Postpartum hemorrhage: Difference between revisions
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##[[Uterine atony]]: | ##[[Uterine atony]]: | ||
###Bimanual Massage | ###Bimanual Massage | ||
###Oxytocin (Pitocin) 10 units IM or 20 | ###Oxytocin (Pitocin) 10 units IM or 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension) | ||
###Misoprostol (Cytotec) 600mcg SL | ###Misoprostol (Cytotec) 600mcg SL | ||
###Methylergonovine (Methergine) 0.2mg IM (contraindicated in pts with HTN or Preeclampsia) | ###Methylergonovine (Methergine) 0.2mg IM (contraindicated in pts with HTN or Preeclampsia) |
Revision as of 20:03, 18 February 2015
Background
Causes
- Uterine atony
- Retained placental fragments
- Lower genital tract lacerations
- Uterine rupture
- Uterine inversion
- 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
- Fluid resuscitation
- Consider Blood Products for Hemodynamic Instability
- Treat underlying cause:
- Uterine atony:
- Bimanual Massage
- Oxytocin (Pitocin) 10 units IM or 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
- Misoprostol (Cytotec) 600mcg SL
- Methylergonovine (Methergine) 0.2mg IM (contraindicated in pts with HTN or Preeclampsia)
- Carboprost (Hemabate) 250mcg IV (avoid in pts with HTN or asthma)
- Bakri balloon placement (or substitute with large or multiple Foleys)
- 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
- Consider nitroglycerine IV 50 mcg, then up to x4 additional doses q3-5 min to relax uterus
- After replacement, oxytocin infusion with 40 units in 1 L of NS at 200 ml/hr
- Uterine atony:
Source
Tintinalli