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.
Removal of Abnormal Placenta
◗ 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.
Removal of Abnormal 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
Summary: remember 4 Ts
◗ “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
Summary: remember 4 Ts
◗ “Tissue” ◗ Inspect placenta for
◗ R/O retained placenta missing cotyledons.
◗ Explore uterus.
◗ Treat abnormal
implantation.
Summary: remember 4 Ts
◗ “TRAUMA”
◗ R/o cervical or vaginal
lacerations.
◗ Obtain good exposure.
◗ Inspect cervix and
vagina.
◗ Worry about slow
bleeders.
◗ Treat hematomas.
Summary: remember 4 Ts
◗ “THROMBIN” ◗ Check labs if
suspicious.