Postpartum Hemorrhage: A Recurring Pregnancy Complication

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Postpartum hemorrhage (PPH) is a potentially life-threatening complication of both vaginal and cesarean deliveries. Although many variables increase the chance for bleeding, a PPH in a previous pregnancy is one of the greatest risk factors for recurrent PPH. A physiologic explanation for this association is not known, but recurrent risk factors such as a retained placenta or underlying medical disorders may account for the majority of recurrent PPH cases. To reduce maternal morbidity and mortality, prevention of PPH in these patients is critical. Steps to minimize hemorrhagic complications include the identification of high-risk patients through a complete history, vigilant management of the third stage of labor, and having uterotonic medications readily available in the delivery room. Patients with inherited coagulopathies require individualized treatment, and their risks for bleeding extend beyond the first 24 hours after delivery. Further studies are needed to determine whether the administration of prophylactic measures such as prostaglandins decrease the PPH occurrence in high-risk patients.

Section snippets

The Epidemiology of Recurrent PPH

The objective of one of the earliest studies on recurrent PPH was to determine whether a patient with a prior PPH was more likely to hemorrhage during or after the third stage of a subsequent labor. They included deliveries from 1936 to 1945 and defined PPH as an estimated blood loss >600 mL.3 Of interest, cesareans, which were excluded from the analysis, accounted for only 1.7% of the deliveries. Of the 12,243 women with vaginal births, the rate of PPH was 5.2%. However, the recurrence rate of

Previous Invasive Treatment for PPH

The primary management of PPH is medical: treatment with uterotonic drugs. In most cases, this is successful; however, surgical techniques to control bleeding, such as hypogastric artery ligation, bilateral uterine artery ligation (O’Leary sutures), and the B-Lynch technique, are alternatives to hysterectomy in cases of persistent bleeding. Arterial embolization or balloon occlusion of radiographically identified bleeding vessels is another nonsurgical option for continued hemorrhage. Patients

Prevention of PPH Recurrence

PPH prevention remains an important issue in obstetrics. The third stage of labor in women with a previous PPH history should be managed vigilantly, with anticipation of a potential hemorrhage. Patients should be appropriately counseled about the potential for recurrence and its implications. Intravenous access during labor and sending a type and screen are appropriate prophylactic measures. Management of the third stage of labor includes administration of oxytocin after the delivery of the

Future Research

All further research on the topic of bleeding complications in pregnancy should define PPH in a consistent manner so that studies can be compared and generalized. A more objective measurement of estimated blood loss, such as a comparison of pre- and postpartum blood counts or calibrated drapes, would be beneficial in prospective studies. Previous retrospective studies have identified the risk factors for PPH and confirmed a significantly increased risk for recurrent PPH in patients with a prior

Conclusions

The key to management of PPH is early recognition and treatment. The goals are to ultimately reduce maternal morbidity and mortality. Predicting the risk of PPH is an essential part of prenatal screening and assessment on labor and delivery and is heavily dependent on an accurate history. During the event, a cause either related to tone, tissue, trauma, or thrombosis should be identified and documented. Evidence shows that a prior PPH increases the risk for recurrence, 8% to 28% for primary PPH

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