Postpartum hemorrhage: Difference between revisions
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==Background== | ==Background== | ||
*Leading cause of maternal death worldwide | |||
**Approx 3% to 5% of obstetric patients will experience PPH<ref>Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017 Apr 1;95(7):442-449. PMID: 28409600.</ref> | |||
**In the US, 11% of maternal deaths are caused by hemorrhage<ref>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.</ref> | |||
===Causes=== | ===Causes=== | ||
*Uterine atony (responsible for 80% of cases) | |||
*[[retained products of conception|Retained placental tissue]] | |||
*Lower genital tract lacerations | |||
*[[Uterine rupture]] | |||
*Uterine inversion | |||
*Underlying [[coagulopathy|coagulation abnormalities]] | |||
*Abnormal placentation: [[Placenta previa]], [[placenta accreta]] | |||
==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 <ref>https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage</ref> | |||
**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<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>: | |||
**Any blood loss to compromising hemodynamic stability | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Postpartum emergencies DDX}} | {{Postpartum emergencies DDX}} | ||
==Evaluation== | |||
*Clinical diagnosis | |||
===Work-up=== | |||
*Quantitative blood loss (QBL): Volumetric containers (V-drapes) can quantify vaginal blood loss | |||
*CBC | |||
*CMP | |||
*Coags | |||
*Type and cross | |||
==Management== | ==Management== | ||
''Treat underlying cause: '''T'''one, '''T'''rauma, '''T'''issue, '''T'''hrombosis'' | |||
*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> | |||
**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> | |||
**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 | ||
*Anderson JM, Etches D. Prevention and | *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) <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> | |||
**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:<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== | |||
*Admit | |||
*May require OR for any of the above etiologies not responsive to first-line treatments | |||
==See Also== | ==See Also== | ||
*[[ | *[[Emergent delivery]] | ||
*[[ | *[[Postpartum emergencies]] | ||
{{DDX undifferentiated VB}} | |||
==External Links== | |||
==References== | |||
<references/> | |||
[[Category: | [[Category:OBGYN]] |
Latest revision as of 20:10, 17 April 2024
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
- Abnormal placentation: Placenta previa, placenta accreta
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
- 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
- Clinical diagnosis
Work-up
- Quantitative blood loss (QBL): Volumetric containers (V-drapes) can quantify vaginal blood loss
- CBC
- CMP
- Coags
- Type and cross
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
- 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]:
- 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
- May require OR for any of the above etiologies not responsive to first-line treatments
See Also
Vaginal bleeding (main)
- Non-pregnant vaginal bleeding
- Pregnant
External Links
References
- ↑ Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017 Apr 1;95(7):442-449. PMID: 28409600.
- ↑ 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.
- ↑ 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.