Postpartum hemorrhage

Postpartum Hemorrhage

Jorge Garcia, MD

December, 2001

Goals of talk

� Definition� Rapid diagnosis and treatment� Review risks

Case 1.

� Healthy 32 yo G2P1.� Augmented vaginal delivery, no tears.� Nurse calls you one hour after delivery

because of heavy bleeding.� What do you do?� What do you order?

Case 2

� 26 yo G4 now P4.� NSVD, with help from medical student.� You leave the room to answer a page while

waiting for placenta to deliver, but are called back overhead, stat.

� Huge blood clot seen in vagina.� What is this, and what do you do next?

Definition

� Mean blood loss with vaginal delivery: 500cc

� > 1000cc is “hemorrhage”� Mean blood loss with C/S: 1000cc� >1500cc is “hemorrhage”� Seen in ~5% of deliveries.

Early vs. Late

� Most authors define early as < 72h.� ALSO defines it as <24h.� Late hemorrhage is more likely due to

infection and retained placental tissue.

Prenatal Risk Factors

� Most patients with hemorrhage have none.� Pre-eclampsia (RR 5.0)� Previous postpartum hemorrhage (RR 3.6)� Multiple gestation (RR 3.3)� Previous C/S (RR 1.7)� Multiparity (RR1.5)

Intrapartum Risk Factors� Prolonged 3rd stage (>30 min) (RR7.5)� medio-lateral episiotomy (RR4.7)� midline episiotomy ( RR1.6)� Arrest of descent (RR 2.9)� Lacerations (RR 2.0)� Augmented labor ( RR1.7)� Forceps delivery (RR 1.7)

Easy to miss

� Physicians underestimate blood loss by 50%

� Slow steady bleeding can be fatal� Most deaths from hemorrhage seen after 5h� Abdominal or pelvic bleeding can be

hidden

Always look for signs of bleeding

� Estimate blood loss accurately.� Evaluate all bleeding, including slow

bleeds.� If mother develops hypotension,

tachycardia or pain…rule out intra-abdominal blood loss.

Initial Assessment

� Identify possible post partum hemorrhage.� Simultaneous evaluation and treatment.� Remember ABCs.� Use O2 4L/min.� If bleeding does not readily resolve, call for

help.� Start two 16g or 18g IVs.

ALSO’s 4 Ts

� Tone (Uterine tone)� Tissue (Retained tissue--placenta)� Trauma (Lacerations and uterine rupture)� Thrombin (Bleeding disorders)

“Tone: Think of Uterine Atony”

� Uterine atony causes 70% of hemorrhage� Assess and treat with uterine massage� Use medication early� Consider prophylactic medication...

Bimanual Uterine Exam

� Confirms diagnosis of uterine atony.� Massage is often adequate for stimulating

uterine involution.

Medications for Uterine Atony

� 1. Oxytocin promotes rhythmic contractions.

� Give IM or IU, not IV. (Can cause ↓ BP)� 40U/L at 250cc/h.

� 2. Methergine 0.2mg (1 amp) IM

� 3. Hemabate 0.25mg IM q 15min (max X8).

Medications: Methergine

� Causes tetanic uterine contraction.� May trap placenta.� Can cause Hypertension, especially IV.� Contraindicated in hypertensive patients

and those with pre-eclampsia.� Some authors skip Methergine altogether.

Prostaglandin F2 15-methyl

� Hemabate 0.25mg IM or IU.� Used to be called Prostin.� Controls hemorrhage in 86% when used

alone, and 95% in combination with above.� Can repeat up to eight times.� Contraindicated in active systemic diseases.� Can cause nausea/vomiting/diarrhea, ↑ BP.

Tissue: Retained placenta� Delay of placental delivery > 30 minutes

seen in ~ 6% of deliveries.� Prior retained placenta increases risk.� Risk increased with: prior C/S, curettage p-

pregnancy, uterine infection, AMA or increased parity.

� Prior C/S scar & previa increases risk (25%)

� Most patients have no risk factors.� Occasionally succenturiate lobe left behind.

Abnormal Placental Implantation

� Attempt to remove the placenta by usual methods.

� Excess traction on cord may cause cord tear or uterine inversion.

� If placenta retained for >30 minutes, this may be caused by abnormal placental implantation.

Abnormal implantation defined.

� Caused by missing or defective decidua.� Placenta Accreta: Placenta adherent to

myometrium.� Placenta Increta: myometrial invasion.� Placenta Percreta: penetration of

myometrium to or beyond serosa.� These only bleed when manual removal

attempted.

Removal of Abnormal Placenta

� Oxytocin 10U in 20cc of NS placed in clamped umbilical vein.

� If this fails, get OB assistance.� Check Hct, type & cross 2-4 u.� Two large bore IVs.� Anesthesia support.


� Relax uterus with halothane general anesthetic and subcutaneous terbutaline.

� Bleeding will increase dramatically.� With fingertips, identify cleavage plane

between placenta and uterus.� Keep placenta intact.� Remove all of the placenta.


� If successful, reverse uterine atony with oxytocin, Methergine, Hemabate.

� Consider surgical set-up prior to separation.� If manual removal not successful, large

blunt curettage or suction catheter, with high risk of perforation.

� Consider prophylactic antibiotics.

Trauma (3rd “T”)

� Episiotomy� Hematoma� Uterine inversion� Uterine rupture

Uterine Inversion

� Rare: ~1/2000 deliveries.� Causes include:� Excessive traction on cord.� Fundal pressure.� Uterine atony.

Uterine Inversion

� Blue-gray mass protruding from vagina.� Copious bleeding.� Hypotension worsened by vaso-vagal

reaction. Consider atropine 0.5mg IV if bradycardia is severe.

� High morbidity and some mortality seen: get help and act rapidly.

Uterine Inversion

� Push center of uterus with three fingers into abdominal cavity.

� Need to replace the uterus before cervical contraction ring develops.

� Otherwise, will need to use MgSO4, tocolytics, anesthesia, and treatment of massive hemorrhage.

� When completed, treat uterine atony.

Uterine Rupture

� Rare: 0.04% of deliveries.� Risk factors include:� Prior C/S: up to 1.7% of these deliveries.� Prior uterine surgery.� Hyperstimulation with oxytocin.� Trauma.� Parity > 4.

Uterine Rupture

� Risk factors include:� Epidural.� Placental abruption.� Forceps delivery (especially mid forceps).� Breech version or extraction.

Uterine Rupture

� Sometimes found incidentally.� During routine exam of uterus.� Small dehiscence, less than 2cm.� Not bleeding.� Not painful.� Can be followed expectantly.

Uterine Rupture before delivery

� Vaginal bleeding.� Abdominal tenderness.� Maternal tachycardia.� Abnormal fetal heart rate tracing.� Cessation of uterine contractions.

Uterine Rupture after delivery

� May be found on routine exam.� Hypotension more than expected with

apparent blood loss.� Increased abdominal girth.

Uterine Rupture

� When recognized, get help.� ABCs.� IV fluids.� Surgical correction.

Birth Trauma

� Lacerations of birth tract not rare: causes post partum hemorrhage in 1/1500 deliveries.

Birth Trauma� Risk factors include:� Instrumented deliveries.� Primiparity.� Pre-eclampsia.� Multiple gestation.� Vulvovaginal varicosities.� Prolonged second stage.� Clotting abnormalities.

Birth Trauma

� Repair lacerations quickly.� Place initial suture above the apex of

laceration to control retracted arteries.

Repair of cervical laceration

Birth Trauma: Hematomas� Hematomas less than 3cm in diameter can

be observed expectantly.� If larger, incision and evacuation of clot is

necessary.� Irrigate and ligate bleeding vessels.� With diffuse oozing, perform layered

closure to eliminate dead space.� Consider prophylactic antibiotics.

Pelvic Hematoma

Vulvar hematoma

Thrombin (4th “T”)

� Coagulopathies are rare.� Suspect if oozing from puncture sites noted.� Work up with platelets, PT, PTT, fibrinogen

level, fibrin split products, and possibly antithrombin III.

Prevention?

� Some evidence supports use of oxytocin after delivery of anterior shoulder, in umbilical vein or IV.

Summary: remember 4 Ts

� Tone� Tissue� Trauma� Thrombin


� “TONE”� Rule out Uterine

Atony

� Palpate fundus.� Massage uterus.� Oxytocin 40U/L @

250cc / h.� Methergine one amp

IM (not in hypertensives)

� Hemabate IM q 15min


� “Tissue”� R/O retained placenta

� Inspect placenta for missing cotyledons.

� Explore uterus.� Treat abnormal

implantation.


� “TRAUMA”� R/o cervical or vaginal

lacerations.

� Obtain good exposure.� Inspect cervix and

vagina.� Worry about slow

bleeders.� Treat hematomas.


� “THROMBIN” � Check labs if suspicious.

Healthcare

Postpartum hemorrhage