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GU: Postpartum Hemorrhage

Dr. Kaczmarczyk
10/13/11 9:00am-10:00 am

Class of 2014
christopherman@pcom.edu

Page 1 of 7

Note: From the Shoulder Dystocia lecture, the rate of shoulder dystocia (SD) recurrence
(slide 33) is a maximum of 16 percent. IF the mom has a recurrent SD, the risk of a brachial
plexus injury is as high as 40 percent.
1. Learning Objectives
a. Define postpartum hemorrhage (PPH)
b. Describe etiology of PPH
c. List PPH risk factors
d. Discuss medical management
e. Describe surgical management
2. PPH Definitions (need to know these)
a. Commonly defined as:
i. Spontaneous Vaginal Delivery > 500cc blood loss
ii. C-Section > 1000cc blood loss
1. Easier to use these two numbers clinically
iii. Considered to be an obstetrical emergency
b. Other Definitions:
i. Hematocrit Change > 10% (not useful in acute setting)
ii. Need for Transfusion and/or symptomatic
c. Primary (Early or Acute PPH)
i. Delivery to < 24h PP
ii. 90% PPH cases
iii. Associated with more bleeding (copious volumes of blood loss)
d. Secondary (Late PPH)
i. 24h 12 weeks postpartum
ii. Affects 1-3% all deliveries
iii. Common causes:
1. Infection (such as chorioamnionitis)
2. Retained products
a. IUFD- intrauterine fetal demise. The whole pregnancy is there
but the baby is dead
b. Retained part of a placenta or a secondary lobe separate from
the placenta
3. Abnormal uterine involution
a. If you have a very large uterus, it begins to involute very
quickly. In some women, it doesnt shrink back to its normal
size
3. PPH Epidemiology
a. Among top 5 causes maternal mortality (Including in the US)
b. #1 cause maternal mortality worldwide
i. Important for medical mission trips (know SD and PPH)
c. Developed countries 1/100,000 births vs. 1/1000 births in developing countries
d. Incidence 5% - 10% deliveries
i. depends on definition used

GU: Postpartum Hemorrhage


Class of 2014
Dr. Kaczmarczyk
christopherman@pcom.edu
10/13/11 9:00am-10:00 am
Page 2 of 7
4. Physiologic Adaptations of Pregnancy
a. All of these are physiological changes that take place that are true adaptations that
prepare the mom for delivery
i. Blood flows through the uterus at 500-800cc a minute
b. Plasma volume 40-50% increase
c. RBC 20-30% increase
d. Cardiac output 40% increase
e. Fibrinogen and factor VIII increase
5. Estimated Blood Loss (EBL)
a. All studies grossly underestimate EBL at delivery
b. Prasertcheroensuk et al. (2000)
i. 228 women in 3rd stage labor
ii. Visual estimation of blood loss (incidence 5.7% satisfied PPH criteria) vs.
measured (incidence 27.63%)
iii. Visually estimated EBL sensitivity 15.87%, specificity 98.18% and accuracy
75.35% (compared to direct measurement)
1. Sensitivity- ability to accurately identify someone who truly has the
condition of interest
iv. Incidence of PPH underestimated by 90% in visual estimations of EBL
1. Surgery tends to report a low EBL due to a number of pressures and
that we arent very good at identifying volumes
6. Blood Loss Signs & Symptoms
a. What happens if you lose a lot of blood at the time of delivery?
Blood Loss Vaginal to CBlood Pressure
Signs & Symptoms
Section (%)
500-1000ml (10-15)
Normal
Palpitations, dizziness,
tachycardia
1000-1500ml (15-25)

Slightly low

Weakness, sweating,
tachycardia

1500-2000ml (25-35)

70-80

Restlessness, pallor, oliguria


(decreased urinary output)

2000-3000ml (35-45)

50-70

Collapse, air hunger, anuria

7. Etiology of PPH
a. 4 vs 5 Ts
i. Tone (Uterine Atony)
1. Uterus doesnt contract (floppy organ)
ii. Tissue (Retained Products, see above)
iii. Trauma (Laceration in the birth canal)
iv. Thrombin (Coagulopathies)
v. Traction (Uterine Inversion)
1. Some people put traction in the trauma category for 4 Ts
2. See picture of this later in lecture

GU: Postpartum Hemorrhage


Class of 2014
Dr. Kaczmarczyk
christopherman@pcom.edu
10/13/11 9:00am-10:00 am
Page 3 of 7
8. Uterine Atony
a. 75-90% PPH mostly 10 PPH (early and acute PPH)
i. Cause of most PPH
b. 6% after C-section
c. Risk factors after C-section
i. Multiples (more than one baby)
ii. Hispanic ethnicity
iii. Induced or augmented labor (used oxytocin)
iv. Macrosomia
v. Chorioamnionitis
9. Retained Placenta or POC (Products of Conception)
a. Retained placenta- 10% PPH cases
b. 10% placentas fundal implantation
c. Placenta accreta 0.005% of all deliveries
i. Invasion of the trophoblast into the
myometrium behaving like a malignancy
ii. Placenta accretes will not separate normally
d. 90% accretas have PPH
e. 50% accreta undergo hysterectomy (abnormal placentation)
i. The more C-sections a woman has, the more likely she will have an abnormal
placentation including placenta accrete
10. Laceration or Uterine Inversion (Trauma category)
a. Etiology PPH 20% cases
b. Genital tract injury during delivery (Odds ratio of 1.7 with a vaginal delivery)
c. 65% uterine inversions have PPH
i. Completely iatrogenic. Excessive traction
before the placenta releases
d. 48% uterine inversions
i. require transfusion
e. Dr. K tells a story when a resident pulls the cord and
the
uterus comes out and invereted. To fix it, you push the
uterus right back up with a fist. You have seconds before the patient presents with
shock.
i. Know the signs of placental separation to avoid this!
ii. The uterus should have rapid involution and the normal supporting structures
should keep it inside
iii. Recurrence depends on the placenta placement (but usually a low rate)
11. Thrombin
a. Etiology 1% PPH
b. Known association with coagulation failure:
i. Abruption (premature separation of the placenta)
ii. Hypertensive disorders
iii. Sepsis
iv. IUFD
1. Told a story about a patient in the Indian Health Station that had two
IUFDs. Had a problem with medical compliance due to her

GU: Postpartum Hemorrhage


Class of 2014
Dr. Kaczmarczyk
christopherman@pcom.edu
10/13/11 9:00am-10:00 am
Page 4 of 7
background (navajo indian). She is at risk of DIC which can cause
PPH.
v. Incompatible blood
vi. Abortion (refers to miscarriage)
12. Risk factors in PPH
a. Table shows all the risk factors and describes their mechanism. Dr. K did not go
through the table, but mentioned that tone PPH can be increased with
polyhydraminos, multiple gestation and macrosomia.

b. Retained Placenta (OR 3.5)


i. Highest risk
c. Failure to Progress 2nd Stage (OR 3.4)
d. Placenta Accreta (OR 3.3)
e. Lacerations (OR 2.4)
f. Instrumental Delivery (OR 2.3)
i. Using either vacuum or forceps
g. Large For Gestation Age (OR 1.9)
h. Hypertensive Disorders (OR 1.7)
i. Induction of Labor (OR 1.4)
j. Augmentation of Labor With Oxytocin (OR 1.4)

GU: Postpartum Hemorrhage


Class of 2014
Dr. Kaczmarczyk
christopherman@pcom.edu
10/13/11 9:00am-10:00 am
Page 5 of 7
13. Factors Associated with PPH
a. DM 30-35% vs 5-10% non-DM
b. Inherited coagulopathies:
i. Von Willebrands Disease most common (guess this on rounds)
1. 1-3% prevalence
2. 70% have type 1
c. Risk PPH 22% with Von Willebrands
i. 18% in hemophilia
d. Important to get blood disease history!!
14. Additional Risk Factors for PPH
a. Age > 35y
b. Asian
c. Hispanic ethnicity
d. Obesity
i. Risk almost doubled by obesity in an article he read
ii. Hot topic in obstetrics
e. Post dates > 42 wks
f. Previous PPH
g. Placenta Previa (abnormal placentation)
i. When the placenta covers the internal os (inhibits a baby delivery)
15. Management
a. Prevention
b. Early Recognition
c. Immediate Appropriate Intervention
16. Initial Management
a. ABCs
b. Examine patient (fundal massageDx etiology)
c. Management determined by etiology
i. If atonyuterotonics
ii. Look for lacerationrepair it
iii. Management determined by etiology
d. IV access and fluid resuscitation
e. Foley catheter
f. Lab (CBC, coag profile, cross match)
g. Reverse coagulation abnormality if there is one
17. Uterotonic Medications (MEMORIZE THIS SLIDE)
a. Oxytocin (Pitocin or PIT)
b. Ergot (Methergine)
c. Hemabate (15-methyl-PGF2)
d. Misoprostol
i. Know this on your medical missions!! Easy access (PO or sublingual)
e. Vasopressin

GU: Postpartum Hemorrhage


Class of 2014
Dr. Kaczmarczyk
christopherman@pcom.edu
10/13/11 9:00am-10:00 am
Page 6 of 7
18. Medications Graph
a. Did not go over the graph specifically.
b. He uses hemabate in the Indian Health Service and inject it intramyometrially
i. Both Asian and Native American women are at risk for PPH

19. Surgical Management


a. Curettage
i. Scrapping whatever is inside the uterus out of the uterus
ii. Can be referred to as a banjo curette (large instrument)
b. Embolization
i. May be the uterine arteries
c. Tamponade (Balloon, packing- can use many yards of material!)
d. Compression sutures- very popular on exams
e. Vessel ligation
f. Hysterectomy
20. Tamponade
a. Definition: using something inside the uterus to
compress the uterus
b. Bakri Balloon
c. Foley catheter with 30cc balloon
d. Sengstaken-Blakemore Balloon (used for
esophageal varices)
e. Vaginal packing
f. Saline filled glove (good for medical missions)
i. Condom

GU: Postpartum Hemorrhage


Dr. Kaczmarczyk
10/13/11 9:00am-10:00 am
21. Vessel Ligation
a. Uterine
i. OLeary Stitch
ii. Chromic 0 passed through lateral aspect
of lower segment as close to cervix as
possible and then through broad ligament
lateral to vessels
b. Ovarian
i. Distal to cornua by passing suture
through myometrium medial to
vessels
c. Be careful of the ureter on both sides!!
22. B-Lynch Suture (FYI, but be aware of it)
23. Algorithm for PPH management

Class of 2014
christopherman@pcom.edu

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