Pocket ObGyn – Postpartum Hemorrhage (PPH)
See Abbreviations
Definition and Epidemiology (Obstet Gynecol 2006;108:1039)
- Bld loss >500 cc w/ a vaginal deliv or >1000 cc w/ a CD (total EBL)
- Common, w/ incid 2–3% of all births in the United States (Am J Obstet Gynecol 2010;202:353). Clinically, excessive bld loss causing symptomatic anemia (palps, SOB, lightheadedness) &/or signs of hypovolemia (tachy, HoTN, hypoxemia)
- Major cause of mat mortality (Cochrane Database Syst Rev 2007;1:CD003249). Risk of death
1:1000 births in developing countries & 1:100,000 births in developed countries.
- Primary (Early) PPH: W/i 24 h of deliv, caused by uterine atony, genital tract lacerations, bladder or urethral lacerations, retained products of conception, invasive placentation (eg, accreta), uterine rupture or inversion, coagulopathy
- Secondary (Late) PPH: From 24 h–12 w after deliv, caused by infxn, retained products of conception, placental site subinvolution, coagulopathy
Etiology
Uterine atony (most common cause) from: Distended uterus (multi gest, polyhydramnios); impaired uterine contractility (tocolytic meds or anesthetics, prolonged use
of meds for labor induction) (Am J Obstet Gynecol 2011;204:56); intraamniotic infxn (chorio); distended bladder (prevents lower uterine segment contraction)
- Trauma: Genital tract laceration (vaginal or cervical); surgical injury
- Retained placental tissue (normally or abnormally implanted)
- Coagulopathy: Consumptive coagulopathy from ongoing hemorrhage; HELLP syn; sev preeclampsia; amniotic fluid embolism (w/ DIC); sepsis; fetal demise
- Bleeding may not be apparent if intraor retroperitoneal bleed, or if genital tract hematoma
Physical Exam
- Bimanual exam to assess for atony or retained placental Consider bedside US to evaluate for retained placental tissue.
- Thorough inspection of the genital tract for laceration or hematoma
- Tachy & HoTN seen when bld loss approaches 1500–2000 cc
Diagnostic Workup/Studies
- Identify origin of bleeding:
Visualize cervix & vagina to evaluate for lacerations Bimanual uterine massage to assess for uterine atony Bedside US to view poss retained products
Manual evacuation of uterine cavity for poss extraction of retained products Place Foley catheter (distended bladder may contribute to poor uterine tone)
- Labs: Bld type & cross, CBC, PT/INR, PTT, 5 mL of bld in red top tube at bedside ® clot in 8–10 min if fibrinogen >150 mg/dL.
- Immediately begin treating for the suspected origin of hemorrhage (eg, for uterine atony administer uterotonics, perform bimanual uterine massage)
Medical Therapies for PPH
- Oxytocin (Pitocin) Routine use during the 3rd stage of labor significantly reduces the incid of PPH (Cochrane Database Syst Rev 2001;(4):CD001808). Can bolus for PPH, though some risk for Onset of action: ~1 min (IV), 3–5 min (IM).
- Misoprostol May cause fever, chills/shivering, GI Onset of action: 100 min (PR) (vs. 8 min PO, 11 min SL, 20 min PV)
- Methylergonovine Onset of action: 2–5 min (IM).
- Carboprost tromethamine (Hemabate) May cause bronchospasm in May rpt q15–90 min as needed, w/ max cumulative dose 2 mg. Onset of action: 15–30 min (IM).
| Medical intervention for postpartum hemorrhage | |||||
|
Agent |
Dose |
Route |
Dosing
frequency |
Side effects |
Contraindications |
| Oxytocin (Pitocin)* | 20–40 U
in 1 L crystalloid or 10U IM |
IV+ IM/IU | Continuous | N/V, emesis, water intoxication | None |
| Misoprostol (Cytotec) | 600–1000 ug | PR+ PO | Single dose | N/V, diarrhea, fever, chills | None |
| Methylergonovine (Methergine) | 0.2 mg | IM+ IU | Every 2–4 h | HTN, HoTN,
N/V |
HTN, preeclampsia |
| Prostaglandin F2a (Hemabate) | 0.25 mg | IM+ IU | Every 15–90 min
(8 dose max) |
N/V, diarrhea, flushing, chills | Active cardiac, pulm, renal, or hepatic dz |
| Prostaglandin E2 (Dinoprostone) | 20 mg | PR | Every 2 h | N/V, diarrhea, fever, chills, HA | HoTN |
| *1st line; + preferred route. | |||||
Procedural Therapies for PPH
- Uterine massage for atony (external, bimanual)
- Manual extraction of placenta
- D&C/ Suction curettage of the uterus for retained placenta
- Uterine tamponade: Balloon catheter placement (Foley or Bakri balloon, or lap packing) for tamponade, esp lower uterine segment atony
- Uterine compression sutures (eg, B-Lynch) or mattress sutures
- Uterine artery embolization (interv radiol)
- Exploratory laparotomy
Compression sutures: B-Lynch, Hayman, Pereira (physically uterine tone)
Vessel ligation: Uterine arteries (O’Leary sutures), hypogastric arteries (¯ perfusion)
- Hysterectomy (definitive therapy)
Figure 11.3 Management of uterine atony with bimanual massage
(Reprinted with permission from Beckmann CRB, Ling FW, Smith RP et al. Obstetrics & Gynecology. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009)
Figure 11.4 Initial surgical management of uterine atony.
| O’Leary Uterine artery ligation
Ligature Ureter Uterine artery
“B-Lynch” Compression Suture
Suture placement on posterior wall of uterus
Uterine incision for cesarean delivery
Start Finish
Tie |
(Reprinted with permission from Beckmann CRB, Ling FW, Smith RP, et al. Obstetrics & Gynecology. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009)
| Example postpartum hemorrhage protocol | ||
| Assessments | Meds/Procedures | Blood bank |
| Routine measures | ||
| Assess for risk for PPH Quantify EBL routinely | Oxytocin IM or IV Fundal massage | Type & screen or crossmatch |
| Bld loss: >500 mL vaginal or >1000 mL cesarean or
VS changes (by >15% or HR >110, BP <85/45, O2 sat <95%) |
||
| Notify nursing & anesthesia
Continuous VS & calculation of EBL Bimanual & visual exam of genital tract, placenta, & (if intra-op) uterus, strict I/Os |
Notify anesthesia team. Ensure adequate IV access.
oxytocin rate. Fluid resusc. Continue bimanual uterine massage Methergine 0.2 mg IM if not hypertensive. May rpt if good resp, otherwise use another uterotonic. Empty bladder, place Foley |
Crossmatch 2 units of pRBCs if not already done. Request FFP when requesting 3rd unit pRBC. |
| Continued bleeding w/ total bld loss under 1500 mL | ||
| Mobilize 2nd obstetrician, rapid resp team (per hospital)
Continue q510min VS, EBL Reexamine uterus, genital tract for bleeding source Send labs, including coagulation panel Consider uterine inversion, amniotic fluid embolism |
Hemabate 0.25 mg IM &/or Misoprostol 800–1000
mcg PR 2nd IV access Vaginal birth Move to OR Repair lacerations Consider D&C for retained placenta Place intrauterine balloon for tamponade Consult interventional radiology for selective embolization Cesarean birth Inspect broad ligament, post uterus, retained placenta B-Lynch suture Place intrauterine balloon for tamponade |
Notify bld bank of OB hemorrhage
2 units RBCs to bedside, transfuse for clinical signs & anticipated loss (not lab values) Use bld warmer for xfusion Consider thawing 2 units FFP, use if transfusing >2 units RBCs at 1:1 Determine availability of additional RBCs & other bld products |
| Bld loss over 1500 mL, or >2 units pRBCs given or VS unstable or suspicion of DIC | ||
| Prepare for postpartum hysterectomy. Call 2nd anesthesia provider, OR staff
Rpt labs including coags/ ABG Consider central line Social worker/family support – Keep family updated |
Activate massive hemorrhage protocol
B-Lynch suture Uterine artery ligation Hysterectomy Fluid warmer Upper body warming device Sequential compression devices |
Transfuse aggressively Near 1:1 pRBC:FFP
1 platelet pack per 6 units pRBCs & as needed If coagulopathy unresponsive after 10 units pRBCs & coagulation factor replacement, consider rFactorVIIa |
| From The California Maternal Quality Care Collaborative, Obstetric Hemorrhage Care Summary 2010. | ||