Postpartum Hemorrhage: A Recurring Pregnancy Complication
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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