Postpartum hemorrhage

Background

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

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
  • 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:
  • 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
  • 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
  • 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)
    • 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).
  • 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::
  • 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

• Emergent delivery
• Postpartum emergencies

Vaginal bleeding (main)

• Non-pregnant vaginal bleeding
  • Prepubertal vaginal bleeding
• Pregnant
  • Vaginal bleeding in pregnancy (less than 20wks)
  • Vaginal bleeding in pregnancy (greater than 20wks)
  • Postpartum hemorrhage