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The Etiology of Postpartum Hemorrhage
THE ETIOLOGY OF POSTPARTUM HEMORRHAGE PETER TERZIAN, M.D., ScHENECTADY, N. Y. (From the Ellis Hospital)
OSTPARTUM hemorrhage is defined as bleeding in excess of 500 mi. within the first twenty-four hours after birth, including third stage bleeding and bleeding from episiotomy. 1 As a cause of maternal death, postpartum hemorrhage ranks high, 2 and is estimated by McGee as causing 30 per cent of maternal deaths. 3 This type of bleeding kills directly by producing shock, and kills indirectly by lowering resistance to infection. It is fitting that we should study and prevent this complication where possible.
P
:Material Accordingly, a review has been made of the recognized cases of post. partum hemorrhage occurring at the Ellis Hospital in the four-year period 1947 to 1950, inclusive. Ellis Hospital is a 400-bed general hospital with a well-regulated obstetrical service, privileges being granted to physicians in proportion to training, ability, and experience. There is one obstetrical resident. There are nine specialists with full privileges, of whom five are Diplomates of the American Board of Obstetrics and Gynecology. Sixty-one general practitioners are privileged to manage normal labor, perform outlet forceps and episiotomy, and repair first- and second-degree lacerations. Eight physicians have intermediate privileges. Mismanaged cases are brought into open discussion at a monthly meeting. Blood loss at delivery is measured with the aid of a blood basin included under a rubber drape. The occurrence of postpartum hemorrhage in oth~r instances has necessarily been judged by estimation by the attending physician, the house staff, and the obstetrical nurses, nevtreheless undoubtedly giving rise to considerable error. During the period studied there were 7,326 deliveries, including 416 cesarean sections ( 5. 7 per cent). Seven thousand four hundred sixteen babies were delivered, including 86 sets of twins and two sets of triplets. Among the 6,910 vaginal deliveries, 190 postpartum hemorrhages were recognized, an incidence of 2.7 per cent. No instance of postpartum hemorrhage was noted among the cases of cesarean section, although blood loss at operation in many of these undoubtedly exceeded 500 mi. Four maternal deaths occurred in this period, one of which was due to postpartum hemorrhage. The maternal death rate at Ellis Hospital during the period studied was therefore 5 per 10,000 deliveries, while the maternal mortality rate in the United States in 1946 was 16 per 10,000 live births. • An attempt was made at first to determine the cause of each hemorrhage from the hospital record. The results by this method were unsatisfactory because the cause could be fairly definitely determined or surmised in only 83 cases. These are listed in Table I. •Data from the National Office or Vital Statistics, Federal Security Agency, United States Children's Bureau.
809
TERZIAX
810
"Difficult operative delivery" signifies any delivery in which the extensiveness of the procedme used (such as midforceps), combined with the duration of anesthesia and the time t'equired to repair episiotomy and lacerations, was the apparent cause of blood loss exceeding- the normal limit. Blood loss in these cases varied from 525 to 1,500 ml. 'l'ABLE
I.
THE CAl'SE m• POS'l'PARTUM HEMORRHAGf; AS DEn;RMlNEIJ FROM THE
HOSPITAl, RECORD
Bleeding lacerations and/or episiotomy Third stage bleeding Laceration of cervix Retained placental cotyledon Low implantation of placenta Traumatic. rupture of lower uterine Kegmen t of rectocele
12 19 ;j
1 1 l
1
"'l'hird stage bleeding" indicates that excessive blood loss was associated with delayed deli\'et·y of the placenta, the potential retroplacental hematoma escaping past a separated margin of the placenta, or that the placenta was retained in the upper uterine segment and required manual extraction with its attendant dangers of atony of the uterus following deep ether anesthesia, and laceration of the uterine wall. 4 GreenhiiP emphasizes. however, that threatened postpartum hemorrhage due to third stage bleeding should he prevented hy manna! extraction of the placenta. "Retained placental tissue" is a rare cause of postpartum hemorrhag<•. hut ranks high as a eause of puerperal bleeding. 6 The oxytoeie routine at this hospital should he m~:>ntioned. In most instances, 1 ml. of Pitocin (10 units) is administered intramuscularly immediately after the birth of the haby. After delivery of the placenta, 0.2 mg. of ergonovine is given intramuscularly. This routine is varied by some. 0.25 ml. of Pitocin being given intravenously with the birth, and the remainder of the Pitoein and the ergonovine being given intramuscularly with the placental exit. On~:> obstetrician gives the ergonovine intravenously at delivery of the baby's anterior· shoulder. Another uses methylergonovine by the latter technique. As demonstrated by others as well aH by a study in this hospital, • intelligent use of the oxytoeics can reduee blood loss to a minimum. The most important detail in the over-all diminution of hiood loss, however, would seem to be a vigilant obset·vation of the activity of the fundus, especially under general anesthesia, whereby gross relaxation of the fundus quickly following the third stage and oceasioning undue loss of blood can be prevented. I<'ive patients in this series were recognized as harboring primary blood dyscrasias, but not one of these incurred abnormal blood loss within th~:> twenty-four hours following delivery. There were two patients with thrombocytopenic plu·pura, one patient with macrocytic anemia of pregnancy, om• with nocturnal par-oxysmal hemoglobinuria, and one with Hodgkin's disease. The course of a known hemophilia carrier was uneventfuL A~ frequent occurrence of physiological anemia of pregnancy and hypochromic iron-deficiency anemia was noted without abnormal bleeding tendency. It is apparent that a consideration of the cause of postpartum hemorrhage in the individual instances has not given a satisfactory explanation for most of the cases. lt was therefore believed that a more illuminating study would be a statistical analysis of any significant factors in all the cases, and that in this way some more satisfaetory conclusions might be reached. The factors will he presenteii in Tables II to VI and Figs. 1 to fi.
811
E'l'IOLOGY OF POI::lTPARTUM HEMORRHAGE
Volume 63 Number+
TABLE II.
PARITY, AND NUMBER AND SIZE OF BABIES AS RELATED TO THE INCIDENCE OF POSTPARTt::M HEMORRHAGE
CONDITION
Multiparity Fifth or later pregnancy Multiple pregnancy Premature delivery 9
It is clear that postpartum hemorrhage is twice as likely to occur in a primigravid parturient as in a multipara. Grand multiparity (fifth or later pregnancy) appears to be particularly benign as far as risk of excessive bleeding is concerned. This observation is not in agreement with the general consensus that this group runs a greater risk of hemorrhage than other parity groups. Multiple pregnancy is recognized as a predisposing cause of postpartum bleeding, but this predisposition, apparently the result of overdistention of the uterus with subsequent atony, is even more marked in the group wherein the baby weighed 9 pounds or more. The tendency to greater cervical, vaginal, and perineal injury is obvious in the latter condition. Premature delivery is less likely to be associated with excessive blood loss than term delivery. TABU: III.
MODE 0~' VAGINAJ, DELIVERY AS RELATED TO THE INCIDENCE 0)' POSTPARTUM HEMORRHAGE
version
1,791 cases 253 cases 22 cases
It is very clear that the more extensive the operative procedure 11ecessary for delivery, the more likely is postpartum hemorrhage. TA!ll,tl IV.
TYPE 0~' ANESTHESIA AS RELATED TO TH~l lNCHJENC~: HEMORRHAGE NUMBER OF SUCH ANES· TIHCTWS ADMINISTERED
0)'
POS'fPARTUM
INCIDENCE OF POST·
Open drop Nitrous oxide and oxygen Spinal No anesthesia Caudal Local and/or pudendal block 2
It is apparent that, over a large series of cases, ether used in the anesthesia for delivery is associated with a higher ineidence of postpartum hemorrhage than any other anesthetic.
TERZIAN
812
Am.
J.
Obst. & Gyn
April, 195.2
Analysis of the only six cases of hemorrhage occurring with the use of nitrous oxide and oxygen revealed that one was associated with pre-eclampsia and premature separation of the placenta, one with pre-eclampsia and primary inertia, two with difficult operative deliveries, and one with manual extraction of the placenta subsequently under ether anesthesia. Nitrous oxide without ether definitely does not predispose to postpartum hemorrhage.
Age Distribution of Parturk:nfs with Postpartum Hemorrha:J<: 190 Ccues ~umber of Palienfs 120 ~ in lhiJ Jerk:s 11 Number of Partunenls /00 ~ in each llqt! Group Numher in New York State 80
of
Paf/eniJ
in ;g4g 60
.1/0 2.0 t0-2'1
25·29
30-34
S5-39
Fig. 1.-The decimal figure at the base of each column represents the ratio between the number of patients in each particular age group in this series, and the number of women In this same age group who delivered babies ln New York State in 1949. From these figures, it Is evident that the parturient age group In which postpartum hemorrhage Is most likely Is. the 25- to 29-year or middle group, with diminution toward either extreme. This dispels a commonly held notion that the older age group Is most likely to hemorrhage. Figures by courtesy of the Office of Vital Statistics of the New York State Department of Health. The figure 100 at the left in Fig. 1 indicat
lnferval Befwe~n Adminisfrafion of Mepuitline Hydrochloride• and Birth of !he Baby in /90 Cases of Postpartum Hemorrhage 30
No. of
r---
r--r---
20
,..---
r---
...--r---
Cases
/0
I
IS-30
Jf-5 -I,JJ
75 ·fJO IOS·/20 1.35·/SO N.5 ·180 195·110
ocr22~
Interval in Ninufes The distribution of times of administration of the drug appears to be that which might be expected in any series. We know that the most common caul!e of Primary uterine inertia In modern obstetrics Is the injudicious use of analgesics.• but there is no convincing evidence on thio graph that analgesia Is related to excessive bleeding. •Demerol (Winthrop-Stearns, Inc.). Fig. 2.-The dose of meperidine used was 100 mg. intramuscularly as a rule.
Volume 63
813
ETIOLOGY OF POSTPARTUM HEMORRHAGE
NumLer 4
The figure given for hemorrhage under spinal anesthesia is misleading because many of these cases comprised a pilot series in the use of spinal anesthesia in obstetrics in this hospital,S during which the anesthetic was frequently administered too early, thus necessitating extensive operative procedures which have been shown above to be associated with bleeding. Here, again, analysis of the six eases of postpartum hemorrhage occurring with spinal anesthesia revealed that four were associated with other difficulties, namely, two difficult operative deliveries, one second-degree laceration of the perineum with excessive bleeding, and one pre-eclampsia in an isoimmunized Rh-negative woman. Spinal anesthesia does not apparently lead to hemorrhage other than by relaxing the perineal blood vessels.
Durofion 80
t:lf
ffher Ane.rfhlsia in CaJcs
of
PoJiparlum Hemorrha9e
No.
of CoJes 20 1·15
11.·25
2'-35'
Jl.-l/5
IJ{,-55
5'ond ottr
/Juration m Minutes Fig. 3.-It ls noted that a majority of the patients In this group Inhaled ether for more than twenty-llve minutes. The obstetrician must keep a clock in hls head to eliminate thia added factor of prolongation of anesthesia. The onset of anesthesia in each case was judged to be the time at which the patient was made unconscious.
The incidence for delivery without anesthesia is again misleading, because one of the two hemorrhages in this group was associated with manual extraction of the placenta subsequently under ether anesthesia, and the other with precipitate delivery of a stillborn macerated fetus in an Rh-negative, isoimmunized patient. The figures for caudal, local, and cyclopropane anesthesia are very gratifying, but rather small in numbers for significance. Grouping of the hemorrhage eases according to the amount of blood loss showed that ether anesthesia was consistently associated through all the groups, both under and over 1,000 ml. On the other hand, no patient receiving spinal anesthesia lost more than 1,000 ml. of blood. Table V demonstrates a nice correlation between the incidence of postpartum hemorrhage and the extent of outlet surgery, the more extensive procedures being associated with a higher incidence. TABLE V.
OUTLET SURGERY AS RELATED TO THE INCIDENCE OF POSTPARTUM HEMORRHAGE
PROCEDURE
degree lacerations of second degree lacerations of third degree lacerations of cervical lacerations of rectocele
Am. J. Obst. & Gyncc. April, 1952
'l'ERZIAN
814
.Manual extraction of the placenta has been associated with postpartum hemorrhage in 33 per cent of instances in this scriPs. This is a signi:fieant figure, emphasizing the p:ravity of the proredure. The association of postpartum hemorrhage with prolonged labor and primary uterine inertia appears to be parallel in the two ('Onditions, which are often coexistent. The gene tal incidence of prolonged labor in this series would he about 2 per cent, 1 " whereby the nineteen hemorrhages in this group signify a 15 per cent occurrenre of bleeding following prolonged labor. This is a significant factor.
Duration of lh~ Second Sta~ in Cas~s of Posfpflrfttm flemtJrrhage 190 ca.ses All PaiJ~nfs
rim1'9ravida s Multiparas
No.
of Cases
30 31-,0
91-120
4./·(10
Duration in M inufl! s
o•120
Fig. 4.-For the multiparas, the curve of duration of the second stage is normal anti requires no comment. F'or the primigravidas. however, it is noted that 75 per cent had a second stage of one hour or less. This is abnormally short and indicates forced accouchement of some type.
Duration of ~~ Third Stag~ in Cases of PoslparfiHf'l Hemor,.,. 190 CQJes
125 No,IOO
of
75
Ct~Jts so 25 0-5'
&dO
11-15 DurofiDn in
1'·20
2.1·2.3
Minutes
Fig. 5.-The cases with long third stages are generally those in which manual extraction of the placenta was performed. The curve otherwise appears normal.
Precipitate labor and secondary uterine inertia do not lead to postpartum hemorrhage of themselves. Postpartum bleeding with eclampsia and pre-eclampsia is similar in ineidence, and significantly high ( 16 to 17 per cent). It is well known that ante- and intrapartum bleeding also occur very frequently in these conditions. Hypertension without other toxemia is 1moommon, therefore the three hemorrhages in this group might be considered definitely related to the hypertension·.
l~TIOLOGY
Volume 63 Number 4
OF POSTPARTUM HEMORRHAGE
81fi
Hydranmios was not a factor in the causation of 'bleeding in this series. Rh-negativity per se definitely does not predispose to postpartum hemorrhage, the incidence in this series being very close to the expected.n However, the incidence among isoimmunized Rlt-negative women is greatly out of proportion to the expected. About 5 per eent of Rh-negative women bceome sensitized following preg·nancy or transfnsion. 12 Sixteen per cent of the Rh-negative women having postpartum hemorrhage in this >;eries were sensitized, more than three times the expected incidence. When l'!tillbirth is associated with isoimmunization, Weiner 10 has demonstrated fibrinogenopenia with a defic•ient clotting mechanism in the mother. TABr.E
VI.
CERTAIN COMPLICATIONR AR R}:LAT~:n •ro Till~ INCiDENCE m· PoRTPARTrM HEMORRHAGf;
Primary uterine inertia Precipitate labor Hecondary uterine inertia Pre·eclampsia (168 ease~ recognizPrl) Eelamp~ia (6 cases) Hypertension without other toxemi;t Hydramuios ( 16 recognized) Rh·negativity Rh·nPgativity with isoimmunization
:? eases
2 27 1 ;; 0 25 4
easelS
cases (16%) f•.ase ( 17%) eaRes cases cases (1:l.3% of seriel<) cams 06% of Rh-negative women with hemor·
The Sex of the Baby.~-The possibility that the sex of the baby might be a factor in the causation of bleeding, with some hormonal ehange affecting the placental site, was eonsidered. Tallying revealed an almost exact similarity in incidence with each sex. This is a gratifying reflection on the reliability of the figures presented.
Summary A survey is made of 190 recognized postpartum hemorrhages which occurred among 6,910 vaginal deliveries over a four-year period in a 400-hed general hospital, an incidence of 2.7 per cent. There was one maternal death from postpartum hemorrhage during this period. A multiplicity of factors determines blood loss in any vaginal delivery, and the optimal method of prevention would be to knmv the cause in each particular instance. Analysis of the individual hospital records divulged the t:ausc of postpartum hemorrhage in only 83 of 190 cases. The next best method of approach for determining the cause was deemed to be the statistieal; therefore, the records were analyzed from this standpoint.
Conclusions 'l'here is no single cause of postpartum hemorrhage. The causes of, and factors predisposing to, postpartum hemorrhage might he listed approximately as follows, in order of importance: 1. Third stage bleeding, including manual extraction of the placenta 2. Difficult operative delivery
3. Eclampsia and pre-eclampsia 4. An overly large baby (about 9 pounds or more)
TERZIAN
816
Am.]. Obst. & Gynec April, 1952
5. Ether anesthesia, especially if prolonged 6. A short second stage of labor in a primigravida, i.e., accouchemellt
force 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Cervical, vaginal, and perineal lacerations Multiple pregnancy Isoimmuunization of an Rh-negative woman Episiotomy Primigravidity The patient in the mild-childbearing period Prolonged labor and primary uterine inertia Hypertensive toxemia of pregnancy Retained secundines Low implantation of the placenta Factors as yet unknown
Procedures and factors which did not predispose to postpartum hemorrhage in this series were as follows: 1. Certain types of anesthesia: nitrous oxide-oxygen; and probably local, regional, and no anesthesia 2. Precipitate labor 3. Secondary uterine inertia 4. The sex of the baby 5. Multiparity, including grand multiparity 6. Premature delivery 7. Spontaneous cephalic delivery 8. Hydramnios 9. Rh-negativity per se 10. The oxytocic treatment, provided the medication is adequate 11. Primary blood dyscrasias. These were conspicuously absent in the causation of postpartum hemorrhage in this series 12. The patient aged over 35 years 13. General analgesia No statement can be made regarding the influence of primary breech delivery, because premature breech deliveries, assisted breech deliveries, and breech extractions have been grouped together in this series. Consideration of the factors leading to postpartum hemorrhage will help us to manage pregnancy, labor, delivery, and the postpartum period in such a way as to reduce to a minimum this very serious complication. 'rhe Record Room staff under Miss Louise S. Haughton, and Miss Janice C. Cronin, R.K., of the Delivery Room, rendered invaluable assistance jn the preparation of ~harts and statistics.
References 1. Eastman, K. ,J.: WilliamH' Obstetrics, ed. 10, New York, 1950, Appleton·Ceutur_y· Crofts, Inc., pp. 912, 913. 2. Ea.stman, N.J.: Reference ~ p. 7. 3. MeGee, W. B.: J. Internat. uoll. Surgeons 13: 64, 1950.
Volume 63 ~umher ~
ETIOLOGY OF POSTPARTUM HEMORRHAGE
817
4. Eastman, N.J.: Reference 1, p. 914. 5. Greenhill, J. P.: Year Book of Obstetrics and Gynecology, Chieago, 1950, The Year Book Publishers, Inc., p. 235. 6. Eastman, N. J.: Reference 1, p. 919. 7. Carpenter. R. J., Jr.: U.S. Armed Porces M . •T. 2: 1567, 1951. 8. Eastman, N. J.: Reference 1, p. 781. 9. Snell, H. A.: New York State J. Med. 48: 2590, 1948. 10. Willson, J. R., and Alesbury, R. J.: AM. J. OBST. & Gnmc. 61: 1253, 1951. 11. Eastman, N.J.: Reference I, p. 1009. 12. Eastman, N.J.: Reference 1, p. 1011. Ia. Weiner, A. E., Reid, Duncan E., Roby, Charles C., and Diamond, Louis K.: AM. J. 0BST. & GY:>EC. 60: 1015, 1950. 10 B 2
SHERIDAN VILLAGE
OSTPARTUM hemorrhage is defined as bleeding in excess of 500 mi. within the first twenty-four hours after birth, including third stage bleeding and bleeding from episiotomy. 1 As a cause of maternal death, postpartum hemorrhage ranks high, 2 and is estimated by McGee as causing 30 per cent of maternal deaths. 3 This type of bleeding kills directly by producing shock, and kills indirectly by lowering resistance to infection. It is fitting that we should study and prevent this complication where possible.
P
:Material Accordingly, a review has been made of the recognized cases of post. partum hemorrhage occurring at the Ellis Hospital in the four-year period 1947 to 1950, inclusive. Ellis Hospital is a 400-bed general hospital with a well-regulated obstetrical service, privileges being granted to physicians in proportion to training, ability, and experience. There is one obstetrical resident. There are nine specialists with full privileges, of whom five are Diplomates of the American Board of Obstetrics and Gynecology. Sixty-one general practitioners are privileged to manage normal labor, perform outlet forceps and episiotomy, and repair first- and second-degree lacerations. Eight physicians have intermediate privileges. Mismanaged cases are brought into open discussion at a monthly meeting. Blood loss at delivery is measured with the aid of a blood basin included under a rubber drape. The occurrence of postpartum hemorrhage in oth~r instances has necessarily been judged by estimation by the attending physician, the house staff, and the obstetrical nurses, nevtreheless undoubtedly giving rise to considerable error. During the period studied there were 7,326 deliveries, including 416 cesarean sections ( 5. 7 per cent). Seven thousand four hundred sixteen babies were delivered, including 86 sets of twins and two sets of triplets. Among the 6,910 vaginal deliveries, 190 postpartum hemorrhages were recognized, an incidence of 2.7 per cent. No instance of postpartum hemorrhage was noted among the cases of cesarean section, although blood loss at operation in many of these undoubtedly exceeded 500 mi. Four maternal deaths occurred in this period, one of which was due to postpartum hemorrhage. The maternal death rate at Ellis Hospital during the period studied was therefore 5 per 10,000 deliveries, while the maternal mortality rate in the United States in 1946 was 16 per 10,000 live births. • An attempt was made at first to determine the cause of each hemorrhage from the hospital record. The results by this method were unsatisfactory because the cause could be fairly definitely determined or surmised in only 83 cases. These are listed in Table I. •Data from the National Office or Vital Statistics, Federal Security Agency, United States Children's Bureau.
809
TERZIAX
810
"Difficult operative delivery" signifies any delivery in which the extensiveness of the procedme used (such as midforceps), combined with the duration of anesthesia and the time t'equired to repair episiotomy and lacerations, was the apparent cause of blood loss exceeding- the normal limit. Blood loss in these cases varied from 525 to 1,500 ml. 'l'ABLE
I.
THE CAl'SE m• POS'l'PARTUM HEMORRHAGf; AS DEn;RMlNEIJ FROM THE
HOSPITAl, RECORD
Bleeding lacerations and/or episiotomy Third stage bleeding Laceration of cervix Retained placental cotyledon Low implantation of placenta Traumatic. rupture of lower uterine Kegmen t of rectocele
12 19 ;j
1 1 l
1
"'l'hird stage bleeding" indicates that excessive blood loss was associated with delayed deli\'et·y of the placenta, the potential retroplacental hematoma escaping past a separated margin of the placenta, or that the placenta was retained in the upper uterine segment and required manual extraction with its attendant dangers of atony of the uterus following deep ether anesthesia, and laceration of the uterine wall. 4 GreenhiiP emphasizes. however, that threatened postpartum hemorrhage due to third stage bleeding should he prevented hy manna! extraction of the placenta. "Retained placental tissue" is a rare cause of postpartum hemorrhag<•. hut ranks high as a eause of puerperal bleeding. 6 The oxytoeie routine at this hospital should he m~:>ntioned. In most instances, 1 ml. of Pitocin (10 units) is administered intramuscularly immediately after the birth of the haby. After delivery of the placenta, 0.2 mg. of ergonovine is given intramuscularly. This routine is varied by some. 0.25 ml. of Pitocin being given intravenously with the birth, and the remainder of the Pitoein and the ergonovine being given intramuscularly with the placental exit. On~:> obstetrician gives the ergonovine intravenously at delivery of the baby's anterior· shoulder. Another uses methylergonovine by the latter technique. As demonstrated by others as well aH by a study in this hospital, • intelligent use of the oxytoeics can reduee blood loss to a minimum. The most important detail in the over-all diminution of hiood loss, however, would seem to be a vigilant obset·vation of the activity of the fundus, especially under general anesthesia, whereby gross relaxation of the fundus quickly following the third stage and oceasioning undue loss of blood can be prevented. I<'ive patients in this series were recognized as harboring primary blood dyscrasias, but not one of these incurred abnormal blood loss within th~:> twenty-four hours following delivery. There were two patients with thrombocytopenic plu·pura, one patient with macrocytic anemia of pregnancy, om• with nocturnal par-oxysmal hemoglobinuria, and one with Hodgkin's disease. The course of a known hemophilia carrier was uneventfuL A~ frequent occurrence of physiological anemia of pregnancy and hypochromic iron-deficiency anemia was noted without abnormal bleeding tendency. It is apparent that a consideration of the cause of postpartum hemorrhage in the individual instances has not given a satisfactory explanation for most of the cases. lt was therefore believed that a more illuminating study would be a statistical analysis of any significant factors in all the cases, and that in this way some more satisfaetory conclusions might be reached. The factors will he presenteii in Tables II to VI and Figs. 1 to fi.
811
E'l'IOLOGY OF POI::lTPARTUM HEMORRHAGE
Volume 63 Number+
TABLE II.
PARITY, AND NUMBER AND SIZE OF BABIES AS RELATED TO THE INCIDENCE OF POSTPARTt::M HEMORRHAGE
CONDITION
Multiparity Fifth or later pregnancy Multiple pregnancy Premature delivery 9
It is clear that postpartum hemorrhage is twice as likely to occur in a primigravid parturient as in a multipara. Grand multiparity (fifth or later pregnancy) appears to be particularly benign as far as risk of excessive bleeding is concerned. This observation is not in agreement with the general consensus that this group runs a greater risk of hemorrhage than other parity groups. Multiple pregnancy is recognized as a predisposing cause of postpartum bleeding, but this predisposition, apparently the result of overdistention of the uterus with subsequent atony, is even more marked in the group wherein the baby weighed 9 pounds or more. The tendency to greater cervical, vaginal, and perineal injury is obvious in the latter condition. Premature delivery is less likely to be associated with excessive blood loss than term delivery. TABU: III.
MODE 0~' VAGINAJ, DELIVERY AS RELATED TO THE INCIDENCE 0)' POSTPARTUM HEMORRHAGE
version
1,791 cases 253 cases 22 cases
It is very clear that the more extensive the operative procedure 11ecessary for delivery, the more likely is postpartum hemorrhage. TA!ll,tl IV.
TYPE 0~' ANESTHESIA AS RELATED TO TH~l lNCHJENC~: HEMORRHAGE NUMBER OF SUCH ANES· TIHCTWS ADMINISTERED
0)'
POS'fPARTUM
INCIDENCE OF POST·
Open drop Nitrous oxide and oxygen Spinal No anesthesia Caudal Local and/or pudendal block 2
It is apparent that, over a large series of cases, ether used in the anesthesia for delivery is associated with a higher ineidence of postpartum hemorrhage than any other anesthetic.
TERZIAN
812
Am.
J.
Obst. & Gyn
April, 195.2
Analysis of the only six cases of hemorrhage occurring with the use of nitrous oxide and oxygen revealed that one was associated with pre-eclampsia and premature separation of the placenta, one with pre-eclampsia and primary inertia, two with difficult operative deliveries, and one with manual extraction of the placenta subsequently under ether anesthesia. Nitrous oxide without ether definitely does not predispose to postpartum hemorrhage.
Age Distribution of Parturk:nfs with Postpartum Hemorrha:J<: 190 Ccues ~umber of Palienfs 120 ~ in lhiJ Jerk:s 11 Number of Partunenls /00 ~ in each llqt! Group Numher in New York State 80
of
Paf/eniJ
in ;g4g 60
.1/0 2.0 t0-2'1
25·29
30-34
S5-39
Fig. 1.-The decimal figure at the base of each column represents the ratio between the number of patients in each particular age group in this series, and the number of women In this same age group who delivered babies ln New York State in 1949. From these figures, it Is evident that the parturient age group In which postpartum hemorrhage Is most likely Is. the 25- to 29-year or middle group, with diminution toward either extreme. This dispels a commonly held notion that the older age group Is most likely to hemorrhage. Figures by courtesy of the Office of Vital Statistics of the New York State Department of Health. The figure 100 at the left in Fig. 1 indicat
lnferval Befwe~n Adminisfrafion of Mepuitline Hydrochloride• and Birth of !he Baby in /90 Cases of Postpartum Hemorrhage 30
No. of
r---
r--r---
20
,..---
r---
...--r---
Cases
/0
I
IS-30
Jf-5 -I,JJ
75 ·fJO IOS·/20 1.35·/SO N.5 ·180 195·110
ocr22~
Interval in Ninufes The distribution of times of administration of the drug appears to be that which might be expected in any series. We know that the most common caul!e of Primary uterine inertia In modern obstetrics Is the injudicious use of analgesics.• but there is no convincing evidence on thio graph that analgesia Is related to excessive bleeding. •Demerol (Winthrop-Stearns, Inc.). Fig. 2.-The dose of meperidine used was 100 mg. intramuscularly as a rule.
Volume 63
813
ETIOLOGY OF POSTPARTUM HEMORRHAGE
NumLer 4
The figure given for hemorrhage under spinal anesthesia is misleading because many of these cases comprised a pilot series in the use of spinal anesthesia in obstetrics in this hospital,S during which the anesthetic was frequently administered too early, thus necessitating extensive operative procedures which have been shown above to be associated with bleeding. Here, again, analysis of the six eases of postpartum hemorrhage occurring with spinal anesthesia revealed that four were associated with other difficulties, namely, two difficult operative deliveries, one second-degree laceration of the perineum with excessive bleeding, and one pre-eclampsia in an isoimmunized Rh-negative woman. Spinal anesthesia does not apparently lead to hemorrhage other than by relaxing the perineal blood vessels.
Durofion 80
t:lf
ffher Ane.rfhlsia in CaJcs
of
PoJiparlum Hemorrha9e
No.
of CoJes 20 1·15
11.·25
2'-35'
Jl.-l/5
IJ{,-55
5'ond ottr
/Juration m Minutes Fig. 3.-It ls noted that a majority of the patients In this group Inhaled ether for more than twenty-llve minutes. The obstetrician must keep a clock in hls head to eliminate thia added factor of prolongation of anesthesia. The onset of anesthesia in each case was judged to be the time at which the patient was made unconscious.
The incidence for delivery without anesthesia is again misleading, because one of the two hemorrhages in this group was associated with manual extraction of the placenta subsequently under ether anesthesia, and the other with precipitate delivery of a stillborn macerated fetus in an Rh-negative, isoimmunized patient. The figures for caudal, local, and cyclopropane anesthesia are very gratifying, but rather small in numbers for significance. Grouping of the hemorrhage eases according to the amount of blood loss showed that ether anesthesia was consistently associated through all the groups, both under and over 1,000 ml. On the other hand, no patient receiving spinal anesthesia lost more than 1,000 ml. of blood. Table V demonstrates a nice correlation between the incidence of postpartum hemorrhage and the extent of outlet surgery, the more extensive procedures being associated with a higher incidence. TABLE V.
OUTLET SURGERY AS RELATED TO THE INCIDENCE OF POSTPARTUM HEMORRHAGE
PROCEDURE
degree lacerations of second degree lacerations of third degree lacerations of cervical lacerations of rectocele
Am. J. Obst. & Gyncc. April, 1952
'l'ERZIAN
814
.Manual extraction of the placenta has been associated with postpartum hemorrhage in 33 per cent of instances in this scriPs. This is a signi:fieant figure, emphasizing the p:ravity of the proredure. The association of postpartum hemorrhage with prolonged labor and primary uterine inertia appears to be parallel in the two ('Onditions, which are often coexistent. The gene tal incidence of prolonged labor in this series would he about 2 per cent, 1 " whereby the nineteen hemorrhages in this group signify a 15 per cent occurrenre of bleeding following prolonged labor. This is a significant factor.
Duration of lh~ Second Sta~ in Cas~s of Posfpflrfttm flemtJrrhage 190 ca.ses All PaiJ~nfs
rim1'9ravida s Multiparas
No.
of Cases
30 31-,0
91-120
4./·(10
Duration in M inufl! s
o•120
Fig. 4.-For the multiparas, the curve of duration of the second stage is normal anti requires no comment. F'or the primigravidas. however, it is noted that 75 per cent had a second stage of one hour or less. This is abnormally short and indicates forced accouchement of some type.
Duration of ~~ Third Stag~ in Cases of PoslparfiHf'l Hemor,.,. 190 CQJes
125 No,IOO
of
75
Ct~Jts so 25 0-5'
&dO
11-15 DurofiDn in
1'·20
2.1·2.3
Minutes
Fig. 5.-The cases with long third stages are generally those in which manual extraction of the placenta was performed. The curve otherwise appears normal.
Precipitate labor and secondary uterine inertia do not lead to postpartum hemorrhage of themselves. Postpartum bleeding with eclampsia and pre-eclampsia is similar in ineidence, and significantly high ( 16 to 17 per cent). It is well known that ante- and intrapartum bleeding also occur very frequently in these conditions. Hypertension without other toxemia is 1moommon, therefore the three hemorrhages in this group might be considered definitely related to the hypertension·.
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Hydranmios was not a factor in the causation of 'bleeding in this series. Rh-negativity per se definitely does not predispose to postpartum hemorrhage, the incidence in this series being very close to the expected.n However, the incidence among isoimmunized Rlt-negative women is greatly out of proportion to the expected. About 5 per eent of Rh-negative women bceome sensitized following preg·nancy or transfnsion. 12 Sixteen per cent of the Rh-negative women having postpartum hemorrhage in this >;eries were sensitized, more than three times the expected incidence. When l'!tillbirth is associated with isoimmunization, Weiner 10 has demonstrated fibrinogenopenia with a defic•ient clotting mechanism in the mother. TABr.E
VI.
CERTAIN COMPLICATIONR AR R}:LAT~:n •ro Till~ INCiDENCE m· PoRTPARTrM HEMORRHAGf;
Primary uterine inertia Precipitate labor Hecondary uterine inertia Pre·eclampsia (168 ease~ recognizPrl) Eelamp~ia (6 cases) Hypertension without other toxemi;t Hydramuios ( 16 recognized) Rh·negativity Rh·nPgativity with isoimmunization
:? eases
2 27 1 ;; 0 25 4
easelS
cases (16%) f•.ase ( 17%) eaRes cases cases (1:l.3% of seriel<) cams 06% of Rh-negative women with hemor·
The Sex of the Baby.~-The possibility that the sex of the baby might be a factor in the causation of bleeding, with some hormonal ehange affecting the placental site, was eonsidered. Tallying revealed an almost exact similarity in incidence with each sex. This is a gratifying reflection on the reliability of the figures presented.
Summary A survey is made of 190 recognized postpartum hemorrhages which occurred among 6,910 vaginal deliveries over a four-year period in a 400-hed general hospital, an incidence of 2.7 per cent. There was one maternal death from postpartum hemorrhage during this period. A multiplicity of factors determines blood loss in any vaginal delivery, and the optimal method of prevention would be to knmv the cause in each particular instance. Analysis of the individual hospital records divulged the t:ausc of postpartum hemorrhage in only 83 of 190 cases. The next best method of approach for determining the cause was deemed to be the statistieal; therefore, the records were analyzed from this standpoint.
Conclusions 'l'here is no single cause of postpartum hemorrhage. The causes of, and factors predisposing to, postpartum hemorrhage might he listed approximately as follows, in order of importance: 1. Third stage bleeding, including manual extraction of the placenta 2. Difficult operative delivery
3. Eclampsia and pre-eclampsia 4. An overly large baby (about 9 pounds or more)
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Am.]. Obst. & Gynec April, 1952
5. Ether anesthesia, especially if prolonged 6. A short second stage of labor in a primigravida, i.e., accouchemellt
force 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Cervical, vaginal, and perineal lacerations Multiple pregnancy Isoimmuunization of an Rh-negative woman Episiotomy Primigravidity The patient in the mild-childbearing period Prolonged labor and primary uterine inertia Hypertensive toxemia of pregnancy Retained secundines Low implantation of the placenta Factors as yet unknown
Procedures and factors which did not predispose to postpartum hemorrhage in this series were as follows: 1. Certain types of anesthesia: nitrous oxide-oxygen; and probably local, regional, and no anesthesia 2. Precipitate labor 3. Secondary uterine inertia 4. The sex of the baby 5. Multiparity, including grand multiparity 6. Premature delivery 7. Spontaneous cephalic delivery 8. Hydramnios 9. Rh-negativity per se 10. The oxytocic treatment, provided the medication is adequate 11. Primary blood dyscrasias. These were conspicuously absent in the causation of postpartum hemorrhage in this series 12. The patient aged over 35 years 13. General analgesia No statement can be made regarding the influence of primary breech delivery, because premature breech deliveries, assisted breech deliveries, and breech extractions have been grouped together in this series. Consideration of the factors leading to postpartum hemorrhage will help us to manage pregnancy, labor, delivery, and the postpartum period in such a way as to reduce to a minimum this very serious complication. 'rhe Record Room staff under Miss Louise S. Haughton, and Miss Janice C. Cronin, R.K., of the Delivery Room, rendered invaluable assistance jn the preparation of ~harts and statistics.
References 1. Eastman, K. ,J.: WilliamH' Obstetrics, ed. 10, New York, 1950, Appleton·Ceutur_y· Crofts, Inc., pp. 912, 913. 2. Ea.stman, N.J.: Reference ~ p. 7. 3. MeGee, W. B.: J. Internat. uoll. Surgeons 13: 64, 1950.
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4. Eastman, N.J.: Reference 1, p. 914. 5. Greenhill, J. P.: Year Book of Obstetrics and Gynecology, Chieago, 1950, The Year Book Publishers, Inc., p. 235. 6. Eastman, N. J.: Reference 1, p. 919. 7. Carpenter. R. J., Jr.: U.S. Armed Porces M . •T. 2: 1567, 1951. 8. Eastman, N. J.: Reference 1, p. 781. 9. Snell, H. A.: New York State J. Med. 48: 2590, 1948. 10. Willson, J. R., and Alesbury, R. J.: AM. J. OBST. & Gnmc. 61: 1253, 1951. 11. Eastman, N.J.: Reference I, p. 1009. 12. Eastman, N.J.: Reference 1, p. 1011. Ia. Weiner, A. E., Reid, Duncan E., Roby, Charles C., and Diamond, Louis K.: AM. J. 0BST. & GY:>EC. 60: 1015, 1950. 10 B 2
SHERIDAN VILLAGE