Obstetric Topic 34. Postpartum hemorrhage. Inversio uteri

I. Postpartum Hemorrhage

Definition

• Postpartum hemorrhage (PPH): excessive bleeding after delivery; obstetric emergency.
• Classic definition: blood loss ≥500 mL after vaginal birth or ≥1000 mL after cesarean section.
• Primary / early PPH: within first 24 h after delivery.
• Secondary / late PPH: abnormal/excessive bleeding from 24 h to 12 weeks postpartum.

Etiology: 4T

1. Tone: uterine atony, most common cause.
   • Risk factors: overdistension, prolonged labor, rapid labor, grand multiparity, chorioamnionitis, retained placenta.
   • Finding: heavy bleeding + soft/doughy enlarged uterus.
2. Trauma: genital tract laceration, second common cause.
   • Cervical/vaginal/perineal tears, episiotomy extension, uterine rupture, hematoma.
   • Finding: bleeding despite firm uterus.
3. Tissue: retained placenta/products of conception.
   • Retained placenta, retained products of conception, placenta accreta spectrum.
   • Finding: placenta incomplete or not delivered; uterus may fail to contract.
4. Thrombin: coagulation disorder.
   • DIC, congenital coagulopathy or acquired bleeding disorder.

Clinical Features and Diagnosis

• Diagnosis is clinical: vaginal bleeding + maternal condition.
• Shock signs: tachycardia, hypotension, pallor, cold skin, altered consciousness, oliguria.
• Assess uterus: soft = atony; firm/contracted = trauma/coagulopathy; absent/non-palpable fundus = uterine inversion.
• Inspect placenta and genital tract: retained tissue, cervical/vaginal/perineal tears, hematoma, uterine rupture.
• Labs: CBC, platelets, coagulation profile, fibrinogen, blood group/crossmatch.

Initial Emergency Management

1. Call obstetric emergency team, anesthesia and blood bank.
2. ABC: oxygen if needed, positioning, keep warm.
3. Two large-bore IV lines → blood sampling and crossmatch.
4. Start IV crystalloids, then blood products if ongoing major hemorrhage.
5. Monitor BP, pulse, SpO2, bleeding and urine output.
6. Uterine massage and bimanual compression if atony suspected.
7. Tranexamic acid: give early, ideally within 3 h of birth, as adjunctive PPH care.
8. Replace blood and clotting factors: RBC, FFP, cryoprecipitate/fibrinogen and platelets according to bleeding/labs.

Treatment by Cause

• Tone / atony:
  • Uterine massage + oxytocin first-line.
  • Additional uterotonics: misoprostol, carboprost, methylergometrine/ergometrine according to contraindications.
• Trauma: expose and repair cervical/vaginal/perineal tears; laparotomy or hysterectomy if uterine rupture.
• Tissue: manual removal of retained placenta; curettage/suction evacuation for retained products after stabilization.
• Thrombin: treat trigger and replace factors/platelets/fibrinogen; do not delay hemorrhage control.

Persistent / Refractory PPH

1. Mechanical: bimanual compression, uterine balloon tamponade (Bakri).
2. Surgery/intervention: B-Lynch compression sutures, uterine/internal iliac artery ligation, uterine artery embolization if stable and available.
3. Hysterectomy: last resort, lifesaving when bleeding cannot be controlled or PAS/rupture is severe.

Secondary PPH and Sheehan Syndrome

• Secondary PPH causes: retained products, subinvolution, endometritis or bleeding disorder.
• Management: assess stability, ultrasound/labs, antibiotics if infection, uterotonics, evacuation if retained products.
• Sheehan syndrome: postpartum pituitary ischemic necrosis after severe hemorrhage/shock.
• Clinical clues: failure to lactate, amenorrhea, fatigue, hypotension and pituitary hormone deficiency.

II. Uterine Inversion / Inversio Uteri

Definition and Risk Factors

• Uterine inversion: uterine fundus collapses into the cavity and may protrude through cervix/vagina.
• Rare but life-threatening emergency after vaginal or cesarean delivery.
• Classic cause: excessive cord traction before placental separation, especially with fundal pressure.
• Risk factors: retained placenta, placenta accreta spectrum, fundal placenta, short cord, uterine atony, macrosomia, rapid/prolonged labor.

Presentation and Diagnosis

• Presentation: sudden postpartum hemorrhage, severe pain, shock often disproportionate to visible bleeding.
• Finding: smooth round red-purple mass protruding from cervix/vagina or beyond introitus.
• Abdominal exam: uterine fundus absent or cup-shaped depression at expected fundal site.
• Diagnosis is clinical; do not delay treatment for imaging.

Management

1. Call help; start hemodynamic support with IV fluids and blood products.
2. Stop uterotonics temporarily until uterus is replaced; do not pull the cord.
3. Immediate manual replacement / Johnson maneuver:
   • Hand in vagina → push fundus upward along vaginal axis toward umbilicus.
   • Replace before removing placenta if placenta is still attached.
4. Analgesia/anesthesia; if stable and replacement fails, give uterine relaxant or general anesthesia.
5. After replacement: start oxytocin/uterotonics, uterine massage, antibiotics if indicated.
6. If unstable or manual replacement fails: urgent surgery.
   • Laparotomy; surgical replacement, with incision of cervical constriction ring if needed.
   • Hysterectomy only if uncontrollable hemorrhage or irreducible severe disease.