signs of hypovolemic shock (recognition may be delayed in previously healthy young women who compensate well until sudden decompensation): tachycardia, hypotension (late sign), pallor, cool extremities, reduced consciousness, oliguria
Uterine atony: uterus feels soft/boggy, poorly contracted, fundus may be difficult to locate
Uterine inversion: severe pain, uterus may be visible at introitus, profound shock often disproportionate to visible blood loss
Uterine rupture: severe abdominal pain, fetal distress if undelivered second twin, palpable fetal parts, loss of presenting part station, hemodynamic instability
Retained placenta: placenta not delivered within 30 minutes (active management) or 60 minutes (physiological management), or appears incomplete on inspection

Primarily clinical: recognize and act on excessive bleeding and/or hemodynamic compromise; investigations support but should not delay resuscitation.

Visual estimation of blood loss (tends to underestimate): calibrated collection drapes improve accuracy where available
Vital sign monitoring: obstetric early warning scores detect deterioration before absolute hypotension develops
FBC, coagulation profile (PT/APTT/fibrinogen: fibrinogen falls early and disproportionately in obstetric hemorrhage/DIC), crossmatch/group and save
Examination: identify source systematically: uterine tone, inspection for genital tract trauma (good lighting/exposure, may need examination under anesthesia), placental inspection for completeness
Ultrasound: assess for retained products, uterine rupture, or abnormal placentation if suspected

Always consider that more than one cause may coexist (e.g., atony plus a laceration).

Immediate, simultaneous approach — call for help early, this is a team emergency:

Call for senior obstetric, anesthetic, and midwifery help immediately: activate massive obstetric hemorrhage protocol
ABC: high-flow oxygen, two large-bore IV access, aggressive fluid resuscitation, early blood product transfusion (activate massive transfusion protocol early, target 1:1:1 packed cells:FFP:platelets)
Tranexamic acid 1g IV (repeat if bleeding continues after 30 min): as early as possible, mortality benefit demonstrated (WOMAN trial), most effective within 3 hours of onset

Uterine atony (the "Tone" T):

Bimanual uterine compression: immediate first action while other measures are arranged
Uterotonic drugs:
- Oxytocin: IV bolus 5-10 units, followed by infusion (40 units in 500mL over 4 hours): first-line
- Ergometrine 0.5mg IM/IV: AVOID in hypertension/pre-eclampsia
- Carboprost 250mcg IM, repeated every 15-90 min (max 8 doses): AVOID in asthma
- Misoprostol 800-1000mcg rectally/sublingually: useful where injectable uterotonics unavailable
Bladder emptying (full bladder impairs uterine contraction)
Uterine massage
If pharmacological measures fail:
- Balloon tamponade (Bakri balloon or condom catheter): effective, especially valuable in resource-limited settings
- Uterine compression sutures (B-Lynch)
- Uterine artery/internal iliac ligation, or interventional radiology embolization if available and patient stable
- Hysterectomy: life-saving last resort: should not be delayed once clearly indicated

Retained placenta/tissue (the "Tissue" T):

Controlled cord traction with counter-pressure if placenta separated
Manual removal under anesthesia if not delivered/incomplete: theatre setting, antibiotic cover
Evacuation of retained products if incomplete delivery identified

Trauma (the "Trauma" T):

Systematic examination for genital tract lacerations under adequate lighting/analgesia: repair tears
Uterine inversion: manual replacement immediately (do NOT remove placenta first if still attached), uterine relaxants (terbutaline, GTN, or general anesthesia) may be needed, then uterotonics once repositioned
Uterine rupture: emergency laparotomy, repair or hysterectomy depending on extent

Coagulopathy (the "Thrombin" T):

Correct with blood products guided by coagulation results: FFP, cryoprecipitate (target fibrinogen >2g/L), platelets
Identify and treat underlying cause

Prevention (all deliveries): active management of third stage (prophylactic oxytocin, controlled cord traction, uterine massage) significantly reduces PPH incidence and is standard practice.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Eclampsia

Also known as: Eclamptic seizure

Occurrence of generalized tonic-clonic seizures in a woman with pre-eclampsia (new-onset hypertension + proteinuria and/or other organ dysfunction after 20 weeks gestation), not attributable to other causes.

Represents the severe end of the pre-eclampsia/HELLP spectrum, a hypertensive emergency of pregnancy with significant maternal and fetal mortality risk. Can occur antepartum, intrapartum, or postpartum (up to 6 weeks, though most occur within 48 hours).

Pre-eclampsia severity features indicating progression risk: severe hypertension (≥160/110), severe headache, visual disturbance (scotomata, blurred vision), epigastric/RUQ pain, hyperreflexia/clonus, rapidly worsening renal function, pulmonary edema, HELLP features (Hemolysis, Elevated Liver enzymes, Low Platelets).

Generalized tonic-clonic seizure, typically preceded by (though sometimes without) warning signs: severe headache, visual disturbance, epigastric pain, hyperreflexia/clonus, sudden severe hypertension
Post-ictal confusion/drowsiness as with any generalized seizure
May occur with BP not extremely elevated — eclampsia can occur even with only mild-moderately elevated BP, so absence of severe hypertension does not exclude the diagnosis
Signs of associated HELLP/severe pre-eclampsia: RUQ/epigastric tenderness, jaundice, easy bruising/petechiae, oliguria
Fetal status: assess for distress (abnormal CTG); placental abruption can coexist (vaginal bleeding, abdominal pain, uterine tenderness)
Complications: HELLP syndrome, DIC, placental abruption, acute kidney injury, pulmonary edema, cerebral hemorrhage (leading cause of eclampsia-related death), hepatic rupture, aspiration pneumonia

Primarily clinical — a new seizure in a pregnant or recently postpartum woman with hypertension/proteinuria is eclampsia until proven otherwise; treatment should not be delayed for extensive workup.

BP measurement, urinalysis (proteinuria — though not required for diagnosis if other severe features present)
FBC (platelets — thrombocytopenia in HELLP), LFTs (elevated transaminases), U&E/creatinine, coagulation profile if HELLP/abruption suspected
Uric acid: often elevated, supportive but not diagnostic
LDH, peripheral blood film (schistocytes — microangiopathic hemolysis)
CTG: assess fetal wellbeing once mother stabilized
CT/MRI head: NOT routinely required if typical eclamptic seizure with prompt recovery — reserved for atypical presentation (focal deficit, onset >48h postpartum, refractory to magnesium, diagnostic uncertainty) to exclude hemorrhage, PRES, venous sinus thrombosis

Differentials: epilepsy, other causes of seizure in pregnancy (hypoglycemia, electrolyte disturbance, cerebral venous sinus thrombosis, PRES, intracranial hemorrhage, TTP) — consider particularly if atypical features (focal deficit, seizure before 20 weeks, very late postpartum onset, poor response to magnesium).

Immediate priorities — ABC, protect airway, prevent injury:

Position in left lateral position (reduces aortocaval compression, protects airway)
Oxygen, suction as needed, protect from injury (do not restrain forcefully)
Most eclamptic seizures are self-limiting within 1-2 minutes

Magnesium sulfate — the definitive treatment, for both acute seizure control AND prevention of further seizures (superior to benzodiazepines/phenytoin for this indication):

Loading dose: 4g IV over 5-10 minutes (or 4-6g per local protocol)
Maintenance infusion: 1g/hour IV, continued for 24 hours after the last seizure or after delivery, whichever is later
If further seizure despite magnesium: additional bolus 2g IV
Monitor for magnesium toxicity — narrow therapeutic window: deep tendon reflexes hourly (loss of reflexes is the earliest sign), respiratory rate (maintain >12/min), urine output (≥25mL/hour — magnesium is renally excreted and accumulates in oliguria)
Antidote for toxicity: calcium gluconate 10mL of 10% solution IV over 10 minutes

BP control (severe hypertension, ≥160/110):

IV labetalol (10-20mg bolus, repeat/double every 10 min to max 80mg per dose or start infusion), or
IV hydralazine (5-10mg bolus, repeat every 20-30 min), or
Oral nifedipine (10mg immediate-release) if IV access delayed
Target: gradual reduction, avoid precipitous drops (uteroplacental perfusion) — SBP 140-150, DBP 90-100

Definitive management — delivery:

Eclampsia is an indication for delivery once the mother is stabilized — delivery is the only definitive cure
Mode per obstetric factors; vaginal delivery not contraindicated by eclampsia alone if maternal/fetal condition allows
Do NOT delay delivery to achieve an arbitrary gestational age once mother stabilized — maternal condition takes priority
Continue magnesium through delivery and postpartum

Fluid management: cautious, restricted to avoid pulmonary edema — typically total fluids limited to 80mL/hour or 1mL/kg/hr unless significant hemorrhage.

Postpartum monitoring: close BP/neurological/renal monitoring for at least 24-48 hours postpartum, watch for HELLP progression.

Referral: obstetric emergency — senior obstetrician, anesthetist, and neonatal team from presentation; ICU/HDU for severe cases; neurology if atypical features.

Postpartum Haemorrhage

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management