Postpartum hemorrhage 12 01

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
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
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.

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.

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” Palpate fundus.
Rule out Uterine Massage uterus.
Atony Oxytocin 40U/L @
250cc / h.
Methergine one amp
IM (not in
hypertensives)
Hemabate IM q 15min

“Tissue” Inspect placenta for
R/O retained placenta missing cotyledons.
Explore uterus.
Treat abnormal
implantation.

“TRAUMA” Obtain good exposure.
R/o cervical or vaginal Inspect cervix and
lacerations. vagina.
Worry about slow
bleeders.
Treat hematomas.

“THROMBIN” Check labs if
suspicious.

Postpartum hemorrhage 12 01

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