Postpartum Hemorrhage – AFP 4/1/17

Epidemiology and Definition:

  • 3-5% of deliveries
  • Cause of 1/4 of obstetrical deaths worldwide, and 12% in the US.
  • ACOG definition:  1000mL of blood loss (or blood loss + hypovolemic symptoms) from prior to placenta delivery up to 24 hours after delivery.
  • 20% occur in women with NO risk factors.

Prevention:

  • Unit prep:  PPH carts, massive transfusion protocols, drills
  • Pre-delivery:  screen for anemia, screen for thalassemia and sickle cell if applicable, U/S in women at risk for invasive placentas, identify JWs.
  • Delivery:  active management of third stage, avoid episiotomy and instruments, measure blood loss and monitor VS
  • PPH:  use a checklist, manage the family
  • Post-event:  debriefs, reviews, QI

Active Management of the Third Stage of Labor (AMTSL):

  • Oxytocin with or soon after delivery of the anterior shoulder (NNT = 7 to prevent one PPH of 500+mL)
    • Prevention: 10 U IM or 5-10 U IV
    • Treatment:  20-40 U in 1L NS, 500mL over 10 min, then 250mL/hr.
  • Controlled cord traction with suprapubic counterpressure
  • Uterine massage after placenta delivery

Misoprostol also an alternative to oxytocin, though most studies suggest oxytocin superior. (Misoprostol –> N, D, fever)

  • 600 mcg PO for prevention
  • 800 – 1000 mcg PR or 600-800 mcg PO/SL for treatment

Diagnosis:

  • Tachycardia may be earliest symptom
  • THE FOUR Ts:
    • TONE: uterine atony (70% of PPH)
    • TRAUMA:  laceration, inversion, hematoma, rupture (20%)
    • TISSUE:  retained or invasive placenta (10%)
    • THROMBIN:  coagulopathy (1% or less)

 

PPH flow

Immediate response to uterine atony with PPH:  bimanual massage!  (Vigorous, consider pain control if possible.)

Signs of hypovolemia or shock disproportionate to visible blood loss:  think hematoma.

  • If > 3-4 cm or expanding, I&D hematoma with hemostasis of bleeding vessels, irrigation.

Uterine inversion:  Around 4/10,000.  May cause shock sxs without much visible blood loss.  AMTSL does not increase rate, but invasive placenta does.  Looks like a blue/gray mass protruding from the vagina.  REPLACE IMMEDIATELY WITH OPEN HAND –> FIST MANEUVER.  If placenta still attached, do NOT remove (to limit bleeding).

  • If Johnson maneuver (above) fails, use MgSO4, terbutaline, nitroglycerin or general anesthesia.

Uterine rupture:  about 8/1000 deliveries with hx of LTCS, risk increased with induction or augmentation.

Retained placenta:  Mean time from delivery to expulsion is 8-9 mins.  Risk of PPH increases after 10 mins.  Retained if 30+ mins.

  • Consider invasive placenta if no tissue plane obvious with attempt to separate with gloved hand.
  • Invasive placenta may need surgery (hyst), but can sometimes be conservatively managed (e.g., weekly PO MTX).

Thrombin:  consider coagulopathy if blood is not clotting in containers or in red top tube in 5-10 minutes, or if oozing from puncture sites.

  • Eval:  PT, aPTT, platelets, FSPs, fibrinogen, D-dimer.
  • Don’t forget other causes:  amniotic fluid embolism, consumptive coagulopathy/DIC, sepsis, HELLP, fetal demise…

INITIAL MANAGEMENT:

Treat it like a trauma:

  • Two large-bore IVs
  • Bolus LR or NS
  • O negative blood if needed while awaiting type-specific
  • Support oxygenation, ventilation
  • Massive transfusion protocols:
    • 4 U FFP + 1 U platelets per 4-6 units of pRBCs given
  • Foley cath

Advanced uterine-saving measures:

  • Uterine packing
  • Uterine artery ligation
  • Balloon tamponade devices
  • B-Lynch procedure

 

 

 

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