Postpartum hemorrhage

Background

Causes

1. Uterine atony
   1. Retained placental fragments
2. Lower genital tract lacerations
3. Uterine rupture
4. Uterine inversion
5. Hereditary coagulopathy

Differential Diagnosis

3rd Trimester/Postpartum Emergencies

• Acute fatty liver of pregnancy
• Amniotic fluid embolus
• Chorioamnionitis
• Eclampsia
• HELLP syndrome
• Mastitis
• Peripartum cardiomyopathy
• Postpartum endometritis (postpartum PID)
• Postpartum headache
• Postpartum hemorrhage
• Preeclampsia
• Resuscitative hysterotomy
• Retained products of conception
• Septic abortion
• Uterine rupture

Management

1. Fluid resuscitation
2. Consider Blood Products for Hemodynamic Instability
3. Treat underlying cause:
   1. Uterine atony:
      1. Bimanual Massage
      2. Oxytocin (Pitocin) 10mg IM or slow IV push (rapid administration may cause hypotension)
      3. Misoprostol (Cytotec) 600mcg SL
      4. Methylergonovine (Methergine) 0.2mg IM (contraindicated in pts with HTN or Preeclampsia)
      5. Carboprost (Hemabate) 250mcg IV (avoid in pts with HTN or asthma)
      6. Bakri balloon placement (large Foley cathether if Bakri not available; fill with NS until tamponaded)
   2. Uterine inversion:
      1. Manually replace placenta:
         1. Place hand inside the vagina and push the fundus cephalad along long axis of vagina

Source

Tintinalli

See Also

• Post-Partum Emergencies
• Vaginal Bleeding (Main)