postpartum%20hemorrhage
POSTPARTUM HEMORRHAGE
Postpartum hemorrhage is defined as blood loss of ≥500 mL for vaginal delivery or 1000 mL for abdominal (Caesarean) delivery after completion of the 3rd stage of labor.
Another proposed definition is a 10% fall in hematocrit value.
Since the clinical estimation of the amount of blood loss is typically inaccurate, the diagnosis of postpartum hemorrhage remains a subjective clinical assessment of the amount of blood loss that jeopardizes a woman's hemodynamic stability.
Postpartum hemorrhage may produce hemodynamic instability during the 1st 24 hours after delivery.

Pharmacotherapy

Uterotonic Agents

  • Prophylactic uterotonic agents should be offered to reduce the risk of postpartum hemorrhage (PPH) 
  • Selection of uterotonic agents will be dependent on the availability of the drug, syringes and needles along with storage capabilities (Oxytocin and Ergometrine injectables require refrigeration)

Oxytocin

  • Preferred agent for prevention of PPH; it has a rapid onset (2-3 minutes) and it does not elevate BP or cause tetanic contractions
    • It is recommended that Oxytocin be administered within 1 minute of delivery of the baby
  • In settings where Oxytocin is unavailable, the use of other injectable uterotonics or oral Misoprostol is recommended for prevention of PPH
  • Effective in treating uterine atony if PPH occurs
  • Several studies have demonstrated that routine use of Oxytocin in the 3rd stage of labor can reduce the risk of PPH by more than 40%
  • Oxytocin can be used in all women: Women delivering vaginally in the absence of risk factors for PPH and those delivering by cesarean section to stimulate uterine contraction and to reduce blood loss  

Carbetocin

  • New synthetic analog of Oxytocin with longer duration of action
    • An alternative to Oxytocin if titrable intravenous (IV) infusion of Oxytocin is not possible
  • May be used for prevention of uterine atony and PPH following cesarean section
  • Some studies show that Carbetocin is well tolerated and appears as effective as Oxytocin
  • Decreases the need for uterine massage to prevent PPH after vaginal delivery

Carboprost

  • Carboprost is a synthetic 15-methyl analogue of prostaglandin F2
  • Effective agent for increasing uterine tone
  • May be used for refractory PPH caused by atony
  • Should not be used in women with cardiovascular (CV), pulmonary, renal or hepatic dysfunction

Ergometrine (Ergonovine)

  • Used in the prevention and treatment of PPH
  • Ergot alkaloid that can produce intense, sustained contractions in the puerperal uterus
  • Ergometrine should not be used in women with hypertension, heart disease, preeclampsia, eclampsia, Raynaud’s phenomenon, or scleroderma

Methylergometrine (Methylergonovine)

  • Used in the prevention and treatment of PPH
  • Tetanic contractions of the uterus occur within 5 minutes of intramuscular (IM) injection
  • Methylergometrine should not be used in women with hypertension, heart disease, preeclampsia, eclampsia, Raynaud’s phenomenon, or scleroderma

Misoprostol

  • Synthetic analog of prostaglandin E1 that causes uterine contraction
  • May be given as an alternative when Oxytocin is not available or cannot be safely used to prevent or treat PPH
    • 600 mcg per orem (PO) may be given to prevent PPH and 800 mcg sublingual (SL) to treat PPH
    • 1000 mcg rectally when uterine atony is perceived to be a cause of bleeding
    • Can be given to patients with asthma or hypertension
  • Used during controlled cord traction only when a skilled attendant is present at the birth

Oxytocin/Ergometrine

  • Appears to be more effective than Oxytocin used alone and has been used in the prevention and treatment of PPH
    • Reduces the risk of minor PPH, ie 500-1000 mL 
  • Associated with more side effects than Oxytocin and cannot be used in women with high BP, heart disease, preeclampsia, or eclampsia

Other

Tranexamic Acid

  • May be used to treat PPH if Oxytocin or other uterotonics are unable to stop the bleeding
  • IV Tranexamic acid may be used with Oxytocin in women delivering by cesarean section who are at risk of PPH  

Non-Pharmacological Therapy

Cord Clamping and Cutting

  • In active management of the 3rd stage of labor, the umbilical cord is clamped 1-3 minutes after birth and cut following delivery
  • Early cord clamping (<1 minute after birth) is not recommended unless newborn needs resuscitation
  • Prompt clamping appears to shorten the 3rd stage of labor though there is no evidence that this decreases the risk of PPH

Controlled Cord Traction

  • Done by downward, gentle pulling on the cord once the uterus has contracted while simultaneously applying pressure on the uterus by pushing on the abdomen just above the pubic bone (counter traction)
  • If the placenta fails to descend within 30-40 seconds, do not continue to pull the cord
    • Wait until the uterus is well contracted again
  • Hastens separation of the placenta from the uterus and its subsequent delivery
  • It is crucial for personnel performing traction to have consistent training and guidelines due to the potential risk of uterine inversion

Acute Treatment of Postpartum Hemorrhage

Oxygenation

  • Establishment of airway is the very first step in resuscitation
  • Oxygen (O2) by mask may be administered and endotracheal intubation may be necessary in the obtunded patient or those with impending respiratory fatigue
  • A high concentration of oxygen at 10-15 L/min can be given to maintain oxygen saturation at ≥95% 

Fluid Resuscitation

  • Until blood is available, begin fluid resuscitation with infusion of warmed clear fluids  
  • Peripheral IV access using large-bore needle allows for a faster flow rate of IV fluids
  • Target an SBP of 90 mmHg and urine output >30 mL/hr

Crystalloid Solution

  • Eg Ringer’s lactate, normal saline (NS)
  • Crystalloid solutions are widely available, safe and inexpensive but they move rapidly from intravascular to extravascular space
    • ≥3x the volume of fluid lost will be needed as replacement and tissue edema ensues
  • Ringer’s lactate may be preferred if large volume (>10 L) are required to avoid hyperchloremic acidosis associated with prolonged use of NS

Colloid Solution

  • Eg albumin, hydroxyethyl starch, dextrans and gelatins
  • Colloid solution contains osmotically-active molecules which stay in the intravascular compartment expanding its volume
  • Use of these agents is limited by cost and availability and a meta-analysis has suggested that crystalloid solutions have better outcome when used for resuscitation
  • May be used together with crystalloids

There is no role for hypotonic dextrose solutions (D5W or diluted NS in 5% dextrose in water) in the management of hemorrhagic shock

Blood Transfusion

  • Patients with blood losses of >20-25% and those with suspected coagulopathy require transfusion
  • Packed red blood cells (RBCs) are used to restore intravascular volume and oxygen-carrying capacity of the blood
    • If immediate transfusion is needed, patient may be given emergency group O, rhesus D (RhD)-negative packed RBCs then switch to group-specific RBCs when feasible 
  • Fresh frozen plasma (FFP) can be given when PTT and PT are prolonged  
    • If no hemostatic test results are available, FFP can be infused after RBC transfusion if bleeding is ongoing or early FFP can be considered with delayed detection of PPH or for conditions such as placental abruption or amniotic fluid embolism 
  • Platelet concentrates are indicated if platelet count is <20,000-50,000/mm3 and hemorrhage is continuing
  • Cryoprecipitate may be given for fibrinogen replacement with fibrinogen level <2 g/L

Vasoactive Agents

  • Inotropic and vasopressor agents are rarely indicated in the management of hemorrhagic shock
  • Should only be used when adequate volume has been achieved, hemorrhage is controlled but hypotension continues

Etiology- Based Therapy of Postpartum Hemorrhage

Uterine Atony (Tone)

  • Massage and/or compression of the uterus or rubbing the uterine fundus and Oxytocin should be administered if the uterus is found to be atonic
    • Bimanual massage (one hand pressing on the fundus while the 2nd hand is placed anterior to the cervix) with the urinary bladder empty
  • Ergometrine, Methylergometrine, Carboprost or Misoprostol may be given if the uterus is still atonic even after administration of Oxytocin
  • A single dose of sublingual Misoprostol 800 mcg is a safe and effective treatment of postpartum hemorrhage (PPH) due to uterine atony in women with or without Oxytocin prophylaxis during the 3rd stage of labor
  • Uterine balloon tamponade may be done to temporarily control active PPH due to uterine atony that has failed to respond to medical therapy
    • May arrest or stop bleeding in 77.5-88.8% of cases that do not need any further surgical therapy
    • Can identify the source of bleeding (if bleeding does not stop with inflation, bleeding is likely secondary to causes other than uterine atony)
  • Aortic compression done after vaginal birth is recommended as a temporizing measure until necessary interventions are available
  • Non-pneumatic anti-shock garment (NASG) is a first-aid garment compression device that can significantly improve shock, decrease blood loss, reduce emergency hysterectomy for atony and decrease maternal mortality
  • Uterine artery embolization is done if there is persistent bleeding after other measures have been tried
    • An option for stable woman before undergoing surgical intervention

Retained Products of Conception (Tissue)

  • Manual exploration of the uterus is performed for possible retained placental tissue
    • Procedure should be performed under general anesthesia unless patient is in profound shock or an epidural is already in place
  • Manual evacuation is done with hand passed through the cervix and into the lower segment
  • Therapeutic uterotonics are maintained throughout the procedure
  • Broad-spectrum antibiotics are recommended after manual removal

Genital Tract Trauma (Trauma)

  • Trauma is the most likely cause of persistent bleeding despite a well-contracted uterus
  • Direct visualization and inspection of the entire cervix aided by ring forceps is performed under appropriate analgesia and repair is undertaken for any laceration
  • Pressure is applied over the laceration and must be observed for bleeding after repair
  • Tranexamic acid may be given if Oxytocin or other uterotonics are unable to stop the bleeding or if the bleeding is partly due to trauma

Coagulopathy (Thrombin)

  • Refer to Blood Transfusion
  • Further evaluation is recommended for patients who do not respond to the usual treatment procedure, do not form blood clots or those in whom blood oozes from puncture sites
  • Platelet count, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen and fibrin split products should be determined
  • Treat underlying disease, restore intravascular volume and monitor coagulation status
  • Recombinant factor VIIa and other medications promoting clot formation may be given as indicated, though it is not recommended to use recombinant factor VIIa routinely  

Other

Management for Anemia

  • Most patients with persistent bleeding are at risk for anemia
  • If indicated, iron supplement should be advised for at least 3 months
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