Postpartum hemorrhage: Difference between revisions
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#[[Fluid resuscitation]] | #[[Fluid resuscitation]] | ||
#Consider Blood Products for Hemodynamic Instability | #Consider Blood Products for Hemodynamic Instability | ||
#Evaluate placenta for retained products | |||
#Examine for tears under good lighting and suction | |||
#Treat underlying cause - 4T's: | #Treat underlying cause - 4T's: | ||
##'''T'''one - [[Uterine atony]]: | ##'''T'''one - [[Uterine atony]]: | ||
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###Oxytocin (Pitocin) 10 units IM or 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension) | ###Oxytocin (Pitocin) 10 units IM or 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension) | ||
###Misoprostol (Cytotec) 600mcg SL or 1000 mcg rectally | ###Misoprostol (Cytotec) 600mcg SL or 1000 mcg rectally | ||
###Methylergonovine (Methergine) 0.2mg IM ( | ###Methylergonovine (Methergine) 0.2mg IM (relative contraindication in pts with HTN or Preeclampsia - may consider in severely unstable BP) | ||
###Carboprost (Hemabate) 250mcg IV (avoid in pts with HTN or asthma) | ###Carboprost (Hemabate) 250mcg IV (avoid in pts with HTN or asthma) | ||
###Bakri balloon placement (or | ###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 | ||
##'''T'''rauma | ##'''T'''rauma | ||
###Genital tract tear - suture lacs, drain hematomas > 3 cm | ###Genital tract tear - suture lacs, drain hematomas > 3 cm | ||
| Line 34: | Line 36: | ||
###Curettage | ###Curettage | ||
###Methotrexate | ###Methotrexate | ||
##'''T'''hrombin - | ##'''T'''hrombin - coagulopathy | ||
### | ###Labs - platelets, coags, fibrinogen, d-dimer | ||
###Replace appropriate blood components | |||
==Source== | ==Source== | ||
Revision as of 22:02, 18 February 2015
Background
Causes
- Uterine atony
- Retained placental fragments
- Lower genital tract lacerations
- Uterine rupture
- Uterine inversion
- Hereditary coagulopathy
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
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 - Uterine atony:
- Bimanual Massage
- Oxytocin (Pitocin) 10 units IM or 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
- Misoprostol (Cytotec) 600mcg SL or 1000 mcg rectally
- Methylergonovine (Methergine) 0.2mg IM (relative contraindication in pts with HTN or Preeclampsia - may consider in severely unstable BP)
- Carboprost (Hemabate) 250mcg IV (avoid in pts with HTN or 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 lacs, 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 - placenta retained
- Manual removal
- Curettage
- Methotrexate
- Thrombin - coagulopathy
- Labs - platelets, coags, fibrinogen, d-dimer
- Replace appropriate blood components
- Tone - Uterine atony:
Source
Tintinalli