Postpartum hemorrhage (PPH) is a serious complication that can occur after childbirth, involving excessive bleeding. For individuals who have experienced PPH, questions about the safety of future pregnancies are common and important. This article provides information on the risks and management strategies for subsequent pregnancies after a previous PPH.
Understanding Postpartum Hemorrhage
Postpartum hemorrhage is characterized by significant blood loss following childbirth, typically defined as losing 1,000 milliliters or more of blood, or any amount of blood loss accompanied by signs of hypovolemia, within 24 hours after delivery. PPH is a medical emergency. It can also occur up to 12 weeks after delivery, termed secondary PPH.
The most common cause of PPH is uterine atony, accounting for approximately 70% of cases. Uterine atony occurs when the uterus fails to contract adequately after the placenta is delivered, preventing the compression of blood vessels at the site where the placenta was attached. Other causes include trauma to the birth canal (lacerations), retained placental tissue, and coagulation disorders.
Recurrence Risks in Future Pregnancies
A history of postpartum hemorrhage increases the likelihood of experiencing it again. Individuals with a previous PPH have approximately a threefold increased risk of recurrence compared to those without a history, with rates around 15% in a second pregnancy. This risk can rise to about 27% after two prior PPH events.
The specific cause of the previous PPH significantly influences recurrence risk. For instance, if the initial PPH was due to uterine atony, the risk of recurrence for atony is increased. Similarly, a prior retained placenta significantly raises the chance of retained placenta in future deliveries, with recurrence rates potentially around 25%. Conditions like placenta accreta, where the placenta abnormally attaches to the uterine wall, also elevate the risk of severe PPH in subsequent pregnancies. The severity of the previous hemorrhage also plays a role, with higher recurrence rates observed after a more severe PPH.
Planning a Subsequent Pregnancy After PPH
Planning a subsequent pregnancy after PPH involves proactive steps to enhance safety. Pre-conception counseling with a healthcare provider, such as an obstetrician or a maternal-fetal medicine specialist, is recommended. This allows for a thorough review of the previous PPH, including its cause and contributing factors.
Identifying underlying conditions, like fibroids or pre-eclampsia, that may have increased the initial risk is an important part of this assessment. During counseling, an individualized risk assessment can be developed, and a plan for managing potential risks in the upcoming pregnancy can be discussed. Consistent and comprehensive prenatal care is important, allowing for close monitoring of the pregnancy. Specialized monitoring, such as ultrasounds, may be recommended to assess placental location, especially if there was a history of retained placenta or concerns about conditions like placenta previa. Open communication with the healthcare team throughout the pregnancy is important to address any concerns and ensure a tailored birth plan is in place in advance.
Managing Labor and Delivery After PPH
Managing labor and delivery for individuals with a history of PPH involves specific strategies to minimize recurrence risk. Active management of the third stage of labor, involving uterotonic medications like oxytocin immediately after birth, is routinely recommended for all deliveries to prevent PPH. This practice helps the uterus contract effectively and reduces blood loss.
Close monitoring for signs of hemorrhage is maintained throughout labor and the immediate postpartum period, including continuous assessment of blood loss. Immediate post-delivery interventions, such as uterine massage, are employed to help the uterus contract and expel any clots. Medications to stimulate contractions may also be administered. The readiness of an experienced medical team, along with the availability of blood products for transfusion if needed, is a component of the management plan.