Postpartum hemorrhage

• Occurs in
  1-5% of births in US

• EBL >
  1000ml

• Causes: 4Ts

  • Tone:
    Usually result of uterine atony, 80%

  • Trauma:
    Lacerations, surgical incisions, uterine rupture

  • Thrombin:
    Coagulopathy leading to consumption of clotting factors and
    hemodilution of remaining clotting factors

  • Tissue:
    Retained placenta

• Risk factors:
  retained or adherent placenta, abnl placentation, prolonged/failure
  to progress labor, instrumental delivery, large gestational age
  newborn, hypertensive disorders (pre/eclampsia, HELLP), induction of
  labor, fetal demise

• Maneuvers to
  manage

  • Bimanual
    uterine massage
    

  • 1^st
    line: Oxytocin 10-40 units diluted in IVF, (typically 40 units in
    1L NS or LR) given IV adjust rate to control uterine atony, or 10
    units IM if no IV access yet

  • 2^nd
    line: Misoprostol (Cytotec, PGE1) 400 mcg SL or 1000 mcg rectal

  • 3rd line:
    Carboprost (Hemabate) 0.25 mg IM q15min max 8 doses (if no asthma
    hx)

  • 3rd line:
    Methylergonovine (Methergine) 0.2 mg IM repeat Q2-4 hrs (if no HTN,
    CAD, Raynaud’s)  Trick to
    remember “Meth” is bad for your heart

  • Fluid
    resuscitate & transfuse:

    • Blood
      products, MTP

    • +/-
      Cryoprecipitate (rich w/ fibrinogen), or fibrinogen concentrate
      (RiaSTAP) to correct coagulopathy

  • Uterine
    balloon tamponade (commercially available, or improvised with #24
    Foley w/ 30ml balloon, Blakemore), packing

• Consider
  amniotic fluid embolism, sending DIC panel