Postpartum hemorrhage: Difference between revisions
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#Examine for tears under good lighting and suction | #Examine for tears under good lighting and suction | ||
#Treat underlying cause - 4T's: | #Treat underlying cause - 4T's: | ||
# | #*'''T'''one - [[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 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 | ||
# | #*'''T'''rauma | ||
# | #**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 | ||
# | #*'''T'''issue - placenta retained | ||
# | #**Manual removal | ||
# | #**Curettage | ||
# | #**Methotrexate | ||
# | #*'''T'''hrombin - coagulopathy | ||
# | #**Labs - platelets, coags, fibrinogen, d-dimer | ||
# | #**Replace appropriate blood components | ||
==See Also== | ==See Also== | ||
| Line 54: | Line 49: | ||
*[[Vaginal Bleeding (Main)]] | *[[Vaginal Bleeding (Main)]] | ||
==Sources== | |||
*Tintinalli | |||
*UpToDate | |||
*Anderson JM, Etches D. Prevention and Management of Postpartum Hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-882. | |||
[[Category:OB/GYN]] | [[Category:OB/GYN]] | ||
Revision as of 15:55, 25 March 2015
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
- Defined as loss of >500 mL blood after SVD
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 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 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:
See Also
Sources
- Tintinalli
- UpToDate
- Anderson JM, Etches D. Prevention and Management of Postpartum Hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-882.