Postpartum Hemorrhage

1. Postpartum Hemorrhage Christopher R. Graber, MD Salina Women’s Clinic 21 Feb 2012

2. Overview • Background • Etiology of postpartum hemorrhage • Primary • Secondary • Risk factors • Evaluation and management • Medical • Surgical

3. Background • Severe bleeding is #1 worldwide cause of maternal death • 140,000 women die each year from hemorrhage • 1 every 4 minutes • Other serious sequelae • ARDS, coagulopathy, shock, loss of fertility • Hemorrhage frequently occurs without any warning

4. Background • Physiologic changes during pregnancy • Increase in plasma volume by 40% • Increase red cell mass by 25% • Definition of postpartum hemorrhage • 500 mL after vaginal delivery • 1000 ml after cesarean delivery

5. Etiology – Primary Hemorrhage • Primary hemorrhage occurs in 1st 24 hours • Occurs in 4-6% of pregnancies • Caused by The Four T’s • Tone – atony (80% of all cases) • Tissue – retained POC, accreta, uterine inversion • Trauma – cervical or vaginal laceration, rupture • Thrombic events – defects in coagulation • Inherited or acquired

6. Etiology–Secondary hemorrhage • Secondary hemorrhage occurs 24h to 6-12w • Causes include: • Subinvolution of pacental site • Retained POC • Infection • Inherited coagulation defects

7. Risk Factors • Prolonged labor (also augmented labor) • Rapid labor • History of postpartum hemorrhage • Preeclampsia • Distended uterus • Macrosomia, twins, polyhydramnios • Chorioamnionitis • Operative delivery

8. What to Do Next?!

9. What to Do Next?! • Postpartum hemorrhage is a sign, not a diagnosis – find out what is causing bleeding • Calmly work your way through the list of possible causes • If you get to the end of the list and don’t have an answer then start again at the top of the list • Call for help if needed • Extra nurses, anesthesia, Ob/Gyn

10. Initial Evaluation • Atony is the most common cause for bleeding • Pelvic exam, uterine massage, expel clots • Manual exam of the uterus • Yes, put your whole hand and arm inside • Consider draining the bladder • Examine for lacerations • Consider move to OR for lighting & exposure • Ask about history of clotting disorders

11. Medical Management • Uterotonic medications • Pitocin 10-40 units IV, continuous • Methergine (methylergonovine) 0.2mg IM • Repeat q2-4h, avoid in hypertension • Hemabate (15-methyl PGF2α) 0.25mg IM • Repeat q15min, avoid in asthma • Higher risk of side-effects: diarrhea, fever, tachycardia • Cytotec (misoprostol, PGE1) 800-1000mcg PR

12. Medical Management • Uterine tamponade • Packing with guaze • Can soak with thrombin • Intrauterine foley catheter • One or more bulbs, 60-80ml of saline • Bakri tamponade balloon • 300-500ml of saline

14. Surgical Management • Consider surgical management when uterotonic agents (± tamponade) don’t work • Uterine curettage • Exploratory laparotomy • Hypogastric artery ligation • Bilateral uterine artery ligation (O’Leary sutures) • B-Lynch technique • Hysterectomy

15. Surgical Management

16. Other Considerations • Placenta accreta • Risk factors: placenta previa, prior CD, Asherman’s syndrome, prior myomectomy • 40% risk if 2 prior CD + placenta previa • If known, consider delivery at tertiary center • Arterial embolization • Not for acute cases

17. Other Considerations • Uterine inversion • If occurs prior to placental delivery, do Not remove the placenta • Replace fundus with firm pressure upwards • Uterine relaxation may be required • Terbutaline, nitroglycerine, anesthesia • Consider activation of massive transfusion protocol

18. Review . • Stay Calm! • Tone, Tissue, Trauma, Thrombin • Postpartum hemorrhage is a symptom, not a diagnosis – find a diagnosis • Return to bedside if more than 1 dose of uterotonic medication is given by phone

19. Questions?