Author:

Sarah H.Michael

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

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 and frequent hemoglobin determination

Diagnostic Tests & Interpretation

Diagnosis is chiefly based on clinical suspicion and exam

Differential Diagnosis

• Consider puerperal hematomas if perineal, rectal, or lower abdominal pain in conjunction with tachycardia and hypotension
• Retained products of conception
• Intra-abdominal (usually hepatic or splenic) hemorrhage

Prehospital

• 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 to monitor urine output

ED Treatment/Procedures

Identify and treat cause of hemorrhage, if possible

• Management of uterine atony:
  • Bimanual massage
  • Uterotonic medications (see Medication)
  • Uterine packing/tamponade (temporizing measure):
    • Can be used for atony or continued bleeding
    • Balloon or packing can be used
    • May use a Foley catheter, Rusch catheter, Sengstaken-Blakemore tube or surgical obstetric silicone (SOS) Bakri tamponade balloon
  • Surgery or embolization 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 cervical relaxation agent (see “Medication”) and reposition
    • Surgical reduction if unsuccessful or if subacute or chronic inversion
• Management of coagulopathies:
  • Fresh-frozen plasma, platelets, cryoprecipitate as indicated
• Other treatments/adjuncts
  • Consider use of antifibrinolytic medication (see “Medication”)
  • Immediate administration of uterotonics after delivery
  • Cord clamping and cutting without delay
  • Cord traction/uterine counter-traction (Brand t-and rews maneuver)

Medication

• Uterotonics - stimulate uterine contraction to control bleeding:
  • Oxytocin: 10 units IM or 20-40 units IV in 1 L normal saline; titrate to achieve uterine contractions
  • Methylergonovine: 0.2 mg IM; 0.2 mg PO q6h; avoid if known hypertensive (stroke risk)
  • Misoprostol: 800 mcg PO once
  • Carboprost: 0.25 mg IM; may repeat in 15-60 min; relatively contraindicated in asthma
• 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
• Antifibrinolytic - prevents breakdown of clot and provides clot stabilization
  • Tranexamic acid: 1 g IV; controversial; consider if uterotonics fail or if trauma is suspected
• Blood products:
  • Utilize to avoid dilutional anemia
  • Packed red blood cells: Goal Hgb >9
  • Consider viscoelastic testing to guide management of hemostasis
  • Cryoprecipitate: Goal fibrinogen >1.5 g/L
  • Fresh frozen plasma: 15 mL/kg if PT/aPTT >1.5× normal
  • Platelets: Transfuse when <75 × 10⁹ to maintain >50 × 10⁹

Disposition

Follow-up Recommendations

• Close follow-up with obstetrician
• Seek immediate care if bleeding recurs

• Chand raharanE, KrishnaA. Diagnosis and management of postpartum haemorrhage . BMJ. 2017;358:j3875.
• CollisRE, CollinsPW. Haemostatic management of obstetric haemorrhage . Anaesthesia. 2015;70:78-86.e27-e28.
• EvensenA, and ersonJM, FontaineP. Postpartum hemorrhage: Prevention and treatment . Am Fam Physician. 2017;95:442-449.
• MousaHA, BlumJ, Abou El SenounG, et al. Treatment for primary postpartum haemorrhage . Cochrane Database Syst Rev. 2014:CD003249.
• WHO recommendations for the prevention and treatment of postpartum haemorrhage . 2012:1-48.

See Also (Topic, Algorithm, Electronic Media Element)

• Vaginal Bleeding
• Placenta Previa
• Placental Abruption
• Pregnancy, Trauma in
• Pregnancy, Uncomplicated
• Labor
• Delivery, Uncomplicated

ICD9

• 666.00 Third-stage postpartum hemorrhage, unspecified as to episode of care or not applicable

• 666.10 Other immediate postpartum hemorrhage, unspecified as to episode of care

• 666.20 Delayed and secondary postpartum hemorrhage, unspecified as to episode of care or not applicable

• 666.30 Postpartum coagulation defects, unspecified as to episode of care or not applicable

• 666.02 Third-stage postpartum hemorrhage, delivered, with mention of postpartum complication

• 666.04 Third-stage postpartum hemorrhage, postpartum condition or complication

• 666.12 Other immediate postpartum hemorrhage, delivered, with mention of postpartum complication

• 666.14 Other immediate postpartum hemorrhage, postpartum condition or complication

• 666.1 Other immediate postpartum hemorrhage

• 666.22 Delayed and secondary postpartum hemorrhage, delivered, with mention of postpartum complication

• 666.24 Delayed and secondary postpartum hemorrhage, postpartum condition or complication

• 666.2 Delayed and secondary postpartum hemorrhage

• 666.32 Postpartum coagulation defects, delivered, with mention of postpartum complication

• 666.34 Postpartum coagulation defects, postpartum condition or complication

• 666.3 Postpartum coagulation defects

• 666 Postpartum hemorrhage

ICD10

• O72.0 Third-stage hemorrhage

• O72.1 Other immediate postpartum hemorrhage

• O72.2 Delayed and secondary postpartum hemorrhage

• O72.3 Postpartum coagulation defects

• O72 Postpartum hemorrhage

SNOMED

• 47821001 Postpartum hemorrhage (disorder)

• 23171006 Delayed and /OR secondary postpartum hemorrhage

• 47236005 Third stage hemorrhage (disorder)

• 49177006 Postpartum coagulation defect with hemorrhage (disorder)