Primary and Secondary Postpartum Hemorrhage:

Postpartum hemorrhage (PPH) is defined as excessive blood loss during or after delivery. It is a leading cause of maternal mortality worldwide. Primary PPH occurs within 24 hours of delivery, and secondary PPH occurs between 24 hours and 12 weeks after delivery.

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Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. PPH is classified into primary and secondary PPH based on the timing of onset after delivery. Primary PPH occurs within the first 24 hours after delivery, whereas secondary PPH occurs between 24 hours and six weeks postpartum. The pathophysiology of PPH is complex and multifactorial, involving both maternal and fetal factors. Risk factors for PPH include uterine atony, genital tract trauma, coagulopathy, and retained placental tissue. Female anatomy and physiology play a crucial role in the development of PPH. In addition, individualized factors rather than ethnic or genetic factors, and national or regional globalized risk factors, may contribute to the etiology of PPH.

What defines primary PPH?

Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality worldwide. PPH is defined as a blood loss of 500ml or more after vaginal delivery or 1000ml or more after caesarean section. PPH can be classified into primary and secondary based on the timing of onset after delivery. Primary PPH occurs within 24 hours of delivery, whereas secondary PPH occurs between 24 hours and 12 weeks after delivery. The pathophysiology of PPH is complex and multifactorial, involving both maternal and fetal factors.

Primary PPH occurs within the first 24 hours after delivery, whereas secondary PPH occurs between 24 hours and six weeks postpartum.

What is the pathophysiology of primary postpartum haemorrhage?

PPH can occur due to various reasons, including uterine atony, genital tract trauma, coagulation disorders, retained products of conception, and uterine rupture.

The uterus is a dynamic organ that undergoes significant changes during pregnancy and labor. After delivery, the uterus contracts and reduces in size, leading to the separation of the placenta from the uterine wall. Failure of the uterus to contract adequately after delivery leads to primary PPH. The most common cause of PPH is uterine atony, which is the inability of the uterus to contract properly. Other causes include retained placenta or placental fragments, genital tract trauma, coagulation disorders, and uterine inversion.

Uterine atony, which is the inability of the uterus to contract adequately after delivery, is the most common cause of PPH. It can be due to prolonged labor, multiple pregnancies, macrosomia, or chorioamnionitis.

Uterine atony is the most common cause of primary PPH, accounting for 70-80% of cases. Other causes of primary PPH include genital tract trauma, coagulopathy, and retained placental tissue. Secondary PPH is often caused by retained placental tissue or infection.

Genital tract trauma can be caused by episiotomy, vaginal tears, or cervical lacerations.

Coagulation disorders can be due to pre-existing conditions such as von Willebrand disease or acquired conditions such as disseminated intravascular coagulation.

Retained products of conception occur when parts of the placenta or membranes are not completely expelled after delivery.

Uterine rupture is a rare but potentially life-threatening condition that can occur due to previous uterine surgery, such as cesarean delivery, or a pre-existing uterine anomaly.

What is the pathophysiology of secondary postpartum haemorrhage?

Secondary postpartum hemorrhage (PPH) is a severe obstetrical emergency that occurs within 24 hours to 12 weeks after delivery. The pathophysiology of secondary PPH is multifactorial and can involve a variety of underlying conditions.

One of the main causes of secondary PPH is retained placental tissue, which can lead to continued bleeding from the placental bed. Other causes include cervical lacerations, uterine atony, genital tract injuries, infection, coagulopathy, and uterine artery pseudoaneurysm.

Retained placental tissue can occur when a portion of the placenta is not expelled from the uterus after delivery. This can cause uterine contractions to continue, leading to bleeding. Cervical lacerations can occur during delivery or postpartum and can cause bleeding from the cervix. Uterine atony is a condition where the uterus fails to contract after delivery, leading to excessive bleeding. Genital tract injuries, such as tears in the vagina or cervix, can also cause secondary PPH.

Infection can also be a contributing factor to secondary PPH. Infections can cause inflammation and damage to the uterine lining, leading to excessive bleeding. Coagulopathy, a condition where the blood does not clot properly, can also cause secondary PPH. Finally, uterine artery pseudoaneurysm, a rare but serious complication, can cause bleeding in the postpartum period.

Secondary PPH can have various underlying causes, including retained placental tissue, cervical lacerations, uterine atony, genital tract injuries, infection, coagulopathy, and uterine artery pseudoaneurysm. A prompt diagnosis and management are critical to prevent severe morbidity and mortality in affected women.

Incidence and Risk Factors:

The incidence of PPH varies globally, with higher rates in low-income countries. According to the World Health Organization (WHO), the incidence of PPH is 6-10% worldwide. The countries with the highest incidence of PPH are predominantly in sub-Saharan Africa and South Asia, where access to quality maternal health care is limited.

List of countries with highest incidences of primary and secondary postpartum hemorrhage:

PPH is a global issue, but it is more common in low-income countries due to inadequate healthcare infrastructure and poor access to obstetric care. The countries with the highest incidences of PPH are India, Nigeria, Pakistan, and Bangladesh.

The Roles of Ethnicity and Culture in the Development of PPH

PPH can affect any woman regardless of race or ethnicity. However, women from low-income countries are at a higher risk due to poor medical facilities and inadequate obstetric care.

Mortality rate and statistics of primary and secondary postpartum hemorrhage:

PPH is a major cause of maternal mortality and morbidity worldwide. According to the World Health Organization, PPH accounts for approximately 27% of maternal deaths globally. The mortality rate for primary PPH is estimated to be between 1% and 4%, while the mortality rate for secondary PPH is lower at around 0.1%.

What conditions increase the risk of PPH during pregnancy?

There are several conditions that can increase the risk of PPH (postpartum hemorrhage) during pregnancy. Some of them are:

1. Placenta previa: A condition in which the placenta is located low in the uterus, blocking the cervix partially or completely. This can cause bleeding during delivery, leading to PPH.
2. Placental abruption: A condition in which the placenta separates from the uterine wall before delivery, leading to bleeding and increasing the risk of PPH.
3. Preeclampsia: A pregnancy complication characterized by high blood pressure and damage to organs, such as the liver and kidneys. Preeclampsia can lead to placental abruption and increase the risk of PPH.
4. Multiple gestations: Pregnancy with multiple fetuses, such as twins or triplets, increases the risk of PPH due to the increased pressure on the uterus and the higher likelihood of preterm delivery.

What are the risk factors for Postpartum Hemorrhage?

Risk factors for PPH include maternal age, parity, mode of delivery, fetal birth weight, and previous PPH. Other factors that increase the risk of PPH include uterine abnormalities, placenta previa, abruptio placentae, multiple gestations, prolonged labor, and induction of labor. Maternal conditions such as hypertension, diabetes, and obesity may also increase the risk of PPH.

The risk factors for PPH include a history of PPH, multiple gestations, large fetus or polyhydramnios, prolonged labor, instrumental delivery, cesarean section, and coagulation disorders.

Role of female anatomy and physiology:

Female anatomy and physiology play a crucial role in the development of PPH. The uterus undergoes significant changes during pregnancy, including an increase in blood supply and muscle mass. The cervical mucus plug and the uterine contractions also play a role in preventing postpartum bleeding. The pelvic floor muscles and vaginal walls also contribute to the integrity of the genital tract and the prevention of trauma during delivery.

The uterus must contract effectively to prevent excessive bleeding

Individualized factors: Individualized factors such as maternal health status, lifestyle, and environmental factors may contribute to the etiology of PPH. These factors may include poor maternal nutrition, maternal stress, lack of prenatal care, and inadequate medical resources. Cultural practices and beliefs may also play a role in the development of PPH.

PPH is a complex and multifactorial condition that can have serious consequences for maternal health. Risk factors for PPH include both maternal and fetal factors, with female anatomy and physiology playing a crucial role in the development of the condition. Individualized factors may also contribute to the etiology of PPH, highlighting the importance of individualized care for pregnant women. Improved understanding of the pathophysiology of PPH and the identification of risk factors can help in the prevention and management of this condition.

What are the factors that contribute to SPPH?

Several factors can contribute to the development of secondary postpartum hemorrhage (SPPH). These may include:

1. Retained placental tissue: SPPH can occur if fragments of the placenta remain in the uterus after delivery, leading to persistent bleeding.
2. Uterine infections: Infections of the uterus, such as endometritis, can cause inflammation and damage to the uterine lining, leading to bleeding.
3. Uterine atony: SPPH can occur if the uterus fails to contract properly after delivery, leading to excessive bleeding.
4. Cervical lacerations: Tears or lacerations of the cervix can occur during delivery and may contribute to bleeding.
5. Trauma to the birth canal: Trauma to the birth canal during delivery, such as tears or lacerations, can contribute to bleeding.
6. Blood clotting disorders: Women with blood clotting disorders, such as von Willebrand disease or thrombocytopenia, may be at increased risk of SPPH.
7. Invasive procedures: Certain invasive procedures during or after delivery, such as manual removal of the placenta or dilation and curettage (D&C), can increase the risk of SPPH.
8. Medications: Certain medications used during or after delivery, such as oxytocin or prostaglandins, can increase the risk of SPPH.

Oxytocin and prostaglandins work by stimulating uterine contractions, which can lead to delivery of the placenta and decrease the risk of postpartum hemorrhage. However, if the uterus does not contract properly or if there is retained placental tissue, bleeding can occur.

Oxytocin and prostaglandins are commonly used medications to induce or augment labor and prevent postpartum hemorrhage. However, they can also increase the risk of secondary postpartum hemorrhage (SPPH) in some cases.

To reduce the risk of SPPH or PPH while using oxytocin or prostaglandins, healthcare providers may monitor the mother and fetus closely during labor, ensure proper dosage and administration of the medication, and address any underlying medical conditions that may increase the risk of hemorrhage.

Management and optimal dosage: The management of SPPH depends on the underlying cause and severity of bleeding. Treatment may include manual removal of retained placental tissue, uterine massage or compression, medications to promote uterine contractions, and, in severe cases, surgery. The optimal dosage of oxytocin or prostaglandins varies depending on individual factors and should be determined by a healthcare provider.

Alternatives: Alternative methods to reduce the risk of SPPH or PPH include prophylactic use of medications such as tranexamic acid or misoprostol, or non-pharmacological methods such as delayed cord clamping or active management of the third stage of labor. The choice of method may depend on individual factors such as medical history, risk factors, and the course of labor.

It is important to note that these are not the only factors that can contribute to SPPH, and individual cases may have unique contributing factors. Prompt diagnosis and management of SPPH are crucial to prevent maternal morbidity and mortality. Women should be aware of the signs and symptoms of SPPH and seek prompt medical attention if they experience any of them. Healthcare providers can work to identify and address any underlying factors that may be contributing to SPPH.

What are the conditions that can cause symptoms similar to PPH or SPPH?

The signs and symptoms of primary postpartum hemorrhage (PPH) and secondary postpartum hemorrhage (SPPH) can be similar and can mimic the symptoms of several other conditions. Some of the most common conditions that produce similar symptoms include:

1. Retained placental tissue: This can cause bleeding similar to PPH or SPPH.
2. Endometritis: Inflammation of the lining of the uterus can cause fever, chills, and abdominal pain similar to PPH or SPPH.
3. Pelvic inflammatory disease (PID): This infection of the female reproductive organs can cause abdominal pain, fever, and vaginal discharge, which can mimic the symptoms of PPH or SPPH.
4. Hematoma: A collection of blood outside of a blood vessel, such as in the vaginal or pelvic area, can cause pain and swelling similar to PPH or SPPH.
5. Thrombocytopenia: A low platelet count can cause excessive bleeding and bruising, which can mimic the symptoms of PPH or SPPH.
6. Disseminated intravascular coagulation (DIC): This is a serious condition in which blood clots form throughout the body, leading to excessive bleeding and organ damage. DIC can cause symptoms similar to PPH or SPPH.
7. Hemorrhagic shock: This is a life-threatening condition in which the body cannot circulate enough blood to vital organs due to severe blood loss. Hemorrhagic shock can cause symptoms similar to PPH or SPPH.

It is important to note that these conditions are not the only ones that can produce similar symptoms. Women who experience symptoms of PPH or SPPH should seek medical attention promptly to determine the underlying cause and receive appropriate treatment.

What are the signs and symptoms of PPH ?

Signs and symptoms of PPH may include:

• Heavy or prolonged bleeding from the vagina
• Passage of large clots or tissue
• Abnormal or excessive uterine contractions or pain
• Low blood pressure or rapid heart rate
• Pale skin or mucous membranes
• Shortness of breath or chest pain
• Dizziness or fainting

What are the signs and symptoms of SPPH?

Signs and symptoms of SPPH may include:

• Heavy or prolonged bleeding from the vagina after initial recovery from delivery
• Abnormal discharge or bleeding from the vagina
• Abnormal or excessive uterine contractions or pain
• Low blood pressure or rapid heart rate
• Pale skin or mucous membranes
• Shortness of breath or chest pain
• Dizziness or fainting

What is one of the first signs of PPH?

One of the first signs of PPH may be a sudden drop in blood pressure (acute hypotension) or increased heart rate (palpitations). This can be followed by heavy or prolonged bleeding from the vagina (postpartum hemorrhage).

What is one of the first signs of SPPH?

Similarly, one of the first signs of SPPH may be heavy or prolonged bleeding from the vagina after initial recovery from delivery (postpartum hemorrhage).

How a woman knows she has PPH?

A woman may know she has PPH if she experiences heavy or prolonged bleeding from the vagina after delivery, especially if it is accompanied by other symptoms such as dizziness, fainting, or low blood pressure. It is important for women to be aware of the signs and symptoms of PPH and to seek prompt medical attention if they experience any of them.

Pulmonary hypertension (PPH) and secondary pulmonary hypertension (SPPH) are typically diagnosed through a combination of clinical evaluation, laboratory tests, and imaging studies. Some of the imaging studies that may be used in the diagnosis of PPH and SPPH include:

1. Chest X-ray: This is usually one of the first imaging studies done to assess the lungs and heart. It may show enlargement of the pulmonary arteries, changes in lung fields, or other findings that suggest pulmonary hypertension.
2. Echocardiography: This is a non-invasive test that uses sound waves to produce images of the heart and lungs. It can show the size and function of the heart, the thickness of the right ventricle, and the presence of any leaks or obstructions in the heart valves.
3. CT scan: A CT (computed tomography) scan of the chest may be done to provide more detailed images of the lungs and pulmonary arteries. It can show the extent of any blockages or narrowing in the pulmonary arteries.
4. MRI: A magnetic resonance imaging (MRI) scan can provide detailed images of the heart and lungs. It can be particularly useful for assessing the function of the right ventricle.
5. Ventilation/perfusion (V/Q) scan: This test involves injecting a radioactive tracer into the bloodstream and then using a scanner to produce images of the lungs. It can show areas of the lungs that are not getting enough blood flow, which may suggest pulmonary hypertension.
6. Right heart catheterization: This is an invasive procedure in which a thin tube (catheter) is inserted into the right side of the heart to measure pressures and blood flow. It is considered the gold standard for diagnosing pulmonary hypertension.

How to diagnose PPH?

To diagnose PPH, healthcare providers may perform a physical examination, including a pelvic exam, to assess the amount and location of bleeding. Blood tests may be done to assess the woman’s hemoglobin and hematocrit levels, as well as her coagulation status. Imaging studies, such as ultrasound or computed tomography (CT) scans, may be used to identify the source of bleeding.

How to diagnose SPPH?

To diagnose SPPH, healthcare providers may perform a similar evaluation, including a pelvic exam and blood tests, to assess the amount and location of bleeding and to identify any underlying causes, such as retained placental tissue or uterine atony. Imaging studies may also be used to identify the source of bleeding.

The signs and symptoms of PPH and SPPH can be similar, and may include heavy or prolonged bleeding, abnormal uterine contractions or pain, low blood pressure, and other symptoms. Prompt diagnosis and management are crucial to prevent maternal morbidity and mortality. Women should be aware of the signs and symptoms of PPH and SPPH and seek prompt medical attention if they experience any of them. Healthcare providers can diagnose PPH and SPPH through a combination of physical examination, blood tests, and imaging studies.

What are the complications of primary postpartum haemorrhage?

PPH is a serious obstetric emergency that can lead to significant complications if left untreated. Some of the complications of PPH include hypovolemic shock, anemia, blood transfusion, disseminated intravascular coagulation (DIC), and end-organ dysfunction.

What happens if PPH is left untreated?

If PPH is left untreated, the excessive bleeding can lead to hypovolemic shock, a condition where the body cannot maintain adequate blood pressure due to a lack of circulating blood volume. This can lead to organ dysfunction and multi-organ failure, potentially resulting in maternal death.

What is the complication of secondary postpartum haemorrhage?

The complications of secondary PPH can be severe and life-threatening. One of the most common complications is hypovolemic shock, which can occur due to excessive blood loss. This can lead to decreased oxygen delivery to vital organs and tissues, leading to organ dysfunction and potential multi-organ failure.

Secondary postpartum hemorrhage (PPH) is a serious obstetrical emergency that can have significant complications. Secondary PPH occurs within 24 hours to 12 weeks after delivery and can be caused by various factors, including retained placental tissue, cervical lacerations, uterine atony, genital tract injuries, infection, coagulopathy, and uterine artery pseudoaneurysm.

Other potential complications of secondary PPH include anemia, blood transfusion, infection, and thromboembolic events. Anemia can occur due to excessive blood loss and can lead to weakness, fatigue, and other symptoms. Blood transfusions may be required to manage severe bleeding and restore blood volume. Infection can occur due to prolonged exposure to blood and tissue, and can lead to sepsis if left untreated. Thromboembolic events, such as deep vein thrombosis or pulmonary embolism, can occur due to prolonged bed rest and immobility, which can be required during management of PPH.

Secondary PPH can lead to significant complications, including hypovolemic shock, anemia, blood transfusion, infection, and thromboembolic events. Prompt diagnosis and management are crucial to prevent these complications and improve maternal outcomes. Healthcare providers should be aware of the risk factors for secondary PPH and be prepared to manage this obstetrical emergency in a timely and effective manner.

What happens if SPPH left untreated?

The complications of SPPH are similar to those of PPH and can include hypovolemic shock, anemia, blood transfusion, infection, and thromboembolic events. If SPPH is left untreated, it can lead to severe morbidity and even maternal death.

What is the best treatment option for PPH?

The best treatment option for PPH depends on the underlying cause of the bleeding. Management may involve uterine massage, administration of uterotonic medications, such as oxytocin or misoprostol, or surgical interventions, such as manual removal of the placenta or uterine artery ligation. Blood transfusions and other supportive measures, such as intravenous fluids and oxygen therapy, may also be necessary.

What is the best treatment option for SPPH?

Similarly, the best treatment option for SPPH depends on the underlying cause. Management may involve surgical interventions, such as curettage or embolization of the uterine arteries. Blood transfusions and other supportive measures may also be required.

In conclusion, both PPH and SPPH are serious obstetric emergencies that can lead to significant complications if left untreated. Prompt diagnosis and management are crucial to prevent maternal morbidity and mortality. Treatment options depend on the underlying cause of the bleeding and may involve a combination of medical and surgical interventions, as well as supportive measures to maintain blood volume and prevent end-organ dysfunction.

Verified by: Rami Diab (April 15, 2023)

Citation: Rami Diab. (April 15, 2023). Primary and Secondary Postpartum Haemorrhage Pathophysiology, Risk Factors, Diagnosis and Treatment. Medcoi Journal of Medicine, 22(2). urn:medcoi:article21650.