What are the possible complications of postpartum hemorrhage (PPH)?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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Answer

Most patients with PPH are quickly identified and successfully treated before major complications develop. The most common problem is anemia and loss of iron stores, which results in fatigue in the postpartum period. Clinicians and patients are more tolerant of low hemoglobin levels, mild postural lightheadedness, and fatigue because of current concerns over blood transfusion. The risks of transfusion with blood products are well known and have been previously described.

Not surprisingly, many of the complications of severe PPH are related to massive blood loss and hypovolemic shock. Damage to all major organs is possible; respiratory (adult respiratory distress syndrome) and renal (acute tubular necrosis) damage are the most common but are rare. These conditions are best managed by specialists. Renal failure is usually self-limited, and renal function recovers fully. Temporary dialysis is seldom required. Pulmonary edema is uncommon in this previously healthy group; however, it may develop acutely or during the recovery phase because of fluid overload or myocardial dysfunction. Response to standard therapy is usually prompt.

Pregnant women are at increased risk of venous thrombosis and embolic events. Many of the risk factors for PPH are also risk factors for venous thrombosis and embolic events, including operative vaginal delivery, cesarean delivery, and pelvic surgery. Venous stasis due to shock and immobility also contribute, and caregivers should maintain a high index of clinical awareness.

Hypopituitarism following severe PPH (Sheehan syndrome) is due to critical ischemia of the hypertrophied pituitary. This condition should be considered if a failure to lactate occurs. Isolated deficiencies of pituitary tropins and hyperprolactinemia have also been reported.

Evidence suggests that prophylaxis against gastrointestinal ulceration is useful in critically ill patients, especially those requiring ventilation. The recommended agents are sucralfate and histamine 2 blockers. Both are effective at reducing the risk of ulcers. Sucralfate may be associated with a lower incidence of pneumonia. [80]

Several of the complications related to surgical interventions have been described. Complications include sterility, uterine perforation, uterine synechiae (Asherman syndrome), urinary tract injury and genitourinary fistula, bowel injury and genitointestinal fistula, vascular injury, pelvic hematoma, and sepsis. Consider ultrasound of the kidneys following complicated emergency pelvic surgery in order to exclude ureteric obstruction. Patients undergoing uterine exploration, instrumentation, or laparotomy in this context probably benefit from antibiotic coverage at the time of the intervention. Good evidence suggests that all patients having cesarean births should receive prophylactic antibiotics. [81] The duration of antibiotic coverage following surgery in these circumstance is unknown.


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