Postpartum Hemorrhage

Postpartum Hemorrhage

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Def’n:

-Definition is variable, but EBL greater than 500mL is most common; EBL at delivery is inaccurate.

-Changes in h/h status may not reflect current hematologic status

-At delivery: 25% increase in RBC mass and 40% increase in plasma volume

-Because of the variation in definitions, the incidence is variable, but it is among the top 3 causes of maternal mortality in both high- and low-income countries

Categories:

Primary: <24hrs PP

Etiologies: Uterine atony, coagulation defects, uterine inversion, retained placenta or accreta

Secondary: 24hrs-6wks(or12wks) PP

Etiologies: Infection, Retained products of conception, inherited coagulation defects, subinvolution of placental site

Prevention:

Establish IV access, type & screen, baseline CBC, pitocin after placental delivery

Risk Factors:

-H/o PPH (~15% chance of recurrence), Prolonged Labor, Augmented Labor, Rapid Labor, Episiotomy (esp. mediolateral), PreE, Uterine distention (multifetal gestation, polyhydramnios, macrosomia), Operative delivery, Asian/Hispanic, Triple I

Primary PPH:

Initial Evaluation:

*Atony - Bimanual pelvic exam, checking for ‘bogginess’, compression or massage to decrease bleeding/clots.

*Lacerations - Examine for lacerations (repair may require an OR or anesthesia).

*Hematomas - (symptoms of rectal pressure/pain) which may require drain placement, sutures, vaginal packing.  

*Retained Products of Conception (POC) – Bimanual pelvic exam, ultrasonography

-A/w non-spontaneous placental expulsion, h/o uterine surgery, poor structural integrity of placenta

-Use U/S guided large blunt instrument (banjo curette or ring forceps) to remove tissue and reduce perforation risk

            *Coagulopathy – Personal/Family History, HELLP; order coagulation studies

Treatments:

First-Line: Uterotonics (Atony)

            -Oxytocin: continuous IV 10-40U (usually a 1L bag has 40U in NS or LR)

                        *At our hospitals we have normal and ‘double strength’

                                    -Normal is 333mL of this bag/hour, ‘double’ is twice the rate

                                    -High doses can cause hypotension, cardiac arrhythmias

                                                *Reason it is an infusion and not bolus

                                    -Large volumes can cause hyponatremia: seizures, coma, death

            -Misoprostol (PGE1/Cytotec): 800-1000mcg PR

                        *Can cause fevers

            -15-methyl PGF2a (Carboprost/Hemabate): 0.25mg IM q15min

*Can result in O2 desaturation from pulmonary artery constriction, may wish to avoid in Asthma/OSA patients

            -Methylergonovine (Methergine): 0.2mg IM q2-4hr

                        *Stimulates uterine contraction

*SE of hypertension, so avoid in PreE

            -Dinoprostone (Prostin E2): 20mg suppository q2hr

Second-Line: Packing

            -Gauze, Sengstaken-Blakemore balloon, or Bakri tamponade balloon

Third-Line: OR

-Uterine Artery Embolization (UAE)

            -Ex lap:

*Uterine artery ligation (O’Leary sutures)

*B-Lynch Suture

                    Image from Wikipedia

*Multiple square sutures 

                                 Image from B-Lynch et al., 2005. 

-If fails: Hysterectomy

Uterine Atony:

- Risk factor is uterine stretching: multiple gestations, polyhydramnios, macrosomia, grand multiparity. Also dysfunctional labor, magnesium, and Triple I

- Most common reason for PP hysterectomy

Placenta Accreta:

            - Second most common reason for post-partum hysterectomy

- Risk factors: Uterine surgery (cesarean section!), placenta previa, AMA, submucous fibroid, Asherman’s syndrome (intrauterine scars after surgery)

- Evaluate with Ultrasonography antepartum

*Placenta Accreta: Placental chorionic villi attach to myometrium

*Placenta Increta: Placental chorionic villi penetrate into the myometrium

*Placenta Percreta: Placenta chorionic villi penetrate into uterine serosa or adjacent organs

- Counsel patient for: increased chance of transfusion/hyst, have blood products available, may need cell saver, alert anesthesia

Uterine Rupture:

            - Risk factors: cesarean section, uterine surgery, placenta accreta

            - Requires surgical repair

Uterine Inversion:

            - A/w significant hemorrhage

- If inversion occurs before detachment of placenta, DON’T remove placenta; removal will make bleeding worse. Restore normal anatomy first; usually manually is adequate

- May require terbutaline (0.25mg SQ), magnesium, nitroglycerine (IV bolus 100-200mcg q2min as needed) for uterine relaxation

- May require Huntington procedure (traction on corpus progressively w/ Allis or Babcocks) or Haultain procedure (incise posterior cervix, restore normal anatomy, repair incision).

Secondary PPH

            - May be a sign of coagulation disorder (often von Willibrand’s Disease)

            - U/S evaluation for retained products of conception; may require curettage

Repleting RBC mass after Acute Blood Loss Anemia:

            - Iron replacement: up to 180mg elemental iron, or 900mg ferrous sulfate

            - Folate: 1mg daily

Sequelae

-Sheehan Syndrome:

*Hypopituitarism due to hypovolemic shock in the setting of an enlarged, postpartum pituitary gland. May occur years after delivery and may be mild (failure to lactate, amenorrhea/oligomenorrhea) or severe (adrenal insufficiency – hypotension, hyponatremia, hypothyroidism).

-Abdominal Compartment Syndrome:

*Sequelae of large volume infusions which may then third-space. Intra-abdominal hypertension results in a tensely distended abdomen, oliguria, and multiorgan failure.

-Venous Thromboembolism:

*Blood transfusion is an independent risk factor for VTE. Patients should be considered for prophylaxis