Postpartum hemorrage

Credit: Drs Wu, A. Ogunniyi, R. Pedigo, R. Fleischman on 
OB Sim Day at Harbor-UCLA

Postpartum hemorrhage

  • Occurs in
    1-5% of births in US

  • EBL >

  • 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

    • Bimanual
      uterine massage

    • 1st
      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

    • 2nd
      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

    • 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

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