Postpartum Hemorrhage

Christopher R. Graber, MDSalina Women’s Clinic

21 Feb 2012

Overview

• Background• Etiology of postpartum hemorrhage– Primary– Secondary

• Risk factors• Evaluation and management– Medical– Surgical

Background

• Severe bleeding is #1 worldwide cause of maternal death– 140,000 women die each year from hemorrhage– 1 every 4 minutes

• Other serious sequelae– ARDS, coagulopathy, shock, loss of fertility

• Hemorrhage frequently occurs without any warning

Background

• Physiologic changes during pregnancy– Increase in plasma volume by 40%– Increase red cell mass by 25%

• Definition of postpartum hemorrhage– 500 mL after vaginal delivery– 1000 ml after cesarean delivery

Etiology – Primary Hemorrhage

• Primary hemorrhage occurs in 1st 24 hours• Occurs in 4-6% of pregnancies• Caused by The Four T’s– Tone – atony (80% of all cases)– Tissue – retained POC, accreta, uterine inversion– Trauma – cervical or vaginal laceration, rupture– Thrombic events – defects in coagulation• Inherited or acquired

Etiology –Secondary hemorrhage

• Secondary hemorrhage occurs 24h to 6-12w• Causes include:– Subinvolution of pacental site– Retained POC– Infection– Inherited coagulation defects

Risk Factors

• Prolonged labor (also augmented labor)• Rapid labor• History of postpartum hemorrhage• Preeclampsia• Distended uterus – Macrosomia, twins, polyhydramnios

• Chorioamnionitis• Operative delivery

What to Do Next?!

What to Do Next?!

• Postpartum hemorrhage is a sign, not a diagnosis – find out what is causing bleeding

• Calmly work your way through the list of possible causes– If you get to the end of the list and don’t have an

answer then start again at the top of the list

• Call for help if needed– Extra nurses, anesthesia, Ob/Gyn

Initial Evaluation

• Atony is the most common cause for bleeding– Pelvic exam, uterine massage, expel clots– Manual exam of the uterus• Yes, put your whole hand and arm inside

– Consider draining the bladder

• Examine for lacerations– Consider move to OR for lighting & exposure

• Ask about history of clotting disorders

Medical Management

• Uterotonic medications– Pitocin 10-40 units IV, continuous – Methergine (methylergonovine) 0.2mg IM• Repeat q2-4h, avoid in hypertension

– Hemabate (15-methyl PGF2α) 0.25mg IM• Repeat q15min, avoid in asthma• Higher risk of side-effects: diarrhea, fever, tachycardia

– Cytotec (misoprostol, PGE1) 800-1000mcg PR

Medical Management

• Uterine tamponade– Packing with guaze• Can soak with thrombin

– Intrauterine foley catheter• One or more bulbs, 60-80ml of saline

– Bakri tamponade balloon• 300-500ml of saline

Surgical Management

• Consider surgical management when uterotonic agents (± tamponade) don’t work

• Uterine curettage• Exploratory laparotomy– Hypogastric artery ligation– Bilateral uterine artery ligation (O’Leary sutures)– B-Lynch technique– Hysterectomy

Surgical Management

Other Considerations

• Placenta accreta– Risk factors: placenta previa, prior CD, Asherman’s

syndrome, prior myomectomy– 40% risk if 2 prior CD + placenta previa– If known, consider delivery at tertiary center

• Arterial embolization– Not for acute cases

Other Considerations

• Uterine inversion– If occurs prior to placental delivery, do Not

remove the placenta– Replace fundus with firm pressure upwards– Uterine relaxation may be required• Terbutaline, nitroglycerine, anesthesia

• Consider activation of massive transfusion protocol

Review .

• Stay Calm!• Tone, Tissue, Trauma, Thrombin• Postpartum hemorrhage is a symptom, not a

diagnosis – find a diagnosis• Return to bedside if more than 1 dose of

uterotonic medication is given by phone

Questions?