Postpartum hemorrhage is responsible for almost 140,000 deaths per year worldwide and can cause serious morbidity. It can occur without warning; therefore, all physicians should be prepared to manage it properly. The American College of Obstetricians and Gynecologists (ACOG) has reviewed the risks associated with postpartum hemorrhage and released recommendations on its management. The full guideline was published in the October 2006 issue of Obstetrics & Gynecology.
The most common cause of hemorrhage is uterine atony. If a patient has excessive bleeding following delivery, the bladder should be emptied and a pelvic examination performed. Massage or compression of the uterine corpus can help slow bleeding and remove blood and clots. If the patient continues to hemorrhage, other causes should be explored (e.g., lacerations, genital tract hematomas, retained placenta, coagulopathy). Baseline studies, including complete blood count with platelets, prothrombin time, activated partial thromboplastin time, fibrinogen, and a type and cross order, should be ordered and repeated if clinically necessary.
First-line treatment of postpartum hemorrhage includes the administration of uterotonics. If these agents fail to stop contractions and bleeding, a tamponade can be effective. If the tamponade does not provide an adequate response, physicians should perform an exploratory laparotomy (a midline vertical incision to the abdomen is preferred because it provides the best possible exposure). There are several methods for controlling continued bleeding, including uterine curettage, uterine artery ligation, B-Lynch suture, hypogastric artery ligation, rupture repair, and hysterectomy.
Placenta accreta is one of the most common reasons for postpartum hysterectomy. Risk factors include placenta previa (with or without previous uterine surgery), previous myomectomy or cesarean delivery, Asherman's syndrome, submucous leiomyomata, and age older than 35 years. The presence of any of these risk factors should create a suspicion of placenta accreta, and the physician should take the appropriate precautionary steps, such as patient counseling, making blood products and clotting factors available, considering the use of cell saver technology, scheduling delivery when and where there is access to surgical personnel and tools, and assessing preoperative anesthesia.
Arterial embolization may be an option in patients with stable vital signs who have persistent bleeding. It can be performed to help stop bleeding after hysterectomy or as an alternative to a hysterectomy. If vital signs are unstable and the blood loss is significant, transfusion may be necessary. Surgical repair is required if a hemorrhage is caused by a ruptured or inverted uterus; the surgical method should be adapted to each individual patient, if possible. No matter what the cause, replacement of red cells in patients with postpartum hemorrhage is key.