SIGNS AND SYMPTOMS 
- Ongoing blood loss, usually painless
- Significant hypovolemia, resulting in:
- Tachycardia
- Tachypnea
- Narrow pulse pressure
- Decreased urine output
- Cool, clammy skin
- Poor capillary refill
- Altered 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 delivery
- Episiotomy
- Prior clotting disorders
- Symptoms of hypovolemia:
- Decreased urine output
- Lightheaded
- Syncope
- Pale 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
[Outline]
ALERT
- 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 oxygen
- Cardiac monitor
- IV fluid resuscitation with normal saline or lactated Ringer solution
- Foley catheter
ED TREATMENT/PROCEDURES
- 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
- 15-methyl prostaglandin F2α (PGF2α; Hemabate) IM if above fails:
- Relatively contraindicated in asthma
- Surgery if medical intervention fails
- Inspect closely for genital tract laceration:
- Repair required if ≥2 cm
- Use 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 uterus
- Place right hand with fingers spread into vagina and push steadily on inverted part to reduce
- If unsuccessful, give terbutaline IV or magnesium sulfate to produce cervical relaxation, and reposition
- Surgery if unsuccessful or if subacute or chronic inversion
- 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
MEDICATION
- Uterotonics—stimulate uterine contraction to control bleeding:
- Ergonovine (Ergotrate): 0.2 mg IM; avoid if known hypertensive
- Methylergonovine (Methergine): 0.2 mg IM; 0.2 mg PO q6h; avoid if known hypertensive
- 15-methyl PGF2α (Hemabate): 0.25 mg IM; may repeat in 15–60 min
- Oxytocin (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 min
- Terbutaline: 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
[Outline]
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
[Outline]
- 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, Gülmezoglu 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.
- Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2012;8:CD000494.
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