Postpartum hemorrhage: Difference between revisions
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==Management== | ==Management== | ||
''Treat underlying cause: '''T'''one, '''T'''rauma, '''T'''issue, '''T'''hrombosis'' | ''Treat underlying cause: '''T'''one, '''T'''rauma, '''T'''issue, '''T'''hrombosis'' | ||
*[[Fluid resuscitation]] | *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 | ||
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**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 | ||
===Tone=== | ===Tone=== | ||
''[[Uterine atony]] (boggy uterus)'' | ''[[Uterine atony]] (boggy uterus)'' | ||
*Bimanual Massage | *Bimanual Massage | ||
*[[Oxytocin]] (Pitocin) | *[[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> | ||
*[[Misoprostol]] (Cytotec) 600mcg SL or 1000 mcg rectally | **IM option (if no IV): | ||
*[[Methylergonovine]] (Methergine) 0.2mg IM q2-4 hrs | ***10 IU IM x 1 | ||
*[[Carboprost]] (Hemabate) 250mcg IM q15 min (avoid in patients with asthma) | *[[Misoprostol]] (Cytotec) | ||
*Bakri balloon placement | **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 [[lacerations]] - figure of eight with 3-0 or 2-0 absorbable | *Examine for tears under good lighting and suction | ||
*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 | |||
===Tissue=== | ===Tissue=== | ||
''Retained placental tissue'' | ''Retained placental tissue'' | ||
*Evaluate placenta for retained products | |||
*Pelvic exam may be normal other than blood | *Pelvic exam may be normal other than blood | ||
*Detect with US | *Detect with US | ||
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===[[Uterine inversion]]=== | ===[[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== | ==Disposition== | ||
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{{DDX undifferentiated VB}} | {{DDX undifferentiated VB}} | ||
==External Links== | |||
==References== | ==References== |
Revision as of 19:59, 22 September 2021
Background
- Leading cause of maternal death worldwide
Causes
- Uterine atony (responsible for 80% of cases)
- Retained placental tissue
- Lower genital tract lacerations
- Uterine rupture
- Uterine inversion
- Underlying coagulation abnormalities
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 [1]
- 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[2]:
- Any blood loss to compromising hemodynamic stability
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
Evaluation
Work-up
- CBC
- Coags
- Type and cross
Evaluation
- 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[3][4]
- 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[5]
- 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)
- Bimanual Massage
- Oxytocin (Pitocin) 1st-line and most important drug
- 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
- Examine for tears under good lighting and suction
- 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
Tissue
Retained placental tissue
- Evaluate placenta for retained products
- 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
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:[8]:
- 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
See Also
Vaginal bleeding (main)
- Non-pregnant vaginal bleeding
- Pregnant
External Links
References
- ↑ https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage
- ↑ 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.
- ↑ Ducloy-Bouthors AS et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15(2):R117.
- ↑ 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.
- ↑ 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.
- ↑ Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.
- ↑ 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.
- ↑ Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th ed. 2013. Chapter 181: Labor and Delivery and their Complications. 2349.
Video
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