Postpartum hemorrhage

Background
  • Leading cause of maternal death worldwide

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 [1]
    • 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[2]:
    • Any blood loss to compromising hemodynamic stability

Differential Diagnosis

3rd Trimester/Postpartum Emergencies

Evaluation

Work-up
  • CBC
  • Coags
  • Type and cross

Evaluation
  • Clinical diagnosis

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[3][4]
    • 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[5]
    • 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)

  • Bimanual Massage
  • Oxytocin (Pitocin)
    • 1st line and most important drug - Oxytocin 80 units in 500 cc NS bag, run it wide open[6]
    • OR 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
    • OR 10 units IM if no IV
  • 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

Trauma

Genital tract tear

  • Examine for tears under good lighting and suction
  • Suture lacerations - 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 retained products
  • 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

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:[7]:
    • Nitroglycerine IV 50-250 mcg bolus over 1-2 min, then up to x3-4 additional doses q3-5 min to relax uterus
    • Magnesium 4-6 g IV over 15 min
    • Terbutaline 0.25mg IV or SQ
  • 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

See Also

Vaginal bleeding (main)

References
  1. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage
  2. 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.
  3. Ducloy-Bouthors AS et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15(2):R117.
  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. 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.
  6. 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.
  7. Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th ed. 2013. Chapter 181: Labor and Delivery and their Complications. 2349.

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