Postpartum hemorrhage: Difference between revisions
| Line 28: | Line 28: | ||
#Treat underlying cause - 4T's: '''Tone, Trauma, Tissue, Thrombosis''' | #Treat underlying cause - 4T's: '''Tone, Trauma, Tissue, Thrombosis''' | ||
===Tone=== | ===Tone=== | ||
[[Uterine atony]] (boggy uterus) | ''[[Uterine atony]] (boggy uterus)'' | ||
#Bimanual Massage | #Bimanual Massage | ||
#[[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) | ||
| Line 36: | Line 36: | ||
#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 | #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=== | ===Trauma=== | ||
*''Genital tract tear'' | |||
*#Suture [[lacerations]] | |||
# | *#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=== | ===Tissue=== | ||
Retained placental tissue | ''Retained placental tissue'' | ||
# | #Pelvic exam may be normal other than blood | ||
# | #Detect with US | ||
# | #Manual removal | ||
# | #Curettage | ||
===Thrombin=== | ===Thrombin=== | ||
Reverse any coagulopathies | ''Reverse any coagulopathies'' | ||
# | #Labs - platelets, coags, fibrinogen, d-dimer | ||
# | #Replace appropriate blood components | ||
==See Also== | ==See Also== | ||
Revision as of 03:12, 13 July 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
- Immediate PPH within 24 hrs following delivery
- Delayed PPH etiologies
- Uterine subinvolution
- von Willebrand disease
- Retained placenta
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, Trauma, Tissue, Thrombosis
Tone
Uterine atony (boggy uterus)
- 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 lacerations
- 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
Retained placental tissue
- Pelvic exam may be normal other than blood
- Detect with US
- Manual removal
- Curettage
Thrombin
Reverse any coagulopathies
- Labs - platelets, coags, fibrinogen, d-dimer
- Replace appropriate blood components