Background

Severe bleeding after childbirth is known as postpartum hemorrhage which can be fatal if not timely and appropriately treated. The overdose of blood loss may result in shock. The purpose of treatment is to identify what is provoking bleeding and to stop it. This could be achieved by using embryo implantation, surgical techniques including hysterectomy or removal of placental pieces as an alternative. In order to prevent serious problems the treatment and identification of the early stage is needed. Women of any risk factors have a chance to represent postpartum hemorrhage which mediates from 1% to 10% of pregnancies and the most common takes place after the delivery. 

Epidemiology

Incidence: Postpartum hemorrhage is one of the major obstetric crisis and its occurrence can vary dramatically across different regions. The next numeric fact is of interest formulated by the World Health Organization (WHO) which states that PPH happens in about 5% of all births around the world.

Geographical Variations: The percentage of PPH may trend differently between countries in the high-income category compared to those in the low-income. The areas which are endowed with poor healthcare facilities and lack adequate resources for male and female labor practitioner, as well as the quick response emergency obstetric care observe higher rates. 

Pathophysiology: The mechanism of PPH involves the exposure of high volume of blood to the uterus and the placenta during normal pregnancy, which in effect makes them lacerate and ooze blood if not tightly controlled. The initial contractile process carries on until the full uterus is exposed, which reveals the placenta and the maternal blood vessels lying beneath it. Following delivery of the placenta, the uterus starts working on constriction, which is closing the veins that feed it and triggering at the same moment.  

Anatomy

Pathophysiology

The pathophysiology of postpartum hemorrhage (PPH) involves disruptions in the normal physiological processes that occur during and after childbirth, leading to excessive bleeding. PPH is typically categorized into primary and secondary types based on the timing of onset.  

• Uterine Atony: It is the most common cause of primary PPH and involves inadequate uterine muscle contraction after delivery. Normally, the uterine muscles contract after childbirth to compress blood vessels and reduce bleeding. If the uterus fails to contract adequately (atony), it cannot effectively control bleeding from the placental bed. 
• Retained Placental Tissue: Incomplete delivery of the placenta or retained placental fragments can lead to ongoing bleeding. The placenta should be expelled from the uterus after childbirth. If fragments remain, they can cause continued blood loss as the uterus attempts to contract. 
• Trauma: Injuries to the birth canal, cervix, or perineum can result in primary PPH. Tears or lacerations in these areas may damage blood vessels, leading to bleeding that exceeds normal postpartum levels. 
• Infections Infections of the uterus (endometritis) or other reproductive organs can cause secondary PPH. Infections may lead to inflammation and breakdown of tissues, causing bleeding. 
• Subinvolution of the Uterus: Failure of the uterus to return to its normal size after childbirth. Incomplete involution means that the uterine blood vessels are still exposed and may bleed. 
• Retained Placental Tissue: Similar to primary PPH, retained placental tissue can cause ongoing bleeding in the postpartum period. If placental fragments were not completely expelled during the primary stage, they can continue to cause bleeding and infection. 

Etiology

Postpartum hemorrhage (PPH) can have several causes but the most frequent one is uterine atony and which occurs when the uterus is unable to shrink and retract after giving birth which results in profuse bleeding.  

Genetics

Prognostic Factors

The prognostic factors of postpartum hemorrhage are highly relevant to identify who is at a higher risk treatment and management of disease and mother’s outcomes improvement. The existing ones are not designed to be utilized in medicine.  

Clinical History

Age group: Inadequate prenatal care, immature reproductive systems, and lack of identifying difficulties may cause to young women in their late twenties and early thirties to become an easy preys to premature pregnancies (PPH). Teenage mothers are also most likely to experience preterm labor, multiparity, and other obstetrics related problems. There might be an increased risk of getting sick among the older women. 

Physical Examination

Assessing uterine tone and size: Uses a hand resting on the fundus and palpating the anterior wall of the uterus.  

Inspecting for retained placenta or clots: If the placenta has been delivered, inspect for retained portions. If undelivered or clots are distending the uterus, manual exploration and removal are necessary.  

Examining for cervical and vaginal lacerations: These may be palpated.  

Inspecting for hematomas: Palpation and inspection may reveal hematomas requiring treatment.  

Visualizing the lower genital tract: If uterine atony has been controlled, it may reveal bleeding sites.  

Age group

Associated comorbidity

Comorbidities: Type 2 diabetes, coagulation problems, and hypertension can all raise the possibility of PPH. Women who are currently experiencing medical problems may be more susceptible to problems during pregnancy and after giving birth. Activities: PPH can be caused by trauma or damage sustained during delivery, particularly in instances of emergency cesarean sections or instrumental births. Women who are physically active or who have had uterus surgery in the past may be more vulnerable. 

Associated activity

Acuity of presentation

Immediate Postpartum Period: The blood loss occurred most commonly during the first 24 hours after labor suspension for primary PPH. Severe cases of ectopic pregnancy that breach the fallopian tube might be accompanied by signs of shock, for instance, tachycardia and low blood pressure. Additionally, women will experience profuse vaginal bleeding as well as a shockingly large uterus. 
Delayed Postpartum Period: Aside from the first 24 hours and a few more weeks that are after giving birth, during such period secondary PPH is also possible. The beginning of the disease is gradually developing and is indicated by apathy, anemia, abnormal bleeding, as well as recurrent infections which may deteriorate to a crisis. 
Severe Acuity: Hemorrhagic shock as a volume deficit state where rapid and significant blood loss might be encountered in dramatic scenarios is a possible outcome. These are some of the symptoms including, slow or fast pulse, cold and clammy skin, marked breathing, and change of mental status. 

Differential Diagnoses

Lacerations: There may be tears of the cervix, of the vagina, or of the perineum which will cause hemorrhaging in some of the most extreme situations. 

Uterine inversion: This condition of complicated nature is though uncommon but still particular in which an uterus goes inside out facing the risk of severe bleeding. 

Retained placenta: The retained parts might cause bleeding if left unnoticed in uterus. 

Coagulation disorders: Abnormalities in Coagulation which is the blood thinning process increase the chance of the bleeding. 

Placenta accreta: Placental harboring reaches adhesive depth of uterus layers, which gives high probability of bleeding to occur. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Initial Assessment and Stabilization for Postpartum Bleeding  

Uterine Massage: Stimulate contractions and control uterine atony. 

Uterotonic Medications: Administer uterotonic agents to promote uterine contractions.  

Bimanual Compression: Considered for persistent bleeding. 

Uterine Tamponade: Used for persistent bleeding.  

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

• Dilation and Curettage (D&C): In cases of retained placental tissue, a D&C may be performed to remove the remaining placenta. 
• Suturing Lacerations: Repair any genital tract lacerations or tears that may be contributing to bleeding. 
• Hemostatic Procedures: In severe cases, surgical interventions such as uterine artery ligation, selective arterial embolization, or hysterectomy may be necessary. 

Coagulopathy Management: Administer blood products, clotting factors, or specific reversal agents to address coagulopathies. 

Interventional Radiology Procedures: Uterine artery embolisation is one interventional radiology treatment that may be explored in situations of chronic bleeding. 

Intrauterine Balloon Tamponade: Placement of a balloon device in the uterus can help control bleeding by applying pressure to the uterine walls. 

Continued Monitoring: Continuous monitoring of vital signs, laboratory parameters, and urine output to assess the response to interventions and detect any recurrence of bleeding. 

Maternal Resuscitation: Ongoing support for maternal well-being, including correction of electrolyte imbalances and organ perfusion. 

Psychological Support: Provide emotional support to the patient and involve mental health professionals as needed. 

Post-Treatment Monitoring: Close monitoring in the postpartum period to identify and address any ongoing complications. 

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-a-non-pharmacological-approach-for-treating-postpartum-hemorrhage

Cervical Massage: A gentle massage of the cervix is a useful method to counter the cervix tension and decrease the bleeding. This period, therefore, helps to control and flush out the blood out from the womb which leads to bleeding. 

Uterine Compression: Utus massaging is done mainly to control bleeding. Here, you just have to put your hand on the womb; press on it slightly to stop the bleeding. 

Bimanual Uterine Compression: This exerting handles pressure with thumbs and fingers. Either one or both hands are inserted into the uterus to press against the uterus using one hand while the other hand is used on the abdomen for extra pressure. 

Uterine Dressings: Otherwise bleeding is needed to be cauterized by means of using gauze or any other absorbent material inserted into the uterus. It must be done carefully in order to check the minimal damage because of possible sensitivity of the organ. 

Balloon Tamponade: In this method, an inflated balloon catheter is introduced inside the uterus and then it is inflated to exert the on the blood clotting and wall of the uterus. Sometimes commercial devices such as Bakri or Sengstaken-Blakemore tubes can be used for this purpose. 

Role of oxytocin in the treatment of Postpartum hemorrhage

The existence of maternal complications and deaths in postpartum period has a great deal to do with PPH. The uterine contractions that are triggered by oxytocin, which is a hormone, improve the uterus from bleeding excessively and reduces the possibility of hemorrhage from occurring. It is aimed at stopping the uterus from failing to contract efficiently after delivery which is otherwise called uterine atonia (in Greek). Along with it occasionally being administered as a preventative measure, oxytocin is one of the most commonly used anesthetics.It is usually given at the third phase of labor to stop excessive bleeding. Another oxytocin analog that promotes contractions and lessens postpartum hemorrhage is carbetocin, particularly when oxytocin is neither practical or efficient. 

Role of Ergot alkaloids in controlling excessive bleeding

The alkaloids of ergot species (also known as methylerzometrine and ergometrine) are absolutely essential for the treatment of postpartum bleeding (PPB) due to their ability to ensure violent contractions of the smooth muscle, including the uterus. Through the process of uterine muscle contraction, the blood vessels that are on the uterus wall will become narrow, hence reducing the amount of blood that will be spilled out. And after labor they will likely receive an IV or IM injection. 
Methylergometrine/Methyergonovine: Ergonovine, is the other drug which can cause complications. It is a member of the ergot class of the ergot alkaloids that produces labor contractions in smooth muscle, particularly in smooth muscle of the uterus. Methylergometrine is a drug which assists in treating and preventing of uterine atony by helping in term of constricting the uterine muscles. 
Ergometrine: The ergot alkaloid ergometrine recently grouped as the ergovine, does very important postpartum hemorrhage (PPH) treatment. Ergometrine is used in a similar manner to control a possibly excessive bleed after delivery, which is achieved by mechanism of action on smooth muscle, specifically, the uterine tissue muscle. The ivermectin drug given against parasitic infections is almost always administered intravenously (IV) or intramuscularly (IM). For the current treatment guidelines, many uterotonic drugs and therapy options are employed along with it. Post-partum hemorrhage protocols are among the regimes where this drug is a frequent, or first-line therapy. 

Role of prostaglandins

Enzymatic inhibitor (prostaglandins) is one of the active ingredients of the therapy of PPH. These include proteins and other substances manufacturing in different organ tissues, such as reproductive organs. The influence on physiological functions is diverse. Prostaglandins, especially some of them, e.g. misoprostol (a misoprostol analogue of prostaglandin E1), can provoke strong uterine contractions (among the prostaglandin types). This is precisely what is required in the postpartum phase as a pre-emptive measure to avoid any bleeding complications. The uterus should contract, giving control to the bleeding. The inefficiency of the uterine to contract following childbirth is the notable cause of postpartum haemorrhage which is a uterine atony. Prostaglandins therefore can be given as a supplemental dose in organic response to uterine atony, thus preventing the progress of any moments. 

Misoprostol: It is a synthanalog of progestagenetob compound that is widely applied in the treatment of postpartum hemorrhage. It is commonly attributed with oral or rectal routes of administrations and constitutes one of a few choices. 

Carboprost: It is achieved by induction of the uterine contraction which results in raising tone and reducing the menstrual blood loss. It moreover induce the uterus softening and dilatation. The first use of which is to manage uterine atonia (reflux of bleeding) after childbirth since failed uterine contractions lead to bleeding. 

use-of-intervention-with-a-procedure-in-treating-postpartum-hemorrhage

Uterine Massage and Compression: Dominating uterine massaging requires a physician or a midwife to apply pressure to the top of the uterus to be able to stimulate contractions that help control postpartum bleeding. This can also be done using uterine compression techniques such as bimanual compression or a uterine balloon enclosing. These are used to add additional pressure and help gain control over bleeding. 

Uterotonics: Usually, oxytocin and other types of uterotonic medications are obtained initially to give contracting for the uterus by stimulating them. If the previous step is ineffective, administrating misoprostol, methylergonovine, and, or carboprost may be included in the next steps. 

Uterine Artery Embolization (UAE): UAE has many similarities to sling procedure. The filling of space between uterine arteries with tiny particles is mean to stop of blood flow and decrease of uterine haemorrhage. It is a gangster-proof mode. It is many times be used when all the available treatment modalities including medical management and surgery are not desirable or are not offering an immediate relief. 

Selective Arterial Embolization: Complications of postpartum hemorrhage can be reduced significantly with appropriate treatment of vascular anomalies or trauma, and options that may be considered are selective arterial embolizations. This can be carried out with the procedure of emulsion agents into the very branches of arteries, which are the source of bleeding. 

B-Lynch Suture: Placement of a compression suture around the uterus that controls bleeding is the laparoscopic approach that is used during this surgery. One of its main utility is during uterine atony. 

Hysterectomy: In severe clinical cases where conservative treatments (employing drugs, medications and other efforts) do not stop the bleeding, uterus may be removed hence hysterectomy (surgical procedure that involves removal of uterus) can be performed. This is a decisive (or concrete) intervention, and normally, it is considered as a last possible solution after everything else has been tried. 

use-of-phases-in-managing-postpartum-hemorrhage

Antenatal care, determining appropriate treatment methods for the final stage of labor labor, and conducting a reliable uterine examination all can assist with the prevention of postpartum hemorrhage. The use of utrotonic drugs and massage to prevent uterine atony can be supplemented by means of compression. Further medication may also be used in cases where previous treatments were ineffective. To cure hypovolemia, fluids can be administered intravenously, and blood transfusions can be given. Two minimally invasive treatments in vogue are selective arterial embolization and uterine artery embolization (UAE). Uterine excision, laparotomy as an exploratory diagnostic, and B-Lynch sutures form the surgical treatment.  

Medication

Future Trends

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References

Acute Postpartum Hemorrhage:ncbi.nlm.nih