Understanding the Causes of Postpartum Hemorrhage (A Comprehensive Analysis)

After the delivery women experience postpartum bleeding which is common. But some women experience unusually known as postpartum hemorrhage. In most cases, women do not know how bad postpartum bleeding is and may confuse PPH with normal bleeding. 

According to WHO each year 14 million women experience PPH resulting in 70,000 deaths. Even if the women survive after PPH they are left with lifelong complications. 

Definition and Classification of PPH

Primary PPH 

 1. Definition: Primary PPH refers to excessive bleeding that occurs within the first 24 hours after giving birth. 

 2. Incidence rates:  In India, the incidence rate of women getting primary PPH is between 2-4% for vaginal deliveries and 6% for c-sections.                                        

3. Risk factors: Some women are more likely than others to acquire primary PPH. 

1. Women who have previously had twins or triplets, 
2. anaemia, 
3. obesity, hypertension or diabetes
4. long labour, 
5. birthing a large baby (more than 4 kg), 
6. use of certain medications to induce labour

Secondary PPH 

1. Definition: Secondary PPH can occur between 24 hours and up to six weeks after childbirth. 

2. Incidence rates: Although the rates of secondary PPH are low as compared to primary PPH it can still pose a threat to the life of women. About 0.21% of women may experience secondary PPH. 

 3. Risk factors: Secondary PPH risk factors include placental retention, placental anomalies such as the placenta attaching to the uterine wall, past c-section, previous uterine surgery, or uterine infection. 

Common Causes of Postpartum Hemorrhage 

Definition and explanation 

When the uterus fails to contract properly after delivery then it is the case of Uterine Atony. It is one of the leading causes of PPH and almost 70% of PPH cases are because of uterine atony. Without sufficient contraction, the blood vessels in the uterus remain open leading to excessive bleeding. 

Contributing factors 

Various factors can contribute to uterine atony such as 

1. This is your first baby or you’ve had 5 babies in the past
2. You delivered  a large baby
3. You’ve had a twin or a triplet delivery
4. You’re older than 35
5. You have too much amniotic fluid
6. Obesity

Management and Prevention Strategies

Uterine Atony cannot usually be prevented. If you’re at risk of developing uterine atony then your healthcare provider will take precautions to manage excessive bleeding. You may be given medicines to promote uterine contractions. In some cases surgical intervention like uterine massage or manual removal of the placental tissue is necessary. 

To have a safe pregnancy, you can take precautions such as taking your prenatal medications on time, visiting your doctor for monthly checkups, eating a balanced diet, and maintaining a healthy weight. 

Types of Trauma (e.g., lacerations, tears) 

Genital tract trauma is a common outcome of vaginal delivery. It can include lacerations (deep cuts) or episiotomy (intentional surgical cuts). These cuts can affect the perineum, vagina, cervix or uterus. 

Risk Factors 

Factors that increase the risk of genital tract trauma include prolonged labour, manipulation by unskilled birth attendants, use of assisted vaginal delivery instruments like forceps and vacuum, and large baby size. 

Treatment and Prevention Pptions

Treatment for genital tract trauma includes stitching the tears immediately to stop the bleeding. Prevention strategies include careful management of labour, perineal massage and warm compress during labour and avoiding unnecessary episiotomies. 

Definition and Explanation

Retained placental tissue refers to fragments of the placenta that remain inside the uterus after delivery. These fragments can prevent the uterus from contracting properly and causing persistent bleeding.

Causes of Retained Placenta 

Retained placenta occurs 

1. If your contractions are not strong enough to expel it
2. You have an unusually strong placenta
3. The placenta attached itself very deep inside the uterus
4. The cervix closes and the placenta particles are trapped inside

Diagnosis and Management

Diagnosis of retained placental tissue is usually confirmed through a physical examination, ultrasound, or examination of the expelled placenta. Management often involves manual removal of the retained fragments, through dilation and curettage (D&C), or, in severe cases, surgical interventions like uterine artery embolization or hysterectomy. Proper monitoring and assessment during the third stage of labour can help promptly identify and address retained placental tissue promptly.

Types of Coagulation Disorders 

Coagulation disorders are rare causes of Postpartum hemorrhage. and Coagulation disorders are conditions that affect the blood’s clotting abilities.

Coagulation disorders are of 6 types: Hemophilia, Von Willebrand disease, clotting factor deficiencies, hypercoagulable states and deep venous thrombosis

Risk Factors 

The risk factors associated with developing coagulated disorders in pregnancy include: 

Genetics, complications in the pregnancy, medical conditions like liver disease or kidney disease, blood infections, certain types of cancer etc. 

Treatment Options and Preventive Measures

Treatment of coagulation disorders generally involves plasma transfusion. In cases where the parents of the pregnant woman have coagulation disorders, the healthcare providers take precautions during the delivery to prevent excess blood loss. 

Rare Causes of Postpartum Hemorrhage 

Uterine Rupture 

Definition and Explanation

The tearing or separating of all layers of the uterine wall during labour or delivery are referred to as uterine rupture. It is a rare but potentially fatal complication. 

Risk Factors 

The major risk factor for uterine rupture is previous cesarean delivery, a previous case of uterine scars, and the uterine being stretched with multiple pregnancies 

Diagnosis and Management

Uterine rupture happen suddenly with no symptoms. If the doctors suspect a uterine rupture, they try cesarean surgery to pull the baby from the mother’s womb, so that the baby’s chances of survival can increase. The doctors have to remove the uterus to stop the excessive blood loss. 

Placenta Accreta, Increta, and Percreta 

Explanation of Each Condition

Placenta Accreta- a condition when the placenta grows too deeply into the uterine wall and grows through the uterus and reaches nearby organs such as the gall bladder. Placenta increta- when the placenta starts penetrating the uterine muscles. 

Risk Factors

1. An increase in maternal age, 
2. history of previous caesarean delivery, 
3. history of previous uterine surgery such as myomectomy, 
4. placenta previa

Treatment and Management

1. Placenta accreta- the doctor may put you on bed rest and you will deliver the baby through a c-section between 34-37 weeks to avoid labour pains and contractions. 
2. Placenta Increta- Delivery of the baby through a c-section and hysterectomy to prevent blood loss. 
3. Placenta percreta- Surgical removal of the uterus. 

Uterine Inversion 

Definition and Explanation 

Uterine inversion occur when the placenta fails to separate from the body and pulls the uterus inside out as it exits the body. It is a potentially fatal complication. 

Risk factors 

include 

1. Women with prior delivery
2. Long labour (more than 24 hours)
3. Short umbilical cord
4. Use of certain drugs while in labour
5. Pulling the umbilical cord too hard when the placenta is still attached 
6. Abnormal placental attachment

Treatment and Prevention Strategies

Treatment options include: 

1. Manually repositioning the uterus
2. Flushing the vagina with saline salt so that the uterus inflates and goes back to its normal position.
3. In severe cases, abdominal surgery has to be done. 

To prevent uterine inversion it is essential to manage the third stage of labour effectively and timely recognition of risk factors. 

Less Common Causes of Postpartum Hemorrhage

Uterine Artery Embolization 

Definition and Explanation 

Uterine Artery Embolization (UAE) is a process to stop excessive vaginal bleeding. There could be many reasons for the bleeding like uterine fibroids, childbirth, trauma, and cancerous tumours. 

Risk Factors 

Uterine artery embolization is an elective procedure during childbirth. Women who have a previous history of UAE are more likely at risk of getting this procedure done again in case of any complication. 

Treatment and Management Options

If uterine artery embolization occurs as a complication during or after childbirth, immediate intervention is necessary. Treatment usually involves angiography to identify the location of the blockage followed by surgical procedures.

Amniotic Fluid Embolism

Definition

Amniotic fluid embolism (AFE) is a rare but life-threatening pregnancy complication that occurs when amniotic fluid, fetal cells and hair enters the bloodstream of the mother. This can happen during labour, delivery, or immediately afterwards.

Risk Factors 

The risk factors of AFR are not fully understood because it’s rare and hard to study but there are certain pregnancy conditions in which the women are at the risk of developing AFE. 

1. Advanced maternal age, 
2. Assisted delivery using forceps or vacuum
3. Multiple pregnancies
4. Labour induced by medicines
5. Abnormal placental attachment
6. Too much amniotic fluid

Diagnosis and Treatment Approach

Diagnosis of AFE is difficult because its symptoms are similar to other childbirth complications. Our doctor will rule out other complications while diagnosing AFE. Typically AFE occurs during delivery or within 30 minutes of delivery. Some symptoms to diagnose AFE are a drop in Blood pressure, difficulty in breathing, cardiovascular collapse, and excessive bleeding. 

The baby must be delivered immediately. Treatment for AFE  includes 

1. oxygen therapy, 
2. Blood Transfusion 
3. hysterectomy, 
4. Medicines

Conclusion  

Postpartum hemorrhage (PPH) is a serious complication of pregnancy. Uterine atony, trauma, retained placental tissue, uterine rupture and uterine inversion are the most common causes of PPH. Early recognition and prompt management of PPH are crucial for ensuring the well-being of both mothers and babies. Delayed or inadequate intervention can lead to severe complications and even death of the mother and the baby. Timely administration of uterotonics, blood transfusions, surgical interventions, and other supportive measures can help control bleeding and stabilize the mother’s condition.

To further improve the management and prevention of PPH, ongoing research is essential. Prevention strategies for PPH should continue to be a priority.

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