Postpartum Hemorrhage, Emergency Medicine

Basics

Description

- Occurs in 4% of vaginal deliveries - Occurs in 6% of C-sections - Leading cause of death in pregnancy worldwide - Accounts for 25% of pregnancy-related deaths - ¢ ˆ ¼50% of postpartum deaths are due to PPH

- Complications: - Hypovolemic shock - Blood transfusion - Acute respiratory distress syndrome - Renal and/or hepatic failure - Sheehan syndrome - Loss of fertility - Disseminated intravascular coagulopathy (DIC)

- Delayed: - Retained products of conception - Postpartum endometritis - Withdrawal of exogenous estrogen - Puerperal hematoma

- Coagulopathies: - Pre-existing idiopathic thrombocytopenic purpura - Thrombotic thrombocytopenic purpura - Von Willebrand disease - DIC

- Symptoms of hypovolemia: - Decreased urine output - Lightheaded - Syncope - Pale skin

- Attempt to simultaneously control bleeding and stabilize hemodynamic status - Manage airway and resuscitate as indicated: - Supplemental oxygen - Cardiac monitor

- Management of uterine atony: - Bimanual massage - Oxytocin (Pitocin) administered IV/IM - Methylergonovine (Methergine) or ergonovine (Ergotrate) IM if oxytocin fails: - Avoid if known hypertensive - Onset in minutes

- Management of uterine inversion (acute): - Reposition uterus using Johnson maneuver or Harris method: - Use left hand on abdominal wall to stabilize fundus of uterus - Place right hand with fingers spread into vagina and push steadily on inverted part to reduce

- Management of coagulopathies in childbirth: - Fresh-frozen plasma, platelets, cryoprecipitate as indicated - Careful attention to volume status - Continuous reassessment - Active over expectant management - Immediate administration of uterotonics after delivery - Cord clamping and cutting without delay - Cord traction/uterine countertraction (Brandt " “Andrews maneuver)

- Uterine tamponade - Can be used for atony or continued bleeding - Temporizing measures only - Balloon or packing can be used - May use a foley catheter, Rusch catheter, Sengstaken " “Blakemore tube or - Surgical Obstetric Silicone (SOS) Bakri tamponade balloon - Specifically designed for control of PPH

Postpartum hemorrhage (PPH) after 20 wk gestation
Primary: Hemorrhage occurring ≤24 hr after delivery
Secondary: Hemorrhage occurring >24 hr after delivery (but <12 wk):Also known as delayed PPH
Definitions:>500 mL after vaginal delivery>1,000 mL after C-section
Occurs in 4% of vaginal deliveries
Occurs in 6% of C-sections
Leading cause of death in pregnancy worldwideAccounts for 25% of pregnancy-related deaths ¢ ˆ ¼50% of postpartum deaths are due to PPH
95% of PPH caused by:Uterine atony (50 " “60%)Retained placenta (20 " “30%)Cervical/vaginal lacerations (10%)
Complications:Hypovolemic shockBlood transfusionAcute respiratory distress syndromeRenal and/or hepatic failureSheehan syndromeLoss of fertilityDisseminated intravascular coagulopathy (DIC)

Etiology

4 Ts:
Immediate:Uterine atonyLower genital lacerationsRetained placental tissuePlacenta accretaUterine ruptureUterine inversionPuerperal hematomaCoagulopathies
Delayed:Retained products of conceptionPostpartum endometritisWithdrawal of exogenous estrogenPuerperal hematoma
Coagulopathies:Pre-existing idiopathic thrombocytopenic purpuraThrombotic thrombocytopenic purpuraVon Willebrand diseaseDIC
Associated conditions:If bleeding is present at other sites, consider coagulopathy
Risk factors:Prior PPHAdvanced maternal ageMultiple gestationsProlonged laborPolyhydramniosInstrumental deliveryFetal demiseAnticoagulation therapyPlacental abruptionFibroidsProlonged use of oxytocinC-sectionPlacenta previa and accretaChorioamnionitisGeneral anesthesia

Diagnosis

Signs and Symptoms

Ongoing blood loss, usually painless
Significant hypovolemia, resulting in:TachycardiaTachypneaNarrow pulse pressureDecreased urine outputCool, clammy skinPoor capillary refillAltered mental status
Maternal tachycardia and hypotension may not occur until blood loss >1,500 mL

History

Condition is typically recognized by obstetrician soon after delivery
Delayed PPH presents as copious vaginal/perineal bleeding
Key historical elements:Complications of deliveryEpisiotomyPrior clotting disorders
Symptoms of hypovolemia:Decreased urine outputLightheadedSyncopePale skin

Physical Exam

Thorough exam of perineum, cervix, vagina, and uterus: ‚

External inspection
Speculum exam
Bimanual exam

Essential Workup

Abdomen and pelvic exam to assess for uterine atony, retained products, or other anatomic abnormality
Type and cross-match for packed red blood cells
Rapid hemoglobin determination

Diagnosis Tests & Interpretation

Diagnosis is chiefly based on clinical suspicion and exam ‚

Lab

CBC, platelets
PT, PTT
Fibrinogen level
Type and cross-match

Imaging

US to evaluate for retained products in delayed PPH or for evaluation of fluid concerning intrauterine or intra-abdominal hemorrhage ‚

Diagnostic Procedures/Surgery

Manual exam preferred over ultrasonography: ‚

Greater sensitivity
Both diagnostic and therapeutic

Differential Diagnosis

Consider puerperal hematomas if perineal, rectal, or lower abdominal pain in conjunction with tachycardia and hypotension
Retained products of conception

Treatment

Patients with PPH may be hemodynamically unstable
IV access, and active resuscitation is important, considering both crystalloid and blood product resuscitation and closely following BP and mental status

Pre-Hospital

Monitor hemodynamics
Aggressive IV fluids to maintain BP

Initial Stabilization/Therapy

Attempt to simultaneously control bleeding and stabilize hemodynamic status
Manage airway and resuscitate as indicated:Supplemental oxygenCardiac monitor
IV fluid resuscitation with normal saline or lactated Ringer solution
Foley catheter

Ed Treatment/Procedures

Management of uterine atony:Bimanual massageOxytocin (Pitocin) administered IV/IMMethylergonovine (Methergine) or ergonovine (Ergotrate) IM if oxytocin fails:Avoid if known hypertensiveOnset in minutes15-methyl prostaglandin F2α (PGF2α; Hemabate) IM if above fails:Relatively contraindicated in asthmaSurgery if medical intervention fails
Inspect closely for genital tract laceration:Repair required if ≥2 cmUse 00 or 000 absorbable suture; continuous, locked recommended
Management of uterine inversion (acute):Reposition uterus using Johnson maneuver or Harris method:Use left hand on abdominal wall to stabilize fundus of uterusPlace right hand with fingers spread into vagina and push steadily on inverted part to reduceIf unsuccessful, give terbutaline IV or magnesium sulfate to produce cervical relaxation, and repositionSurgery if unsuccessful or if subacute or chronic inversion
Management of coagulopathies in childbirth:Fresh-frozen plasma, platelets, cryoprecipitate as indicatedCareful attention to volume statusContinuous reassessmentActive over expectant managementImmediate administration of uterotonics after deliveryCord clamping and cutting without delayCord traction/uterine countertraction (Brandt " “Andrews maneuver)
Uterine tamponadeCan be used for atony or continued bleedingTemporizing measures onlyBalloon or packing can be usedMay use a foley catheter, Rusch catheter, Sengstaken " “Blakemore tube orSurgical Obstetric Silicone (SOS) Bakri tamponade balloonSpecifically designed for control of PPH

Medication

Uterotonics " ”stimulate uterine contraction to control bleeding:Ergonovine (Ergotrate): 0.2 mg IM; avoid if known hypertensiveMethylergonovine (Methergine): 0.2 mg IM; 0.2 mg PO q6h; avoid if known hypertensive15-methyl PGF2α (Hemabate): 0.25 mg IM; may repeat in 15 " “60 minOxytocin (Pitocin): 10 U IM or 20 " “40 U IV in 1 L normal saline; titrate to achieve uterine contractions
Cervical relaxation agents facilitate uterine inversion reduction:Magnesium sulfate 20%: 2 g IM bolus over 10 minTerbutaline: 0.25 mg IV; avoid if hypotensive

First Line

Uterotonics
Oxytocin
Methylergonovine

Second Line

Surgical intervention:Hysterectomy is required in management of PPH in 1/1,000 deliveries
Radiologic embolization

Follow-Up

Disposition

Admission Criteria

All patients with immediate PPH require admission to a closely monitored setting
Early obstetrics consultation is recommended
Early surgical intervention is dependent on cause
ICU setting if DIC or evidence of hemodynamic compromise
Patients with endometritis should be admitted for parenteral antibiotics

Discharge Criteria

Delayed PPH that is easily controlled without excessive bleeding
Outpatient management with methylergonovine 0.2 mg PO every 6 hr may be considered in consultation and close follow-up with obstetrician

Follow-Up Recommendations

Close follow-up with obstetrician
Seek immediate care if bleeding recurs

Pearls and Pitfalls

Active over expectant managementMost deaths are due to delayed diagnosis and/or inadequate resuscitation with blood products
Uterotonics are the first line of treatment
Aggressive use of fluid and blood products for resuscitation
Manual exam is the preferred diagnostic approach
Immediate obstetric consult

Additional Reading

Cabero Roura ‚ L, Keith ‚ LG. Post-partum haemorrhage: Diagnosis, prevention and management. J Matern Fetal Neonatal Med. 2009;22(suppl 2):38 " “45.
Hofmeyr ‚ GJ, G ƒ ¼lmezoglu ‚ AM. Misoprostol for the prevention and treatment of postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2008;22:1025 " “1041.
Mercier ‚ FJ, Van de Velde ‚ M. Major obstetric hemorrhage. Anesthesiology Clin. 2008;26:53 " “66.
Mousa ‚ HA, Alfirevic ‚ Z. Treatment for primary postpartum haemorrhage. Cochrane Database Syst Rev. 2007;(1):CD003249.
Oyelese ‚ Y, Scorza ‚ WE, Mastrolia ‚ R, et al. Postpartum hemorrhage. Obstet Gynecol Clin North Am. 2007;34:421 " “441.
Rath ‚ WH. Postpartum hemorrhage " ”update on problems of definitions and diagnosis. Acta Obstet Gyencol Scand. 2011;90:421 " “428.
Su ‚ CW. Postpartum hemorrhage. Prim Care. 2012;39:167 " “187.
Tun ƒ §alp ‚ ƒ –, Hofmeyr ‚ GJ, G ƒ ¼lmezoglu ‚ AM. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2012;8:CD000494.

Codes

ICD9

666.00 Third-stage postpartum hemorrhage, unspecified as to episode of care or not applicable
666.10 Other immediate postpartum hemorrhage, unspecified as to episode of care
666.20 Delayed and secondary postpartum hemorrhage, unspecified as to episode of care or not applicable
666.30 Postpartum coagulation defects, unspecified as to episode of care or not applicable
666.02 Third-stage postpartum hemorrhage, delivered, with mention of postpartum complication
666.04 Third-stage postpartum hemorrhage, postpartum condition or complication
666.12 Other immediate postpartum hemorrhage, delivered, with mention of postpartum complication
666.14 Other immediate postpartum hemorrhage, postpartum condition or complication
666.1 Other immediate postpartum hemorrhage
666.22 Delayed and secondary postpartum hemorrhage, delivered, with mention of postpartum complication
666.24 Delayed and secondary postpartum hemorrhage, postpartum condition or complication
666.2 Delayed and secondary postpartum hemorrhage
666.32 Postpartum coagulation defects, delivered, with mention of postpartum complication
666.34 Postpartum coagulation defects, postpartum condition or complication
666.3 Postpartum coagulation defects
666 Postpartum hemorrhage

ICD10

O72.0 Third-stage hemorrhage
O72.1 Other immediate postpartum hemorrhage
O72.2 Delayed and secondary postpartum hemorrhage
O72.3 Postpartum coagulation defects
O72 Postpartum hemorrhage

SNOMED

47821001 Postpartum hemorrhage (disorder)
23171006 Delayed AND/OR secondary postpartum hemorrhage
47236005 Third stage hemorrhage (disorder)
49177006 Postpartum coagulation defect with hemorrhage (disorder)