Postpartum hemorrhage: Difference between revisions
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#**Labs - platelets, coags, fibrinogen, d-dimer | #**Labs - platelets, coags, fibrinogen, d-dimer | ||
#**Replace appropriate blood components | #**Replace appropriate blood components | ||
==Medications== | |||
===Oxytocin (Pitocin)=== | |||
*First line therapy | |||
*10 international units (IU) can be injected intramuscularly OR<ref>Soriano D et al. A prospective cohort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage. Br J Obstet Gynaecol. 1996;103:1068–73.</ref> | |||
*20 IU in 1 L of saline may be infused at a rate of 250 mL per hour | |||
**500 mL can be infused over 10 minutes without complications. | |||
===Misoprostol (Cytotec)=== | |||
*Second Line therapy and can be administered sublingually, orally, vaginally, and rectally.<ref>Mousa HA, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2003;(1):CD003249.</ref> | |||
*1,000 mcg administered rectally | |||
*800 mcg PO | |||
==See Also== | ==See Also== | ||
Revision as of 21:58, 17 April 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:
Medications
Oxytocin (Pitocin)
- First line therapy
- 10 international units (IU) can be injected intramuscularly OR[1]
- 20 IU in 1 L of saline may be infused at a rate of 250 mL per hour
- 500 mL can be infused over 10 minutes without complications.
Misoprostol (Cytotec)
- Second Line therapy and can be administered sublingually, orally, vaginally, and rectally.[2]
- 1,000 mcg administered rectally
- 800 mcg PO
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.
- ↑ Soriano D et al. A prospective cohort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage. Br J Obstet Gynaecol. 1996;103:1068–73.
- ↑ Mousa HA, Alfirevic Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2003;(1):CD003249.