Refractory postpartum uterine hemorrhage
Understanding Refractory Postpartum Uterine Hemorrhage
Postpartum uterine hemorrhage (PPH) is a type of abnormal bleeding after the delivery of a baby. It occurs due to uterine atony, when the uterine muscles don't contract properly and are unable to hold back the bleeding. Most cases can be effectively managed with timely medical intervention, but in some cases the bleeding can be so severe that it becomes refractory, or resistant to medical and surgical methods.
Refractory PPH causes a dangerous decline in a woman's hemoglobin levels, resulting in acute anemia. It is estimated that up to 6% of reported PPH cases become refractory.
Causes of Refractory Postpartum Uterine Hemorrhage
The exact cause of refractory PPH is still unknown but there are several possible contributing factors, including:
- Severe uterine atony
- Retained placental fragments
- Cervical or vaginal lacerations
- Uterine infection or sepsis
- Endometritis
- Uterine trauma, such as from manual removal of the placenta
Diagnosing Refractory Postpartum Uterine Hemorrhage
The diagnosis is typically based on clinical history and physical examination, looking for signs of acute anemia, such as pallor, rapid pulse and low blood pressure. Ultrasound may also be used to look for signs of retained placental fragments in the uterus.
Treating Refractory Postpartum Uterine Hemorrhage
In mild cases, the goal of treatment is to stop the bleeding and restore blood volume and hemoglobin levels. This can be accomplished with the following methods:
- High-dose oxytocin or carboprost to contract the uterus and stop the bleeding
- Intravenous infusion of fluids, blood, or blood products to restore lost blood volume
- Retained placental fragment removal by curettage or vacuum aspiration
- Uterine artery ligation to stop bleeding from certain parts of the uterus
In more severe cases, a hysterectomy may be necessary to stop the bleeding and prevent life-threatening complications.
