Primary Postpartum Haemorrhage

The loss of >500 ml of blood per-vagina within 24 hours of delivery

Aetiology

The causes for primary post-partum haemorrhage can be broadly categorised by the 4 T’s - tone, tissue, trauma and thrombin:

Tone

  • Refers to uterine atony - the most common cause of primary PPH
  • This is where the uterus fails to contract adequately following delivery, due to a lack of tone in the uterine muscle

Tissue

  • Refers to the retention of placental tissue which prevents the uterus from contracting
  • It is the 2nd most common cause of primary PPH

Trauma

  • Refers to damage sustained to the reproductive tract during delivery (e.g. vaginal tears, cervical tears)

Thrombin

  • Refers to coagulopathies and vascular abnormalities which increase the risk of primary PPH
    • Vascular - placental abruption, hypertension, pre-eclampsia.
    • Coagulopathies - von Willebrand’s disease, haemophilia A/B, ITP or acquired coagulopathy i.e. DIC, HELLP

Clinical presentation

Symptoms

  • Bleeding from the vagina
  • If there is substantial blood loss, the patient may complain of dizziness, palpitations, and shortness of breath

Signs

  • General examination may reveal haemodynamic instability with tachypnoea, prolonged capillary refill time, tachycardia, and hypotension
  • Abdominal examination may show signs of uterine rupture i.e. palpation of fetal parts as it moves into the abdomen from the uterus
  • Speculum examination may reveal sites of local trauma causing bleeding
  • Examine the placenta to ensure that the placenta is complete

Clinical Classification of PPH-Related Shock

Shock Stage
Approx. Blood Loss
Clinical Features
WHO / ACOG Interpretation
Compensated Shock
500–1000 mL
Tachycardia, palpitations, dizziness, normal BP
Early hypovolemia – do not wait
Mild Shock
1000–1500 mL
Tachycardia, weakness, diaphoresis, SBP 80–100 mmHg
PPH diagnosis established
Moderate Shock
1500–2000 mL
Pallor, anxiety, oliguria, hypotension
Hemorrhagic shock
Severe Shock
≥2000 mL
Collapse, air hunger, anuria, SBP <70 mmHg
Life-threatening / Class III–IV shock
Important WHO / ACOG Notes
  • Shock Index (HR/SBP) ≥ 1.0 → severe hemorrhage
  • Normal BP does not exclude shock
  • Visual blood loss underestimates severity

Investigations

  • Bloods - FBC, cross match 4-6 units of blood, coag. screen, U+Es, LFTs

Management

  • Resuscitation with ABCDE approach
  • Definitive management depends on cause

Uterine atony

  • Bimanual compression to stimulate uterine contraction
  • Empty bladder - Foley catheter
  • Pharmacological measures which increase uterine myometrial contraction e.g. oxytocin (syntocinon), ergometrine, carboprost, misoprostol
  • If unsuccessful consider surgical measures - intrauterine balloon tamponade, haemostatic suture around uterus (e.g. B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (last resort)

Trauma

  • Primary repair of laceration, if uterine rupture: laparotomy and repair or hysterectomy

Tissue

  • Administer IV oxytocin, manual removal of placenta with regional or general anaesthetic, and prophylactic antibiotics in theatre
  • Start IV oxytocin infusion after removal

Thrombin

  • Correct any coagulation abnormalities with blood products under the advice of the haematology team

Prevention

  • Identify and if possible treat antenatal and intrapartum risk factors
  • Active management of third stage of labour - syntocinon/syntometrine IM/IV

Drugs Dosing

First-Line Uterotonic
Drug
Dose
Route
Frequency / Max
Key Notes
Oxytocin
10 IU
IM
Single dose
Preferred prophylaxis & treatment
ㅤ
10–40 IU in 1 L
IV infusion
60–200 mU/min
Avoid IV bolus (hypotension)
Second-Line Uterotonics
Drug
Dose
Route
Frequency / Max
Contraindications
Ergometrine
0.2 mg
IM / slow IV
q2–4 h, max 1 mg
HTN, pre-eclampsia, cardiac disease
Methylergometrine
0.2 mg
IM
q2–4 h
Same as ergometrine
Carboprost (15-methyl PGF₂α)
250 µg
IM
q15–90 min, max 2 mg (8 doses)
Asthma, pulmonary disease
Misoprostol
800–1000 µg
PR / SL
Single dose
Fever, shivering common
Antifibrinolytic
Drug
Dose
Route
Timing
Notes
Tranexamic Acid (TXA)
1 g
IV over 10 min
Within 3 hours of birth
Repeat 1 g if bleeding continues after 30 min or recurs within 24 h
Adjunctive Drugs
Drug
Indication
Dose
Calcium gluconate
Hypocalcemia during massive transfusion
10 mL of 10% IV
Broad-spectrum antibiotics
Suspected infection / prolonged labour
As per protocol
Fibrinogen concentrate
Fibrinogen <200 mg/dL
2–4 g IV
Massive Transfusion Reference (Drug-Related)
Component
Trigger
PRBC
Hb <7 g/dL or ongoing shock
FFP
INR >1.5
Platelets
<50,000/µL
Cryoprecipitate
Fibrinogen <200 mg/dL