Postpartum hemorrhage: Difference between revisions

(Add MedicationDose SMW entries for oxytocin, misoprostol, methylergonovine, tranexamic acid; doses verified against ACOG/WHO guidelines)
(Strip excess bold)
 
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==Management==
==Management==
''Treat underlying cause: '''T'''one, '''T'''rauma, '''T'''issue, '''T'''hrombosis''
''Treat underlying cause: Tone, Trauma, Tissue, Thrombosis''
*Consider [[Fluid resuscitation]] vs [[blood products]] for hemodynamic instability
*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>
*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
**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>
**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
**No difference between placebo and TXA in adverse events, including thromboembolism
**All-cause mortality and hysterectomy not reduced with TXA
**All-cause mortality and hysterectomy not reduced with TXA
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**External uterine massage stimulates uterine contraction
**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.
**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'''
*[[Oxytocin]] (Pitocin) 1st-line and most important drug
**IV options:
**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>
***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>
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*Examine for tears in vaginal, cervical, and perineal areas under good lighting and suction
*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
*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'''
*Deep lacerations such as those by the cervix may require OR
*Drain hematomas >3 cm
*Drain hematomas >3 cm


Latest revision as of 09:35, 22 March 2026

Background

  • Leading cause of maternal death worldwide
    • Approx 3% to 5% of obstetric patients will experience PPH[1]
    • In the US, 11% of maternal deaths are caused by hemorrhage[2]

Causes

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 [3]
    • 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[4]:
    • Any blood loss to compromising hemodynamic stability

Differential Diagnosis

3rd Trimester/Postpartum Emergencies

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[5][6]
    • 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[7]
    • 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) [8]
      • 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). [9]
    • 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:[10]:
  • 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

  • Oxytocin 20 IU in 1L NS at 250 mL/hr (or 10 IU IM) IV/IM
  • Misoprostol 600 mcg SL or 1000 mcg PR SL/PR
  • Methylergonovine 0.2 mg q2-4hr IM — Contraindicated in hypertension/preeclampsia

Antifibrinolytic

  • Tranexamic acid 1 g over 10 min, repeat in 30 min if ongoing bleed IV — Give as early as possible; WOMAN trial showed reduced death from bleeding

See Also

Vaginal bleeding (main)

External Links

References

  1. ↑ Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017 Apr 1;95(7):442-449. PMID: 28409600.
  2. ↑ 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.
  3. ↑ https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage
  4. ↑ 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.
  5. ↑ Ducloy-Bouthors AS et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15(2):R117.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.
  9. ↑ 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.
  10. ↑ Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th ed. 2013. Chapter 181: Labor and Delivery and their Complications. 2349.
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