Management of massive postpartum haemorrhage and coagulopathy

Abstract 

Postpartum haemorrhage (PPH) continues to remain the leading cause of maternal morbidity and mortality worldwide. Whilst this is especially true in resource limited countries, it also remains a significant problem in developed countries. The traditional definition of primary PPH is blood loss from the genital tract of 500 ml or more within 24 h of delivery (or >1000 ml during caesarean section). Secondary PPH refers to an excessive blood loss between 24 h and 6 weeks, postnatally. Massive PPH refers to a blood loss of over 2000 ml (or >30% of blood volume) and hence, is an obstetric emergency that requires a systematic, multi-disciplinary approach to restore the volume, clotting system and the oxygen carrying capacity of blood, whilst steps are taken to arrest bleeding as quickly as possible.

The last confidential enquiry into maternal deaths (CEMACH, 2003–2005) in the UK cited ‘haemorrhage’ as the third highest cause of direct maternal deaths with 6.6 deaths per million maternities. This report found that 58% of these deaths may have been preventable and ‘too little being done, too late’ (failure to appreciate clinical picture, delay in instituting appropriate treatment, delay is summoning senior help and system failures) continues to contribute to maternal morbidity and mortality, even in the developed world.

Massive obstetric haemorrhage may occur in the antepartum (placenta praevia, placental abruption and placenta accreta) or postpartum period. It is has been observed that the incidence of massive PPH is likely to be increasing due to the increased incidence of risk factors such as morbidly adherent placenta secondary to previous caesarean sections and maternal obesity. However, massive obstetric haemorrhage and the resultant coagulopathy can occur in women deemed to be at ‘low risk’ and hence, all clinicians managing women during pregnancy and labour need to possess knowledge and skills to recognize symptoms, signs and complications of massive obstetric haemorrhage. This may ensure institution of timely and appropriate treatment that could save lives.

Keywords: coagulopathy, communication, massive obstetric haemorrhage, shock index, resuscitation