View source for Postpartum hemorrhage

==Background==
*Leading cause of maternal death worldwide
**Approx 3% to 5% of obstetric patients will experience PPH<ref>Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017 Apr 1;95(7):442-449. PMID: 28409600.</ref>
**In the US, 11% of maternal deaths are caused by hemorrhage<ref>Bienstock JL, Eke AC, Hueppchen NA. Postpartum Hemorrhage. N Engl J Med. 2021 Apr 29;384(17):1635-1645. doi: 10.1056/NEJMra1513247. PMID: 33913640; PMCID: PMC10181876.</ref>

===Causes===
*Uterine atony (responsible for 80% of cases)
*[[retained products of conception|Retained placental tissue]]
*Lower genital tract lacerations
*[[Uterine rupture]]
*Uterine inversion
*Underlying [[coagulopathy|coagulation abnormalities]]
*Abnormal placentation: [[Placenta previa]], [[placenta accreta]]

==Clinical Features==
*Loss of ≥1000mL blood in first 24hrs and up to 12wks postpartum with either vaginal [[delivery]] or c-section, or bleeding associated with signs/symptoms of hypovolemia within 24 hours of birth <ref>https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage</ref>
**However, ≥500mL of blood loss after vaginal delivery is abnormal and warrants further investigation
*Usually within 24 hours of delivery
*If occurs more than 24 hours after delivery, consider: retained POC, [[coagulopathy]], etc
*Other pertinent definitions<ref>WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 Apr 26. pii: S0140-6736(17)30638-4.</ref>:
**Any blood loss to compromising hemodynamic stability

==Differential Diagnosis==
{{Postpartum emergencies DDX}}

==Evaluation==
===Work-up===
*Quantitative blood loss (QBL): Volumetric containers (V-drapes) can quantify vaginal blood loss
*CBC
*CMP
*Coags
*Type and cross

===Diagnosis===
*Clinical diagnosis

==Management==
''Treat underlying cause: Tone, Trauma, Tissue, Thrombosis''
*Consider [[Fluid resuscitation]] vs [[blood products]] for hemodynamic instability
*Early [[tranexamic acid]] (TXA) reduces death due to bleeding<ref>Ducloy-Bouthors AS et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15(2):R117.</ref><ref>WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 Apr 26. pii: S0140-6736(17)30638-4.</ref>
**Give as soon as possible relative to bleeding onset
**1 g IV of TXA over 10 min, with 2nd dose 30 min later if continual bleed OR bleed restarts within 24 hrs after 1st dose<ref>Shakur H et al. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010 Apr 16;11:40.</ref>
**No difference between placebo and TXA in adverse events, including thromboembolism
**All-cause mortality and hysterectomy not reduced with TXA

===Tone===
''[[Uterine atony]] (boggy uterus)''
*Assess intravaginally for lower segment atony, which may occur even when the fundus is well-contracted
*Uterine massage
**External uterine massage stimulates uterine contraction
**Bimanual massage: One fist is placed intravaginally in the anterior fornix. Other hand massages the fundus while compressing against the vaginal hand.
*[[Oxytocin]] (Pitocin) 1st-line and most important drug
**IV options:
***20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>
***80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>
**IM option (if no IV):
***10 IU IM x 1
*[[Misoprostol]] (Cytotec)
**600mcg SL or 1000 mcg rectally
*[[Methylergonovine]] (Methergine)
**0.2mg IM q2-4 hrs
**Relative contraindication in patients with hypertension or [[Preeclampsia]]; may consider in severely unstable BP
*[[Carboprost]] (Hemabate)
**250mcg IM q15 min (avoid in patients with asthma)
*Bakri balloon placement
**Fill with warm 500ml NS (or large/multiple Foleys or pack)
**Use US to place to top of fundus and ensure no retained placenta
*Uterine/vaginal packing
**Kerlix packing may be utilized when balloon is not available, but can result in increased rates of iatrogenic foreign body and infection
*Uterine artery embolization
**May be considered in a stable patient, if bleeding persists

===Trauma===
''Genital tract tear''
*Examine for tears in vaginal, cervical, and perineal areas under good lighting and suction
*Suture [[lacerations]] - simple running or figure of eight with 3-0 or 2-0 absorbable
*Deep lacerations such as those by the cervix may require OR
*Drain hematomas >3 cm

===Tissue===
''Retained placental tissue''
*Evaluate placenta for pieces that may become retained products
**Pelvic exam may be normal other than blood
**Detect with manual exam or US
*Manual removal
**Adequate anesthesia and uterine relaxants may be needed (if no atony noted)
**Manual exploration of uterine cavity with sterile gloves, removal of placental fragments
*Curettage

===Thrombin===
''Reverse any coagulopathies''
*Labs - platelets, coags, fibrinogen, d-dimer
*Replace appropriate blood components

===[[Uterine inversion]]===
*Manually replace placenta '''OR''' do not remove placenta until uterus has been replaced:
*Place hand inside the vagina and push the fundus cephalad along long axis of vagina
*Prompt replacement important since cervix contracts over time creating a constriction ring
*Discontinue uterotonic meds (oxytocin) if uterus not reduced, and consider uterine relaxant options:<ref>Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th ed. 2013. Chapter 181: Labor and Delivery and their Complications. 2349.</ref>:
**[[Nitroglycerine]] IV 50-250 mcg bolus over 1-2 min, then up to x3-4 additional doses q3-5 min to relax uterus
**[[Magnesium]] 4-6 g IV over 15 min
**[[Terbutaline]] 0.25mg IV or SQ
*After replacement:
**Fundal massage ± bimanual massage/compression
**Then [[oxytocin]] infusion with 40 units in 1 L of NS at 200-1000 cc/hr

==Disposition==
*Admit
*May require OR for any of the above etiologies not responsive to first-line treatments


==Medication Dosing==
===Uterotonics===
*{{MedicationDose|drug=Oxytocin|dose=20 IU in 1L NS at 250 mL/hr (or 10 IU IM)|route=IV/IM|context=1st line uterotonic|indication=Postpartum hemorrhage|population=Adult}}
*{{MedicationDose|drug=Misoprostol|dose=600 mcg SL or 1000 mcg PR|route=SL/PR|context=2nd line uterotonic|indication=Postpartum hemorrhage|population=Adult}}
*{{MedicationDose|drug=Methylergonovine|dose=0.2 mg q2-4hr|route=IM|context=Uterotonic|indication=Postpartum hemorrhage|population=Adult|notes=Contraindicated in hypertension/preeclampsia}}

===Antifibrinolytic===
*{{MedicationDose|drug=Tranexamic acid|dose=1 g over 10 min, repeat in 30 min if ongoing bleed|route=IV|context=Antifibrinolytic|indication=Postpartum hemorrhage|population=Adult|notes=Give as early as possible; WOMAN trial showed reduced death from bleeding}}

==See Also==
*[[Emergent delivery]]
*[[Postpartum emergencies]]

{{DDX undifferentiated VB}}

==External Links==

==References==
<references/>

[[Category:OBGYN]]