Postpartum Hemorrhage: Prevention, Diagnosis and Non-Surgical Management

Alves, Álvaro Luiz Lage et al. Postpartum hemorrhage: prevention, diagnosis and non-surgical management. Revista Brasileira de Ginecologia e Obstetrícia [online]. 2020, v. 42, n. 11

Key points
Postpartum hemorrhage is the world’s leading cause of maternal death and peripartum hysterectomy.
The main causes of postpartum hemorrhage are uterine atony, birth canal trauma, retention of placental remains and coagulation disorders.
Risk stratification for postpartum hemorrhage optimizes care planning and promotes early adoption of preventive measures.
Bleeding control within the first hour of diagnosis (“golden hour”) is the most effective measure for treating postpartum hemorrhage.
The shock index is the clinical method of choice for estimating blood loss and a good parameter to guide the need for blood transfusion.
The main drugs used in pharmacological therapy for postpartum hemorrhage are oxytocin, ergot derivatives, misoprostol and tranexamic acid.
In uterine atony with pharmacological therapy failure, the intrauterine balloon tamponade should precede the surgical approach.
The non-pneumatic anti-shock garment is useful in postpartum hemorrhage with hemodynamic instability and enables continuity of treatment and patient transfers.

Recommendations
Every pregnant woman with a previous cesarean section should have an ultrasound scan for placental location. In case of placenta previa, placental dopplerfluxometry and investigation of other ultrasound signs of placenta accreta are indicated. Faced with the suspicion of parametrial invasion and in the placenta previa located on posterior wall, nuclear magnetic resonance or three-dimensional ultrasound may contribute to the investigation. The delivery of these pregnant women must take place in a tertiary service.
The main preventive measure for postpartum hemorrhage is the intramuscular administration of 10 units of oxytocin immediately after birth, associated with active management of the third stage.
The sequencing of care in postpartum hemorrhage should include requesting help, performing a uterine compression maneuver, rapid assessment of etiology, maintaining oxygenation and tissue perfusion, obtaining large venous accesses with blood sample collection and request for laboratory tests, blood volume replacement, administration of tranexamic acid and uterotonics, evaluation of antibiotic prophylaxis and blood loss estimation.
Blood loss can be estimated by visual assessment, weighing of surgical compresses, use of collecting devices or by clinical methods.
Volume resuscitation with crystalloids should not exceed 2,000 mL and transfusion of blood components is indicated for hypovolemic shock, especially if moderate or severe. Hemodynamically unstable patients with significant blood loss should receive emergency transfusion of two red cell concentrates. If crossmatching is not available, O negative blood should be transfused.
The intrauterine balloon tamponade can be employed after vaginal delivery and during or after cesarean section with specific volumes of infusion. Depending on the tamponade test, balloons with drainage function should be preferred. Uterotonics and antibiotics should be administered during the entire tamponade time. The balloon should be removed after hemodynamic stability, through deflation in stages and with a reserved operating room.

Clinical context
Postpartum haemorrhage (PPH) is defined as the cumulative blood loss of 1,000 mL or more, accompanied by signs or symptoms of hypovolemia within 24 hours after birth.1 Currently, this is the leading cause of maternal death worldwide, with about 140,000 deaths annually and the frequency of one death every four minutes.2 Most of these deaths are considered preventable and occur in low- and middle-income countries.3
In addition to high mortality, a significant number of patients who survive severe PPH evolve with physical and/or emotional sequelae.4 Therefore, it is essential that all institutions and professionals that provide childbirth care are properly prepared to prevent, diagnose and manage a condition of PPH.

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