Postpartum hemorrhage

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

• Loss of >500 mL blood after vaginal delivery
• Usually within 24 hours of delivery
• If occurs more than 24 hours after delivery, consider: retained POC, coagulopathy, etc

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

Work-up

• CBC
• Coags
• Type and cross

Evaluation

• Clinical diagnosis

Management

• Fluid resuscitation
• Consider Blood Products for Hemodynamic Instability
• Consider tranexamic acid (TXA) to reduce blood loss and hysterectomy
  • For refractory atonic or traumatic bleed
  • WOMAN trial underway - 1 g IV of TXA, with 2nd dose 30 min later if continual bleed OR bleed restarts within 24 hrs after 1st dose
  • Weigh risks and benefits, as pregnant females are hypercoagulable
• 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
  • 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 - 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
• 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::
    • 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 0.25 mg 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

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

• Post-Partum Emergencies
• Vaginal Bleeding (Main)
• Emergent delivery

Video

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