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
**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]]
*Uterine atony (responsible for 80% of cases)
*Retained placental tissue
*[[retained products of conception|Retained placental tissue]]
*Lower genital tract lacerations
*Lower genital tract lacerations
*[[Uterine rupture]]
*[[Uterine rupture]]
*Uterine inversion
*Uterine inversion
*Underlying [[coagulopathy|coagulation abnormalities]]
*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}}


==Diagnosis==
==Evaluation==
===Immediate===
*Clinical diagnosis
*Defined as loss of >500 mL blood after spontaneous vaginal [[delivery]]
*Within 24 hrs following delivery


===Delayed===
===Work-up===
*Uterine subinvolution
*Quantitative blood loss (QBL): Volumetric containers (V-drapes) can quantify vaginal blood loss
*von Willebrand disease
*CBC
*Retained placenta
*CMP
*Coags
*Type and cross


==Management==
==Management==
#[[Fluid resuscitation]]
''Treat underlying cause: '''T'''one, '''T'''rauma, '''T'''issue, '''T'''hrombosis''
#Consider Blood Products for Hemodynamic Instability
*Consider [[Fluid resuscitation]] vs [[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
 
===Tone===
===Tone===
''[[Uterine atony]] (boggy uterus)''
''[[Uterine atony]] (boggy uterus)''
#Bimanual Massage
*Assess intravaginally for lower segment atony, which may occur even when the fundus is well-contracted
#[[Oxytocin]] (Pitocin)
*Uterine massage
##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 Pt 1):293-300.</ref>
**External uterine massage stimulates uterine contraction
##OR 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
**Bimanual massage: One fist is placed intravaginally in the anterior fornix. Other hand massages the fundus while compressing against the vaginal hand.
##OR 10 units IM if no IV
*[[Oxytocin]] (Pitocin) '''1st-line and most important drug'''
#[[Misoprostol]] (Cytotec) 600mcg SL or 1000 mcg rectally
**IV options:
#[[Methylergonovine]] (Methergine) 0.2mg IM q2-4 hrs (relative contraindication in pts with HTN or Preeclampsia - may consider in severely unstable BP)
***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>
#[[Carboprost]] (Hemabate) 250mcg IM q15 min (avoid in pts with asthma)
***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>
#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
**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===
===Trauma===
*''Genital tract tear''
''Genital tract tear''
*#Suture [[lacerations]]
*Examine for tears in vaginal, cervical, and perineal areas under good lighting and suction
*#Drain hematomas >3 cm
*Suture [[lacerations]] - simple running or figure of eight with 3-0 or 2-0 absorbable
*''[[Uterine inversion]]''
*Deep lacerations such as those by the cervix may require '''OR'''
*#Manually replace placenta OR do not remove placenta until uterus has been replaced:
*Drain hematomas >3 cm
*#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
===Tissue===
===Tissue===
''Retained placental tissue''
''Retained placental tissue''
#Pelvic exam may be normal other than blood
*Evaluate placenta for pieces that may become retained products
#Detect with US
**Pelvic exam may be normal other than blood
#Manual removal
**Detect with manual exam or US
#Curettage
*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===
===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
 
===[[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==
*[[Post-Partum Emergencies]]
*[[Vaginal Bleeding (Main)]]
*[[Emergent delivery]]
*[[Emergent delivery]]
*[[Postpartum emergencies]]
{{DDX undifferentiated VB}}
==External Links==


==References==
==References==
<references/>
<references/>


[[Category:OB/GYN]]
[[Category:OBGYN]]

Latest revision as of 20:10, 17 April 2024

Background

  • Leading cause of maternal death worldwide
    • Approx 3% to 5% of obstetric patients will experience PPH[1]
    • In the US, 11% of maternal deaths are caused by hemorrhage[2]

Causes

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

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
    • IV options:
      • 20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) [8]
      • 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). [9]
    • 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:[10]:
  • 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)

External Links

References

  1. ↑ Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017 Apr 1;95(7):442-449. PMID: 28409600.
  2. ↑ 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.
  3. ↑ https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage
  4. ↑ 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.
  5. ↑ Ducloy-Bouthors AS et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15(2):R117.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.
  9. ↑ 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.
  10. ↑ Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th ed. 2013. Chapter 181: Labor and Delivery and their Complications. 2349.
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