Postpartum hemorrhage

Background

• Uterine atony is responsible for 80% of postpartum hemorrhage cases

Causes

• Uterine atony
• Retained placental tissue
• Lower genital tract lacerations
• Uterine rupture
• Uterine inversion
• Underlying coagulation abnormalities

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

1. Fluid resuscitation
2. Consider Blood Products for Hemodynamic Instability
3. Evaluate placenta for retained products
4. Examine for tears under good lighting and suction
5. Treat underlying cause - 4T's: Tone, Trauma, Tissue, Thrombosis

Tone

Uterine atony (boggy uterus)

1. Bimanual Massage
2. Oxytocin (Pitocin)
   1. 1st line and most important drug - Oxytocin 80 units in 500 cc NS bag, run it wide open
   2. OR 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
   3. OR 10 units IM if no IV
3. Misoprostol (Cytotec) 600mcg SL or 1000 mcg rectally
4. Methylergonovine (Methergine) 0.2mg IM q2-4 hrs (relative contraindication in pts with HTN or Preeclampsia - may consider in severely unstable BP)
5. Carboprost (Hemabate) 250mcg IM q15 min (avoid in pts with asthma)
6. 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
  1. Suture lacerations
  2. Drain hematomas >3 cm
• Uterine inversion
  1. Manually replace placenta OR do not remove placenta until uterus has been replaced:
  2. Place hand inside the vagina and push the fundus cephalad along long axis of vagina
  3. Prompt replacement important since cervix contracts over time creating a constriction ring
  4. Consider nitroglycerine IV 50 mcg, then up to x4 additional doses q3-5 min to relax uterus
  5. After replacement, oxytocin infusion with 40 units in 1 L of NS at 200 ml/hr

Tissue

Retained placental tissue

1. Pelvic exam may be normal other than blood
2. Detect with US
3. Manual removal
4. Curettage

Thrombin

Reverse any coagulopathies

1. Labs - platelets, coags, fibrinogen, d-dimer
2. Replace appropriate blood components

See Also

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