Postpartum hemorrhage: Difference between revisions
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==Background== | ==Background== | ||
===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== | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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#Examine for tears under good lighting and suction | #Examine for tears under good lighting and suction | ||
#Treat underlying cause - 4T's: '''Tone, Trauma, Tissue, Thrombosis''' | #Treat underlying cause - 4T's: '''Tone, Trauma, Tissue, Thrombosis''' | ||
===Tone=== | ===Tone=== | ||
''[[Uterine atony]] (boggy uterus)'' | ''[[Uterine atony]] (boggy uterus)'' | ||
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*#Consider nitroglycerine IV 50 mcg, then up to x4 additional doses q3-5 min to relax uterus | *#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 | *#After replacement, oxytocin infusion with 40 units in 1 L of NS at 200 ml/hr | ||
===Tissue=== | ===Tissue=== | ||
''Retained placental tissue'' | ''Retained placental tissue'' | ||
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#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 | ||
==Disposition== | |||
Admit | |||
==See Also== | ==See Also== | ||
Revision as of 04:41, 9 August 2015
Background
Causes
- Uterine atony (responsible for 80% of cases)
- Retained placental tissue
- Lower genital tract lacerations
- Uterine rupture
- Uterine inversion
- Underlying coagulation abnormalities
Clinical Features
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
Diagnosis
Immediate
- Defined as loss of >500 mL blood after spontaneous vaginal delivery
- Within 24 hrs following delivery
Delayed
- Uterine subinvolution
- von Willebrand disease
- Retained placenta
Management
- Fluid resuscitation
- Consider Blood Products for Hemodynamic Instability
- 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[1]
- 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 pts with HTN or Preeclampsia - may consider in severely unstable BP)
- Carboprost (Hemabate) 250mcg IM q15 min (avoid in pts with asthma)
- 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
Trauma
- Genital tract tear
- Suture lacerations
- 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
- 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
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
- ↑ 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.