Postpartum hemorrhage

Background

  • Leading cause of maternal death worldwide
    • Approx 3% to 5% of obstetric patients will experience PPH[1]
    • In the US, 11% of maternal deaths are caused by hemorrhage[2]

Causes

Clinical Features

  • Loss of ≥1000mL blood in first 24hrs and up to 12wks postpartum with either vaginal delivery or c-section, or bleeding associated with signs/symptoms of hypovolemia within 24 hours of birth [3]
    • However, ≥500mL of blood loss after vaginal delivery is abnormal and warrants further investigation
  • Usually within 24 hours of delivery
  • If occurs more than 24 hours after delivery, consider: retained POC, coagulopathy, etc
  • Other pertinent definitions[4]:
    • Any blood loss to compromising hemodynamic stability

Differential Diagnosis

3rd Trimester/Postpartum Emergencies

Evaluation

  • Clinical diagnosis

Work-up

  • Quantitative blood loss (QBL): Volumetric containers (V-drapes) can quantify vaginal blood loss
  • CBC
  • CMP
  • Coags
  • Type and cross

Management

Treat underlying cause: Tone, Trauma, Tissue, Thrombosis

  • Consider Fluid resuscitation vs blood products for hemodynamic instability
  • Early tranexamic acid (TXA) reduces death due to bleeding[5][6]
    • Give as soon as possible relative to bleeding onset
    • 1 g IV of TXA over 10 min, with 2nd dose 30 min later if continual bleed OR bleed restarts within 24 hrs after 1st dose[7]
    • No difference between placebo and TXA in adverse events, including thromboembolism
    • All-cause mortality and hysterectomy not reduced with TXA

Tone

Uterine atony (boggy uterus)

  • Assess intravaginally for lower segment atony, which may occur even when the fundus is well-contracted
  • Uterine massage
    • External uterine massage stimulates uterine contraction
    • Bimanual massage: One fist is placed intravaginally in the anterior fornix. Other hand massages the fundus while compressing against the vaginal hand.
  • Oxytocin (Pitocin) 1st-line and most important drug
    • IV options:
      • 20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) [8]
      • 80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). [9]
    • IM option (if no IV):
      • 10 IU IM x 1
  • Misoprostol (Cytotec)
    • 600mcg SL or 1000 mcg rectally
  • Methylergonovine (Methergine)
    • 0.2mg IM q2-4 hrs
    • Relative contraindication in patients with hypertension or Preeclampsia; may consider in severely unstable BP
  • Carboprost (Hemabate)
    • 250mcg IM q15 min (avoid in patients with asthma)
  • Bakri balloon placement
    • Fill with warm 500ml NS (or large/multiple Foleys or pack)
    • Use US to place to top of fundus and ensure no retained placenta
  • Uterine/vaginal packing
    • Kerlix packing may be utilized when balloon is not available, but can result in increased rates of iatrogenic foreign body and infection
  • Uterine artery embolization
    • May be considered in a stable patient, if bleeding persists

Trauma

Genital tract tear

  • Examine for tears in vaginal, cervical, and perineal areas under good lighting and suction
  • Suture lacerations - simple running or figure of eight with 3-0 or 2-0 absorbable
  • Deep lacerations such as those by the cervix may require OR
  • Drain hematomas >3 cm

Tissue

Retained placental tissue

  • Evaluate placenta for pieces that may become retained products
    • Pelvic exam may be normal other than blood
    • Detect with manual exam or US
  • Manual removal
    • Adequate anesthesia and uterine relaxants may be needed (if no atony noted)
    • Manual exploration of uterine cavity with sterile gloves, removal of placental fragments
  • Curettage

Thrombin

Reverse any coagulopathies

  • Labs - platelets, coags, fibrinogen, d-dimer
  • Replace appropriate blood components

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
  • Discontinue uterotonic meds (oxytocin) if uterus not reduced, and consider uterine relaxant options:[10]:
  • After replacement:
    • Fundal massage ± bimanual massage/compression
    • Then oxytocin infusion with 40 units in 1 L of NS at 200-1000 cc/hr

Disposition

  • Admit
  • May require OR for any of the above etiologies not responsive to first-line treatments

See Also

Vaginal bleeding (main)

External Links

References

  1. Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017 Apr 1;95(7):442-449. PMID: 28409600.
  2. Bienstock JL, Eke AC, Hueppchen NA. Postpartum Hemorrhage. N Engl J Med. 2021 Apr 29;384(17):1635-1645. doi: 10.1056/NEJMra1513247. PMID: 33913640; PMCID: PMC10181876.
  3. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage
  4. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 Apr 26. pii: S0140-6736(17)30638-4.
  5. Ducloy-Bouthors AS et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15(2):R117.
  6. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 Apr 26. pii: S0140-6736(17)30638-4.
  7. Shakur H et al. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010 Apr 16;11:40.
  8. Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.
  9. Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.
  10. Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th ed. 2013. Chapter 181: Labor and Delivery and their Complications. 2349.

Video

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