Postpartum Hemorrhage

Jorge Garcia, MD December, 2001

Goals of talk
Definition  Rapid diagnosis and treatment  Review risks
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Case 1.
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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
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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
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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.
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Prenatal Risk Factors
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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
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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
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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 intraabdominal blood loss.
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Initial Assessment
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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)
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“Tone: Think of Uterine Atony”
Uterine atony causes 70% of hemorrhage  Assess and treat with uterine massage  Use medication early  Consider prophylactic medication...
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Bimanual Uterine Exam
Confirms diagnosis of uterine atony.  Massage is often adequate for stimulating uterine involution.
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Medications for Uterine Atony
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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
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X8).

Medications: Methergine
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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
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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
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Delay of placental delivery > 30 minutes seen in ~ 6% of deliveries. Prior retained placenta increases risk. Risk increased with: prior C/S, curettage ppregnancy, 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.
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Abnormal implantation defined.
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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
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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
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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.
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Trauma (3rd “T”)
Episiotomy  Hematoma  Uterine inversion  Uterine rupture
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Uterine Inversion
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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.
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Uterine Inversion
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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
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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
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Risk factors include: Epidural. Placental abruption. Forceps delivery (especially mid forceps). Breech version or extraction.

Uterine Rupture
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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
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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.
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Uterine Rupture
When recognized, get help.  ABCs.  IV fluids.  Surgical correction.
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Birth Trauma
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Lacerations of birth tract not rare: causes post partum hemorrhage in 1/1500 deliveries.

Birth Trauma
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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.
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Repair of cervical laceration

Birth Trauma: Hematomas
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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.
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Prevention?
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Some evidence supports use of oxytocin after delivery of anterior shoulder, in umbilical vein or IV.

Summary: remember 4 Ts
Tone  Tissue  Trauma  Thrombin
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Summary: remember 4 Ts
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“TONE” Rule out Uterine Atony

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

Summary: remember 4 Ts
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“Tissue” R/O retained placenta

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Inspect placenta for missing cotyledons. Explore uterus. Treat abnormal implantation.

Summary: remember 4 Ts
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“TRAUMA” R/o cervical or vaginal lacerations.

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Obtain good exposure. Inspect cervix and vagina. Worry about slow bleeders. Treat hematomas.

Summary: remember 4 Ts
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“THROMBIN”

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Check labs if suspicious.

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