Massive bleeding after delivery: PPH
K,38, would never forget the experience soon after her delivery. She had a massive bleed and had to be resuscitated in the intensive care unit (ICU).
This was her third pregnancy. Her two previous pregnancies were normal and the deliveries were smooth and uncomplicated. For this pregnancy, she had mild gestational diabetes and the amniotic fluid was found to be excessive during the last trimester. Her water bag burst at about 37 weeks and she delivered a baby girl weighing 3.2 kg normally after 6 hours of labour.
Soon after the placenta(afterbirth) was delivered, there was a sudden gush of blood flowing out of her uterus. The uterus was massaged instantaneously to make it contracted like a hard ball. Intravenous medication was also given to help sustain the uterine contractions. All these measures were done to cause occlusion of the blood vessels in the placental bed to stop the bleeding.
But within seconds, her uterus began to relax again. With rapid loss of blood, K was soon in a state of shock. Her blood pressure dropped from 120/70 mm Hg to 80/40 mm Hg. Her pulse rate went up from 78/ min to 110/min. Her skin was cold and clammy and the breathing was shallow and fast. She was also feeling weak and confused. She was immediately transferred to the ICU for resuscitation with intravenous infusion and blood transfusion. Blood loss was estimated to be around 1000ml.
K was having a massive postpartum haemorrhage (PPH), a condition in which heavy bleeding occurs after giving birth. It is a serious life-threatening condition and is ranked among the major causes of maternal mortality. Fortunately, it is not common locally, with an incidence varying between one to five per 100 deliveries.
When it occurs within 24 hours after delivery it is called primary PPH. Less often, it may happen within 6 weeks after delivery and is termed secondary PPH. The amount of blood loss is often difficult to estimate. Arbitrarily, for vaginal delivery, PPH is said to occur if 500 ml of blood is lost.
There are many causes of PPH, the most common being uterine atony in which the uterine muscles do not contract well after birth. This can happen if the uterus is overstretched when the mother gives birth to twins or a big baby or if excessive amniotic fluid is present. Poor uterine contraction can also result from fatigue due to prolonged labour or from a uterine infection.
Other common causes of PPH include;
Retained placenta, in which part or whole of the placenta is not expelled from the uterus after birth. This would prevent the uterus from contracting and occluding the blood vessels.
Lacerations of the vagina and cervix.
K continued to bleed in spite of resuscitation efforts with 1200ml of blood transfused and medications to contract the uterus. Her blood pressure remained low. She was put under general anaesthesia and the uterus, cervix and vagina were gently explored to ensure there was no lacerations or retained placenta. A Bakri intrauterine balloon was then inserted into the uterine cavity under ultrasound guidance (fig 1).
This device acts as a tamponade by exerting pressure on the blood vessels against the uterine wall. K responded well to the treatment and the bleeding gradually stopped 6 hours after the delivery. The balloon was taken out the next day as she recovered from the shock.
At the post-natal review 6 weeks later, K’s husband cheekily declared, "Doc, thanks for your help, her application for admission to heaven had been rejected!”