Postpartum hemorrhage

Background

Causes

1. Uterine atony
2. Retained placental fragments
3. Lower genital tract lacerations
4. Uterine rupture
5. Uterine inversion
6. 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

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:
   1. Tone - Uterine atony:
      1. Bimanual Massage
      2. Oxytocin (Pitocin) 10 units IM or 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
      3. Misoprostol (Cytotec) 600mcg SL or 1000 mcg rectally
      4. Methylergonovine (Methergine) 0.2mg IM (relative contraindication in pts with HTN or Preeclampsia - may consider in severely unstable BP)
      5. Carboprost (Hemabate) 250mcg IV (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
   2. Trauma
      1. Genital tract tear - suture lacs, drain hematomas > 3 cm
      2. 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
   3. Tissue - placenta retained
      1. Manual removal
      2. Curettage
      3. Methotrexate
   4. Thrombin - coagulopathy
      1. Labs - platelets, coags, fibrinogen, d-dimer
      2. Replace appropriate blood components

Source

• Tintinalli
• UpToDate
• Anderson JM, Etches D. Prevention and Management of Postpartum Hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-882.

See Also

• Post-Partum Emergencies
• Vaginal Bleeding (Main)