Postpartum hemorrhage: Difference between revisions
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==Background==
==Background==
*Uterine atony is responsible for 80% of postpartum hemorrhage cases
*Leading cause of maternal death worldwide
 
===Causes===
===Causes===
*[[Uterine atony]]
*Uterine atony (responsible for 80% of cases)
*Retained placental tissue
*Retained placental tissue
*Lower genital tract lacerations
*Lower genital tract lacerations
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*Uterine inversion
*Uterine inversion
*Underlying [[coagulopathy|coagulation abnormalities]]
*Underlying [[coagulopathy|coagulation abnormalities]]
==Clinical Features==
*Loss of >500 mL blood after vaginal [[delivery]]
*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>:
**> 1000 ml after c-section
**Any blood loss to compromising hemodynamic stability


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


==Diagnosis==
==Evaluation==
*Defined as loss of >500 mL blood after SVD
===Work-up===
*Immediate PPH within 24 hrs following delivery
*CBC
*Delayed PPH etiologies
*Coags
**Uterine subinvolution
*Type and cross
**von Willebrand disease
 
**Retained placenta
===Evaluation===
*Clinical diagnosis


==Management==
==Management==
#[[Fluid resuscitation]]
*[[Fluid resuscitation]]
#Consider Blood Products for Hemodynamic Instability
*Consider Blood Products for Hemodynamic Instability
#Evaluate placenta for retained products
*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>
#Examine for tears under good lighting and suction
**Give as soon as possible relative to bleeding onset
#Treat underlying cause - 4T's: '''Tone, Trauma, Tissue, Thrombosis'''
**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
*Evaluate placenta for retained products
*Examine for tears under good lighting and suction
*Treat underlying cause - 4T's: '''Tone, Trauma, Tissue, Thrombosis'''
 
===Tone===
===Tone===
[[Uterine atony]] (boggy uterus):
''[[Uterine atony]] (boggy uterus)''
#Bimanual Massage
*Bimanual Massage
#[[Oxytocin]] (Pitocin) 10 units IM or 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
*[[Oxytocin]] (Pitocin)
#[[Misoprostol]] (Cytotec) 600mcg SL or 1000 mcg rectally
**1st line and most important drug - '''Oxytocin 80 units in 500 cc NS bag''', run it wide open<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>
#[[Methylergonovine]] (Methergine) 0.2mg IM q2-4 hrs (relative contraindication in pts with HTN or Preeclampsia - may consider in severely unstable BP)
**'''OR''' 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
#[[Carboprost]] (Hemabate) 250mcg IM q15 min (avoid in pts with asthma)
**'''OR''' 10 units IM if no IV
#Bakri balloon placement, fill with warm 500 ml NS (or large/multiple Foleys or pack) - use US to place to top of fundus and ensure no retained placenta
*[[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
 
===Trauma===
===Trauma===
#Genital tract tear - suture lacs, drain hematomas > 3 cm
*''Genital tract tear''
#[[Uterine inversion]]:
**Suture [[lacerations]] - figure of eight with 3-0 or 2-0 absorbable
#*Manually replace placenta OR do not remove placenta until uterus has been replaced:
**Deep lacerations such as those by the cervix may require '''OR'''
#*Place hand inside the vagina and push the fundus cephalad along long axis of vagina
**Drain hematomas >3 cm
#*Prompt replacement important since cervix contracts over time creating a constriction ring
*''[[Uterine inversion]]''
#*Consider nitroglycerine IV 50 mcg, then up to x4 additional doses q3-5 min to relax uterus
**Manually replace placenta '''OR''' do not remove placenta until uterus has been replaced:
#*After replacement, oxytocin infusion with 40 units in 1 L of NS at 200 ml/hr
**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
 
===Tissue===
===Tissue===
Retained placental tissue
''Retained placental tissue''
#*Pelvic exam may be normal other than blood
*Pelvic exam may be normal other than blood
#*Detect with US
*Detect with US
#*Manual removal
*Manual removal
#*Curettage
*Curettage
 
===Thrombin===
===Thrombin===
Reverse any coagulopathies
''Reverse any coagulopathies''
#*Labs - platelets, coags, fibrinogen, d-dimer
*Labs - platelets, coags, fibrinogen, d-dimer
#*Replace appropriate blood components
*Replace appropriate blood components
 
==Medications==


===Misoprostol (Cytotec)===
==Disposition==
*Second Line therapy and can be administered sublingually, orally, vaginally, and rectally.<ref>Mousa HA, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2003;(1):CD003249.</ref>
*Admit
*1,000 mcg administered rectally
*800 mcg PO


==See Also==
==See Also==
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<references/>
<references/>


[[Category:OB/GYN]]
==Video==
{{#widget:YouTube|id=dz2gYz4FQcY}}
 
[[Category:OBGYN]]

Revision as of 06:07, 6 March 2019

Background

  • Leading cause of maternal death worldwide

Causes

Clinical Features

  • Loss of >500 mL blood after vaginal delivery
  • Usually within 24 hours of delivery
  • If occurs more than 24 hours after delivery, consider: retained POC, coagulopathy, etc
  • Other pertinent definitions[1]:
    • > 1000 ml after c-section
    • Any blood loss to compromising hemodynamic stability

Differential Diagnosis

3rd Trimester/Postpartum Emergencies

Evaluation

Work-up

  • CBC
  • Coags
  • Type and cross

Evaluation

  • Clinical diagnosis

Management

  • Fluid resuscitation
  • Consider Blood Products for Hemodynamic Instability
  • Early tranexamic acid (TXA) reduces death due to bleeding[2][3]
    • 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[4]
    • No difference between placebo and TXA in adverse events, including thromboembolism
    • All-cause mortality and hysterectomy not reduced with TXA
  • Evaluate placenta for retained products
  • Examine for tears under good lighting and suction
  • Treat underlying cause - 4T's: Tone, Trauma, Tissue, Thrombosis

Tone

Uterine atony (boggy uterus)

  • Bimanual Massage
  • Oxytocin (Pitocin)
    • 1st line and most important drug - Oxytocin 80 units in 500 cc NS bag, run it wide open[5]
    • OR 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
    • OR 10 units IM if no IV
  • 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

Trauma

  • Genital tract tear
    • Suture lacerations - 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
  • 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:[6]:
    • After replacement:
      • Fundal massage ± bimanual massage/compression
      • Then oxytocin infusion with 40 units in 1 L of NS at 200-1000 cc/hr

Tissue

Retained placental tissue

  • Pelvic exam may be normal other than blood
  • Detect with US
  • Manual removal
  • Curettage

Thrombin

Reverse any coagulopathies

  • Labs - platelets, coags, fibrinogen, d-dimer
  • Replace appropriate blood components

Disposition

  • Admit

See Also

References

  1. ↑ 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.
  2. ↑ Ducloy-Bouthors AS et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15(2):R117.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th ed. 2013. Chapter 181: Labor and Delivery and their Complications. 2349.

Video

{{#widget:YouTube|id=dz2gYz4FQcY}}

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