Postpartum Hemorrhage Quick Facts PB183
PPH Definition = >500 cc vaginal delivery, >1000 cc cesarean delivery (in many normal deliveries, EBL approaches these cut-offs), decline in Hct >10% *risk factors include prolonged labor, rapid labor, augmented labor, h/o PPH, PreE, large uterus, operative delivery, chorio, Asian and Hispanic ethnicity *recurrence is ~10%
- Primary: w/in first 24 hours after delivery, occurs after 4-6% of deliveries (due to atony in 80% of cases, other 20% due to retained placenta/coagulation defects/uterine inversion…)
- Secondary: b/t 24 hours and 6-12 weeks after delivery, occurs after 1% of deliveries (due to subinvolution of placenta site/atony, retained POCs, infection, coagulation defects)
o Evaluate for vWD, especially if h/o heavy periods
o Ultrasound to evaluate for retained POCs -> D&C under US guidance
- Transfusion indicated when “blood loss is significant and ongoing, particularly if VS are unstable”. Purpose is replacing coagulation factors and maintaining O2 carrying capacity, NOT volume replacement.
o PRBCS: 1u = 240 cc, RBCs/WBCs/plasma, increase Hct 3%/Hgb 1g
o Plts: 1u = 50 cc, Plts/RBCs/WBCs/plasma, increase Plts by 5-10K
o FFP: 1u = 250 cc, fibrinogen/ATIII/FV/FVIII, increase fibrinogen by 10 mg
o Cryo: 1u = 40 cc, fibrinogen/FVIII/FXIII/vWF, increase fibrinogen by 10 mg
- Regardless of timing or etiology, patients should continue daily PNV (60 mg elemental iron + 1 mg folic acid) and start BID 300-325 mg iron supplement
(each with 60 mg elemental iron)
Evaluation and Management of PPH
1. Initial management is emptying bladder, bimanual massage of uterus
2. Examine for lacerations and hematomas (progressively enlarging hematomas require I&D, +/- placement of a drain, repair of incision and vaginal packing…if unsuccessful, then consider IR), hematomas often do not present for several hours after delivery when patient complains of severe pelvic and/or rectal pressure
3. Ultrasound to evaluate for retained POCs…prior to instrumentation!
4. Labs studies to evaluate for coagulopathy (suspect this in HELLP, abruption, fetal demise, sepsis)
a. CBC, PTT, aPTT, fibrinogen, T&C
b. Red top test (5 cc blood in tube, will clot w/in 10 minutes if fibrinogen is >150)
5. If situationally appropriate, evaluate for uterine rupture and/or uterine inversion.
a. Uterine rupture requires surgical repair, often with revision followed by primary closure.
b. Uterine inversion requires replacement. If placenta I still attached, do not remove! Relax with uterus with Terbutaline, Mag Sulfate, Halogenated anesthetics and/or Nitroglycerin. Attempt to replace uterus with vaginal hand. If not successful, proceed with laparotomy to perform either 1) the Huntington procedure = progressive upward traction on inverted fundus using Babcock/Allis or 2) the Haultain procedure = incise cervical ring posteriorly, digitally replace the fundus, repair cervical incision.
Management of Uterine Atony
1. Medical Management (uterotonic agents are first-line)
a. Oxytocin: IV 10-40u in 1L (rapid infusion can cause hypotension, excessive infusion >60u/24h can cause hyponatremia), IM 10u
b. Methergine: IM 0.2 mg every 2-4h (avoid if hypertension)
c. Hemabate: IM 0.25 mg every 15-90m, max 8 doses (avoid if asthma, hepatic/renal/ cardiac disease, can cause diarrhea/fever/tachycardia)
d. Cytotec (i.e Misoprostol): 800-1000 mcg rectally
e. Prostin E2 (i.e. Dinoprostone): 20 mg rectal q2h (avoid if hypotension, can cause fever)
f. Tranexamic Acid (anti-fibrinolytic agent): 1g IV within 3 hours of delivery reduces mortality from post-partum hemorrhage, doesn’t increase risk of thrombosis
g. Factor VIIa: 50-100 mcg/kg q2h, rarely used due to expense and risk of VTE
2. Uterine packing/tamponade: can use 4-inch gauze soaked in 5000u thrombin + 5 cc saline, but Foley catheter/s with 60-80 cc or Bakri balloon with 300-500 cc are more commonly used
3. Surgical Management (technically second-line after uteronic agents…if exploratory laparotomy is required, VMI is preferred)
a. Uterine curettage
b. Bilateral uterine artery ligation (O’Leary’s) + uteroovarian ligament ligation
c. B-Lynch or multiple square sutures to eliminate the free space in the uterine cavity
d. Hypogastric artery ligation (technically difficult and also not that effective)
4. Interventional Radiology – Only appropriate in patients with stable VS and persistent, but not excessive, blood loss.
- Risk Factors: previa w/ or w/o prior uterine surgery, prior myomectomy, prior C/S, Asherman’s syndrome, submucosal myomas, age >35
o Risk of accreta w/o previa: 0.2%, 0.3%, 0.6%, 2.1%, 2.3% and 7.7% (C/S 1-6)
o Risk of accreta with previa: -------, 3.0%, 11%, 40%, 61% and 67% (C/S 2-6)
- Prior to Delivery: counsel patient re: high likelihood of hysterectomy and receiving blood products, consent for use cell saver if possible, plan for delivery at “appropriate location”, pre-op anesthesia consult
- Treatment: occasionally small/focal accreta can be treated with curettage, wedge resection or medical management…but most require hysterectomy