Postpartum hemorrhage

Background

Causes

• Uterine atony (responsible for 80% of cases)
• Retained placental tissue
• Lower genital tract lacerations
• Uterine rupture
• Uterine inversion
• Underlying coagulation abnormalities

Clinical Features

• Loss of >500 mL blood after vaginal delivery
• Usually within 24 hours of delivery
• If occurs more than 24 hours after delivery, consider: retained POC, coagulopathy, etc

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

Work-up

• CBC
• Coags
• Type and cross

Evaluation

• Clinical diagnosis

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)

1. Bimanual Massage
2. Oxytocin (Pitocin)
   1. 1st line and most important drug - Oxytocin 80 units in 500 cc NS bag, run it wide open
   2. OR 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
   3. OR 10 units IM if no IV
3. Misoprostol (Cytotec) 600mcg SL or 1000 mcg rectally
4. Methylergonovine (Methergine) 0.2mg IM q2-4 hrs (relative contraindication in pts with HTN or Preeclampsia - may consider in severely unstable BP)
5. Carboprost (Hemabate) 250mcg IM q15 min (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

Trauma

• Genital tract tear
  1. Suture lacerations
  2. Drain hematomas >3 cm
• 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. Discontinue uterotonic meds (oxytocin) if uterus not reduced, and consider uterine relaxant options for::
     1. Nitroglycerine IV 50-250 mcg bolus over 1-2 min, then up to x3-4 additional doses q3-5 min to relax uterus
     2. Magnesium 4-6 g IV over 15 min
     3. Terbutaline 0.25 mg IV or SQ
  5. After replacement:
     1. Fundal massage ± bimanual massage/compression
     2. Then oxytocin infusion with 40 units in 1 L of NS at 200-1000 cc/hr

Tissue

Retained placental tissue

1. Pelvic exam may be normal other than blood
2. Detect with US
3. Manual removal
4. Curettage

Thrombin

Reverse any coagulopathies

1. Labs - platelets, coags, fibrinogen, d-dimer
2. Replace appropriate blood components

Disposition

Admit

See Also

• Post-Partum Emergencies
• Vaginal Bleeding (Main)
• Emergent delivery