Postpartum HemorrhageWHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC). The purpose of this document is to review the etiology, evaluation, and management of postpartum hemorrhage. Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning. Attention to improving the hospital systems necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage. The creation of a patient safety team that works to improve the hospital systems for caring for women at risk for major obstetric hemorrhage can help to identify and manage these situations and save lives. Development of clinical pathways, guidelines and protocols designed to provide early diagnosis of patients at risk for major obstetric hemorrhage and for streamlined care in emergency situations are essential. A multidisciplinary patient safety team that includes individuals from the Division of Obstetric Anesthesiology, Maternal Fetal Medicine, Neonatology, and the Blood Bank as well as Departments of Nursing, Communication, and Administration and quarterly mock drills of rapid response team, helps to respond to these situations effectively. Postpartum Hemorrage from Vaginal Delivery Checklist: (view/download pdf document) Postpartum hemorrhage (PPH) is defined as a blood loss of more than 500 ml after vaginal delivery and more than 1,000 ml after cesarean delivery. The American College of Obstetricians and Gynecologists (ACOG) defines it as a decrease in hematocrit of more than 10% from before to after delivery. Massive uncontrolled hemorrhage after childbirth is the leading cause of pregnancy-related death in the United States and developing countries both. Moreover, obstetric hemorrhage can cause shock, renal failure, and Sheehan's syndrome (postpartum pituitary necrosis). Uterine atony, degrees of retained placenta - including placenta accrete and its variants and genital tract lacerations account for most cases of postpartum hemorrhage. Hemorrhage after the first 24 hours is designated late postpartum hemorrhage. Although PPH cannot always be anticipated, the cornerstones of effective treatment remain rapid diagnosis and intervention. Our goal here is to review new interventions, and revisit old ones that can assist in controlling acute hemorrhage. Predisposing Factors: Clinical Characteristics: Postpartum hemorrhage before placental delivery is called third-stage hemorrhage. Whether bleeding begins before or after placental delivery, or at both times, there may be no sudden massive hemorrhage but rather steady bleeding that at any given instant appears to be moderate, but persists until serious hypovolemia develops. Especially with hemorrhage after placental delivery, the constant seepage may lead to enormous blood loss. The effects of hemorrhage depend to a considerable degree upon the non-pregnant blood volume, magnitude of pregnancy induced hypervolemia, and degree of anemia at the time of delivery. A treacherous feature of postpartum hemorrhage is the failure of the pulse and blood pressure to undergo more than moderate alterations until large amounts of blood have been lost. Sometimes the hypovolemia may not be recognized until very late. When excessive hemorrhage is even suspected in the woman with severe pregnancy-induced hypertension, efforts should be made immediately to identify those clinical and laboratory findings that would prompt vigorous crystalloid and blood replacement. The differentiation between bleeding from uterine atony and from lacerations is tentatively made on the condition of the uterus. If bleeding persists despite a firm, well-contracted uterus, the cause of the hemorrhage most probably is from lacerations. Bright red blood also suggests lacerations. To ascertain the role of lacerations as a cause of bleeding, careful inspection of the vagina, cervix and uterus is essential. Sometimes bleeding may be caused by both atony and trauma, especially after major operative delivery. Anesthesia should be adequate to prevent discomfort during such an examination. Management of Third-Stage Bleeding: Some bleeding is inevitable during the third-stage as the result of transient partial separation of the placenta. If the signs of placental separation have appeared, expression of the placenta should be attempted by manual fundal pressure. Descent of placenta is indicated by the cord becoming slack. If bleeding continues, manual removal of the placenta is mandatory. Technique of Manual Removal: adequate analgesia and anesthesia is mandatory. Aseptic surgical technique should be employed. After grasping the fundus through the abdominal wall with one hand, the other hand is introduced into the vagina and passed into the uterus, along the umbilical cord. As soon as the placenta is reached, its margin is located and the ulnar border of the hand insinuated between it and the uterine wall. Then with the back of the hand in contact with the uterus, the placenta is peeled off its uterine attachment by a motion similar to that employed in separating the leaves of a book. After its complete separation, the placenta should be grasped with the entire hand, which is then gradually withdrawn. Membranes are removed at the same time by carefully teasing them from the deciduas, using ring forceps to grasp them as necessary. Some clinicians prefer to wipe out the uterine cavity with a sponge. If this is done, it is imperative that the sponge not be left in the uterus or vagina. (Source-21st edition William's Obstetrics) Management After Delivery of Placenta: The fundus should always be palpated following placental delivery to make certain that the uterus is well contracted. If not firm vigorous fundal massage is indicated. Most often 20 U of oxytocin in 1000 ml of lactated Ringer or normal saline proves effective when administered intravenously at approximately 10 ml/minute (200 mU of oxytocin per minute) simultaneously with effective uterine massage. Oxytocin should never be given as an undiluted bolus dose as serious hypotension or cardiac arrhythmias may follow. Bleeding Unresponsive to Oxytocics: continued bleeding after multiple oxytocic administrations may be from unrecognized genital tract lacerations, including in some cases of uterine rupture. The following management is suggested to be initiated immediately: Medical Management of Postpartum Hemorrhage (Source: ACOG Practice Bulletin No. 76, October 2006) Dose/Route Frequency Comment Oxytocin (Pitocin) IV: 10-40 units in 1 liter normal saline or lactated Ringer's solution. Continuous Avoid undiluted rapid IV infusion, which causes hypotension. Methylergonovine (Methergine) IM: 0.2 mg Every 2-4 hour Avoid if patient is hypertensive. 15-methyl PGF2α (Carboprost) IM: 0.25 mg Every 15-90 min, Avoid in asthmatic patients; relative contraindication if hepatic, renal and cardiac disease. Diarrhea, fever, tachycardia can occur. Dinoprostone Suppository: vaginal or rectal; 20 mg Every 2 hour Avoid if patient is hypotensive. Fever is common. Stored frozen, it must be thawed to room temperature. Misoprostol 800-1,000 mcg rectally Can cause nausea and vomiting. Inversion of the uterus: Complete uterine inversion after delivery of the infant is almost always the consequence of strong traction on an umbilical cord attached to a placenta implanted in the fundus. Incomplete uterine inversion may also occur. Uterine inversion is most often associated with immediate life-threatening hemorrhage, and without prompt treatment it may be fatal. Delay in treatment increases the mortality rate appreciably. It is imperative that a number of steps be taken immediately and simultaneously: Long-term effects of PPH: Often, the consequences of PPH are more severe because of baseline maternal anemia. High doses of iron may be needed and injectable iron preparations are generally quite effective. Erythropoietin (EPO) is a hormone secreted by the kidney that regulates the differentiation and maturation of erythrocytes. In the normal pregnancy, EPO levels rise to two to four times that seen in nonpregnant, nonanemic controls and peak in the third trimester. Use of recombinant human erythropoietin (rHuEPO) during pregnancy has been reported in women with severe anemia due to renal failure, thalassemia, leukemia, and iron-deficiency anemia. RHuEPO is useful in: (1) antepartum management of the severely anemic patient at risk for hemorrhage, (2) antepartum management of the nonanemic woman at risk for hemorrhage to allow for autologous blood transfusion, (3) the postpartum augmentation of anemia due to hemorrhage. All patients on rHuEPO therapy require iron supplementation. Sheehan Syndrome: severe intrapartum or early postpartum hemorrhage is on rare occasions followed by pituitary failure. The classical case of Sheehan syndrome is characterized by failure of lactation, amenorrhoea, breast atrophy, loss of pubic and axillary hair, hypothyroidism, and adrenal cortical insufficiency. Lactation after delivery usually, but not always, excludes extensive pituitary necrosis. The incidence of Sheehan syndrome was originally estimated to be 1 per 10,000 deliveries, and it appears to be even rarer today in the United States. Application of the tests of hypothalamic and pituitary function now available should identify milder forms of the syndrome and define their prevalence. The anterior pituitary of some women who develop hypopituitarism after puerperal hemorrhage does respond to various releasing hormones, which at the least implies impaired hypothalamic function. Conclusion: We have described a variety of novel techniques, in addition to our traditional approach, that can be highly successful in managing PPH. Depending on the availability of resources (anesthesia, interventional radiology, cost) most of these approaches can be incorporated into routine practice with little hardship in the majority of modern obstetrical suites. Introducing these techniques can help to lower maternal death rates, minimize hysterectomies and blood transfusions, and improve patient satisfaction. Suggested Reading: |