Postpartum Hemorrhage (TINTINALI)

Postpartum hemorrhage is the most common cause of maternal mortality worldwide and remains among the top three causes of maternal mortality in the U.S. and industrial nations, after thromboembolism and hypertension.44 There are 1.4 deaths per 100,000 live births due to hemorrhage. The risk of hemorrhage and death is much higher in black women and other nonwhite women than in white women.45Postpartum hemorrhage usually occurs within the first 24 hours of delivery and is referred to as primary postpartum hemorrhage. Secondary postpartum hemorrhage occurs after the first 24 hours and up to 6 weeks postpartum. The main causes of primary postpartum hemorrhage are uterine atony, retained placental fragments, lower genital tract lacerations, uterine rupture, uterine inversion, and hereditary coagulopathy.Excessive blood loss in the postpartum period is defined as a 10% drop in the hematocrit, a need for transfusion of packed red blood cells, or volume loss that causes symptoms of hypovolemia. Normally, plasma volume increases by 40% and red blood cell volume by 25% at the end of the third trimester. The hematologic changes of pregnancy can mask the typical symptoms of hemorrhage. A high clinical suspicion for postpartum hemorrhage is important to avoid significant morbidity. Patients may initially present with only a mild increase in pulse rate. Up to a 30% loss in total blood volume may be required before a significant change in blood pressure occurs.Initial treatment of postpartum hemorrhage should focus on aggressive fluid resuscitation and identification and treatment of the underlying cause. Severe hemorrhage may require transfusion of blood products. The clinician should examine the state of contractility of the uterus and apply bimanual compression, if needed. A thorough examination looking for signs of laceration or retained products or any other cause requiring specific treatment should be performed. US is important to identify retained products. Genital tract lesions should be repaired. Pharmacologic treatment of postpartum hemorrhage focuses on promoting uterine contraction and correcting coagulopathies and is outlined in Table 104-11.Table 104-11 Pharmacologic Treatment of Postpartum Hemorrhage

DrugComments

Oxytocin, 10 milligrams IM or slow IV pushFirst-line treatment

Uterotonic agent

Rapid administration may cause hypotension

Methylergonovine, 0.2 milligram IM Ergot

Contraindicated in patients with hypertension or preeclampsia

Misoprostol, 600 micrograms SL47Prostaglandin

Side effects: nausea, vomiting, diarrhea

Carboprost, 250 micrograms IV47Prostaglandin

Side effects: nausea, vomiting, diarrhea, hypertension, bronchospasm

Avoid in patients with hypertension or asthma

A trial of recombinant activated factor VII may be considered if other pharmacologic therapy fails. Recombinant activated factor VII has been successfully used to control hemorrhage in both hemophiliacs and non hemophiliacs, presumably by increasing the levels of thrombin and therefore aid in hemostasis. Currently, recombinant activated Factor VII is used on a case-by-case basis, and further studies are necessary to determine its role in managing postpartum hemorrhage.46Other Considerations in Postpartum HemorrhageUterine atony can occur from overdistention of the uterus due to fetal macrosomia, polyhydramnios, or multifetal gestation. Patients may require large doses of oxytocin and fluid resuscitation. Uterine inversion, which occurs in 1 in 2000 deliveries due to overzealous attempts to remove the placenta, requires immediate manual replacement of the placenta. This is a very painful and difficult procedure that may require general anesthesia and uterine relaxation agents. Retention of placental fragments and abnormal placental implantation may also lead to severe hemorrhage and may require emergency peripartum hysterectomy.47

POSTPARTUM HEMORRHAGE (practice guideline gery morgan)I. Third Stage HemorrhageA. Definition. Third stage hemorrhage is defined as blood loss of 500 ml or more between the time the baby is delivered and the time the placenta is delivered.B. Etiology. Partial separation of the placentaC. Management1. Prevent by managing third stage properly.a. Do not massage the uterus during third stage.P.270b. Do not pull the placenta. Allow physiologic separation, which may take up to 30 minutes.2. If third stage hemorrhage occurs:a. Thoroughly massage the uterus to contract and complete placental separation, while applying mild cord traction to effect delivery (Brandt-Andrews maneuver).b. Instruct assistant to start IV or insure patency if already in place. (Ringer's lactate is best.)c. If there is difficulty delivering the placenta and/or hemorrhage continues, have assistant call for physician immediately.d. If physician has not yet arrived and hemorrhage continues, perform manual removal of the placenta. If time and conditions permit, have epidural re-dosed or give patient 2 mg Stadol or Demerol 50 mg IV before manual removal is attempted.e. If the placenta is out but bleeding continues, explore the uterus for retained placenta fragments (premedicate if time allows) and perform bimanual compression.(1) Order 10 to 20 units Pitocin to current IV if not already given.(2) If not improving, see Fourth Stage Hemorrhage Management guidelines below.f. If signs and symptoms of shock develop:(1) Infuse Ringer's lactate solution (RL) rapidly.(2) Place patient flat with legs slightly elevated.(3) Give oxygen per mask.(4) Keep patient warm, cover with warm blankets.(5) Continue monitoring vital signs.II. Fourth Stage HemorrhageA. Definition. Fourth stage hemorrhage is defined as blood loss of 500 ml (some references use 650 ml) or more between the time the placenta is delivered and 24 hours after.B. Etiology1. Uterine atony due to:a. Primary atonyb. Overdistended uterus(1) Multiple gestation(2) Large baby(3) Polyhydramniosc. Exhaustion of uterine muscle(1) Multiparity(2) Prolonged labor(3) Use of oxytocin in labord. Inability of the uterus to contract properly:P.271(1) Precipitous labor, delivery, or both(2) Uterine myomas(3) Full bladder2. Trauma and lacerationsa. Episiotomy. Blood loss can reach 200 cc normally. When arterioles or large veins are cut or torn, the amount of blood loss can be considerably more.b. Lacerations of the vulva, vagina, or cervixc. Ruptured uterus, possibly from a previous cesarean scard. Uterine inversione. Puerperal hematomas3. Retained placental fragments or clotsC. Management1. Preventive techniquesa. Clamp bleeding vessels immediately to conserve blood.b. Avoid an episiotomy if possible. If an episiotomy is necessary, avoid a prolonged interval between performance of episiotomy and delivery of the baby.c. Avoid undue delay from birth of the baby to repair of episiotomy or lacerations.d. Routinely inspect upper vaginal vault and cervix.e. Start repair above apex to avoid failure to secure a bleeding vessel there.f. Routinely inspect placenta for missing parts and broken vessels. Be aware of trailing membranes at time of delivery of the placenta. Remove them slowly.g. If there is reason to believe placental fragments are retained, medicate as necessary, manually explore uterus, inform physician as necessary.h. Give 10 mg of Pitocin in current IV or 200 mg of Cytotec orally to aid with uterine contractions.2. Consult with physician if:a. Physician was not notified during the emergencyb. Bleeding persists or returnsc. Symptoms of hypovolemia, such as dizziness, faintness, tachycardia, are unrelieved with hydration.d. There is a significant drop in the hematocrit3. If there is a significant drop in hematocrit, start patient on iron supplements and educate regarding dietary sources of iron and folic acid.4. Prophylactic antibodies should be given if the uterus was explored.5. Be alert for signs of postpartum infection.6. Blood or blood products should never be given except as a last resort and after consulting.P.272III. Late Postpartum HemorrhageA. Definition. Blood loss of 500 ml or more after the first 24 hours of delivery and within six weeks.B. Etiology1. Retained fragments of placenta; infection usually follows.2. Subinvolution of the uterus and placental site3. Uterine myoma, especially when submucosal4. Hematoma or reproductive tract laceration5. Idiopathic, tendency to recurrence6. Late detachment of thrombi at the placental site with reopening of the vascular sinuses7. Abnormalities in the separation of the decidua vera8. Intrauterine infection, leading to dissolution of the thrombosis in the vesselsC. Clinical Signs1. The first clinical sign is a rapid pulse. A blood pressure drop will follow later.2. She will feel week, cold and may have a headache.3. Going through four maxi pads in two hours or passing clots that total the size of a lemon every hour times two is considered excessive.4. Orthostatic hypotension: When placed in a sitting or standing position, patient gets lightheaded, dizzy and my pass out.D. Management1. Usual treatmenta. Oxytocics(1) Methergine 0.2 mg orally every four hours for six doses. Back with a pain medication for cramping.(2) May need to be admitted to hospital for D&C if presently hemorrhaging.b. Antibiotics if infection exists2. Immediate managementa. Support the lower uterine segment and express clots.b. Check the consistency of the uterus.(1) If atonic, massage it.(2) If no response, do bimanual compression.(3) Give oxytocics and/or ergots listed here in order of preference:(a) Pitocin 10 to 20 units to 1000 cc IV fluids(b) Methergine 0.2 mg intramuscularly if no history of hypertension(c) Prostin suppositories per vagina, uterus, or rectum(d) If still bleeding administer Hemabate one amp IM every five minutes three times. Give first dose 10 minutes post Prostin.P.273(4) Send someone to call physician.(5) Continue bimanual compression.(6) Have assistant monitor vital signs and watch for signs of shock.c. If bleeding is not under control, have assistant get type and cross if not already done.d. If uterus is well-contracted and bleeding continues, look for lacerations.(1) If first or second degree lacerations of vagina or perineum, repair.(2) If lacerations of cervix or third or fourth degree lacerations of vagina or perineum:(a) Clamp any bleeders and wait for physician.(b) If physician still has not arrived and hemostasis is not attained, repair as necessary to attain hemostasis.e. If signs of shock develop:(1) Infuse LR rapidly.(2) Place patient flat with legs slightly elevated.(3) Give oxygen per mask.(4) Keep patient warm, cover with blankets.(5) Have assistant monitor vital signs.f. In extreme cases, consider the following:(1) Injection of oxytocin directly into the uterus with Iowa trumpet(2) Aortic compression(3) Alert OR in case a D&C or hysterectomy are necessary3. Follow-up managementa. Obtain hematocrit:(1) Twelve hours after delivery(2) Twenty-four hours after deliveryb. Consider ordering supplemental iron