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    Postpartum Hemorrhage

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    Sep.18.2024

    Postpartum Hemorrhage

    Synopsis

    Key Points

    • Postpartum hemorrhage is a life-threatening obstetric complication characterized by excessive blood loss after delivery; generally defined as blood loss in excess of 500 to 1000 mL r1r2r3
      • Primary postpartum hemorrhage occurs within 24 hours of delivery
      • Secondary hemorrhage occurs 24 hours to 12 weeks after delivery
    • Most common cause of primary hemorrhage is uterine atony, but lacerations, coagulation disorders, or retained tissue are also potential causes r2
    • Secondary postpartum hemorrhage may result from retained tissue, subinvolution of the placental site, endometritis, or inherited coagulopathy r2
    • Blood loss is usually obvious and may be quantified by a combination of visual estimation, the weight of saturated gauze and linens, and/or direct measurement of blood in the suction canister and in the collection pouches of specially designed drapes r4
      • Occult blood loss may occur as perineal or pelvic hematoma; clinical clues include unexplained severe pain, tachycardia, and hypotension
    • Laboratory studies such as CBC, prothrombin time, INR, partial thromboplastin time, fibrinogen, fibrin degradation products, electrolytes, creatinine, and calcium are primarily useful as a baseline for monitoring r5r6
      • Type and crossmatch are done in advance in high-risk patients or immediately upon recognition of hemorrhage in others
    • Management involves rapid and simultaneous measures: r7
      • Initiation of fluid resuscitation followed by transfusion of blood, platelets, and fresh frozen plasma as soon as available
      • Careful inspection to identify source of bleeding, repair lacerations, remove retained tissue, and reposition uterus (if inverted)
      • If atony is suspected, administer uterotonic agents and perform uterine massage or bimanual compression; tranexamic acid is recommended by some authoritiesr2r8
      • If conservative measures fail to control bleeding, other interventions include uterine tamponade by balloon or packing, uterine artery embolization or ligation, and placement of compression sutures around the uterus; hysterectomy is a lifesaving last resort
    • Complications include disseminated intravascular coagulation, end-organ damage, infertility, and death
    • Prevention focuses on active management of the third stage of labor, including administration of oxytocin, uterine massage, controlled cord traction, and manual removal of placenta if necessary r2r9

    Urgent Action

    • Simultaneous efforts must be made to maintain or restore hemodynamic stability, control source of bleeding, replace lost blood and fluids, and address coagulopathy if present; protocols have been published and their use improves outcomes r7r10
    • It is suggested that no more than 30 minutes elapse before resorting to the next step in management (eg, primary measures to control bleeding, secondary interventions, hysterectomy) r10

    Pitfalls

    • Under- and overestimation of blood loss are common based on visual estimation alone
    • Multiple sources of bleeding may be present

    Terminology

    Clinical Clarification

    • Postpartum hemorrhage is an obstetric emergency characterized by excessive blood loss after delivery r1r2r3
      • Quantitative parameters differ among guidelines but generally define the condition as blood loss exceeding either 500 mL (vaginal delivery) or 1000 mL (cesarean delivery) or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours of birth r1r2
        • Historically, some defined postpartum hemorrhage as a hemoglobin drop of 4 g/dL or more, or a decrease in hematocrit of 10% or greater r2r3

    Classification

    • By extent of blood loss and physiologic response r11
      • Class 1: 1000 mL (10%-15% blood volume) loss
        • Clinical response characterized by dizziness, palpitations, and small drop in blood pressure
      • Class 2: 1500 mL (20%-25%) loss
        • Accompanied by tachycardia, tachypnea, diaphoresis, weakness, narrowed pulse pressure, and orthostatic hypotension
      • Class 3: 2000 mL (30%-35%) loss
        • Manifested by significant tachycardia and tachypnea, restlessness, pallor, and cool extremities
      • Class 4: 2500 mL loss or more (40% or more)
        • Associated with shock, air hunger, and decreased urine output
    • By time since delivery r2
      • Primary (early) postpartum hemorrhage: within 24 hours after delivery
      • Secondary (late) postpartum hemorrhage: abnormal and excessive bleeding from 24 hours up to 12 weeks after delivery

    Diagnosis

    Clinical Presentation

    History

    • Primary postpartum hemorrhage
      • Patient or caregiver may note steady, heavy bleeding. Saturation of 1 or more pads in 5 minutes is concerning; however, visual estimates of blood loss are inaccurate c1
      • Patients with severe hemorrhage may become light-headed, nauseated, clammy, or dyspneic c2c3c4c5
      • In some cases, bleeding into soft tissues results in an expanding hematoma and severe pain at the site c6
    • Secondary postpartum hemorrhage
      • Patients may note gradual or abrupt escalation of vaginal bleeding c7
        • In cases caused by infection or retained products of conception, bloody discharge may be characterized by a foul odor and patients may experience low abdominal pain or cramping c8c9c10c11
      • Patients may have symptoms of anemia (eg, easy fatigability, light-headedness, dyspnea) c12c13c14

    Physical examination

    • Primary postpartum hemorrhage
      • Assess airway and vital signs r12
        • Moderate blood loss may occur without affecting vital signs; presence of tachycardia, tachypnea, or low blood pressure indicates loss of 1500 mL or more r11c15
        • Altered mental status may be evident, and may indicate inadequate perfusion c16
      • Blood loss may be quantified by a combination of the following: r4r13
        • Visual estimation by an experienced observer c17c18
          • Under- and overestimation are common based on visual estimation alone
        • Comparing weight of saturated gauze and linens with previously established dry weights c19
        • Direct measurement of blood in the suction canister and in the collection pouches of specially designed drapes c20
      • Conduct a thorough visual and manual examination of the perineum, vulva, vagina, cervix, and uterus to identify source(s) of bleeding r14c21c22
        • Inspect for lacerations, hematomas, retained placental cotyledons, or fetal membranes c23c24c25
        • Palpate for unexplained mass or tenderness c26
        • Assess uterine tone, which should be taut; bogginess suggests atony c27
      • Inspect placenta for missing cotyledons r14c28
    • Secondary postpartum hemorrhage
      • If bleeding has been severe or continuous, there may be tachypnea and/or tachycardia c29c30c31
      • Pallor of conjunctivae, face, or palms may be evident c32c33
      • On pelvic examination, bleeding from the os may be observed; rarely, previously undetected tears or lacerations may be seen c34c35c36c37

    Causes and Risk Factors

    Causes

    • Primary postpartum hemorrhage (within 24 hours of delivery) r2c38
      • Uterine atony (most common, causing up to 80% of cases) c39
        • Inadequate involution of uterus after delivery; may or may not be associated with retained placenta or placental abnormalities c40c41
      • Trauma (second most frequent cause) c42
        • Includes spontaneous tears, incisions, and other instrumentation, as well as uterine rupture
      • Coagulopathy c43
        • Previously recognized conditions or medication
        • Rare hematologic conditions associated with pregnancy (eg, idiopathic thrombocytopenia, thrombotic thrombocytopenic purpura, HELLP syndrome) c44c45c46d1
        • Secondary coagulopathies resulting from the underlying obstetric event, increasing blood loss and complicating management
          • Amniotic fluid embolism results in acute overwhelming disseminated intravascular coagulation c47c48
          • Abruptio placentae and severe preeclampsia may also cause disseminated intravascular coagulation c49c50
          • Massive hemorrhage may trigger a consumptive coagulopathy; volume resuscitation may result in dilutional coagulopathy
      • Retained placenta c51
        • Placenta may tear, resulting in retained fragments
        • Placenta accreta (adherence to uterine wall) may prevent normal separation and expulsion
      • Uterine inversion c52
        • May occur spontaneously or may be iatrogenic, caused by incorrect use of fundal pressure and traction on the cord
    • Secondary postpartum hemorrhage (24 hours to 12 weeks after delivery) r2r15
      • Retained products of conception c53
      • Subinvolution of the placental site
      • Infection (endometritis) c54
      • Inherited coagulation disorder c55
      • Gestational trophoblastic disease c56

    Risk factors and/or associations

    Ethnicity/race
    • White women (both Hispanic and non-Hispanic) are at higher risk r16c57c58c59
    Other risk factors/associations
    • Factors resulting in overdistention of the uterus r1
      • Multiple gestation (eg, twins) c60
      • Fetal macrosomia c61
      • Polyhydramnios c62
    • Nature of labor and delivery r1
      • Induced labor c63
      • Precipitous labor (lasting less than 3 hours) c64
      • Prolonged labor c65
      • Forceps or vacuum-assisted delivery c66
      • Cesarean delivery c67
    • Factors relating to the placenta r1
      • Abruptio placentae c68
      • Placenta previa c69
      • Abnormal implantation c70
    • High multiparity r1c71
    • Preeclampsia r1c72
    • Chorioamnionitis r1c73
    • Amniotic fluid embolism r1c74
      • May precipitate disseminated intravascular coagulation, resulting in consumptive coagulopathy and uncontrolled blood loss
    • General anesthesia r17c75
    • Medications
      • Prolonged oxytocin use r1c76
      • Magnesium sulfate c77
      • Anticoagulation c78

    Diagnostic Procedures

    Primary diagnostic tools

    • Primary postpartum hemorrhage
      • Quantify blood loss by visual estimation, by comparing weight of saturated gauze and linens with previously established dry weights, and/or by direct measurement of blood in measurement containers c79
      • Thoroughly examine the perineum, vulva, vagina, cervix, uterus, and placenta to locate main source(s) of bleeding r2c80c81
      • Occult blood loss may occur as perineal or pelvic hematoma; clinical clues include unexplained severe pain, tachycardia, and hypotension r4
      • Assess hemoglobin, hematocrit, and fibrinogen levels; platelet count; prothrombin time and INR; partial thromboplastin time; and fibrin degradation products at hemorrhage onset and periodically until stable r5r6c82c83c84
      • Obtain routine chemistries, particularly electrolyte and creatinine levels, at hemorrhage onset and periodically until stable r7c85
      • Obtain blood for type and crossmatch c86c87
      • Obtain imaging if source of bleeding is not obvious on examination, or if patient continues to deteriorate despite measures to control identified source(s) of blood loss r2
    • Secondary postpartum hemorrhage
      • Obtain CBC and routine coagulation studies (eg, prothrombin time, INR, partial thromboplastin time) in all patients r18r19
      • Perform ultrasonography to evaluate for retained products of conception r20c88
      • Refer patients who present with hemorrhage onset 48 hours after delivery to a hematologist for screening for von Willebrand disease and other inherited or acquired coagulopathy r20

    Laboratory

    • CBC c89
      • Hemoglobin and hematocrit levels do not reflect blood loss immediately, but initial measure serves as a baseline for monitoring serial changes that may occur from further loss and dilution through fluid resuscitation
    • Coagulation studies c90c91c92
      • Abnormalities in results may suggest previously undiagnosed condition (eg, clotting factor deficiency) or disseminated intravascular coagulopathy; the latter may be due to hemorrhage itself or another cause (eg, amniotic fluid embolism)
        • Disseminated intravascular coagulopathy is characterized by low or falling platelet count, prolonged prothrombin or partial thromboplastin time, elevated INR, low fibrinogen levels, and presence of fibrin degradation products r5
          • Fibrinogen levels are typically elevated in pregnancy; therefore, a level within general reference limits may be abnormally low in the context of pregnancy (ie, outside the pregnancy reference range) r6
            • Level below 200 mg/dL predicts severe postpartum hemorrhage
    • Biochemistry panel c93
      • Disturbances of serum electrolytes and alterations in renal function are common in hemorrhages that require transfusion and fluid resuscitation; symptomatic hypocalcemia may complicate massive transfusion r12
    • Consider β-hCG testing in late presentations of secondary postpartum hemorrhage; persistently high levels may suggest gestational trophoblastic disease r15c94

    Imaging

    • Ultrasonography r2c95
      • The American College of Radiology indicates that, for initial imaging, US duplex Doppler pelvis, US pelvis transabdominal, and US transvaginal are usually appropriate; the procedures are considered complementary r21
      • Indicated when source of bleeding is not evident on examination, particularly in secondary postpartum hemorrhage (which may be caused by retained product of conception)
      • May identify cause or location (eg, retained placenta, deep soft tissue hematoma)
      • May be done at the bedside

    Other diagnostic tools

    • Obstetric shock index has been proposed to aid in diagnosis and monitoring r22
      • Calculated as pulse rate divided by systolic blood pressure, measured at 10 minutes and 30 minutes after onset of postpartum bleeding
      • Value greater than 1 indicates significant blood loss
      • Presence of preeclampsia and high systolic blood pressure may result in a low value despite significant blood loss

    Treatment

    Goals

    • Replace blood and fluid loss to restore or maintain hemodynamic stability
    • Control bleeding and manage cause

    Disposition

    Admission criteria

    Admit all patients with primary postpartum hemorrhage if not already in hospital

    • Patients in whom bleeding is not promptly controlled in delivery or postdelivery setting require transfer to operating room

    Patients with secondary postpartum hemorrhage require admission if bleeding is extensive or if signs and symptoms of infection are present (eg, fever, abdominal tenderness)

    Criteria for ICU admission
    • Patients with postpartum hemorrhage exceeding 1500 mL, coagulopathy, or abnormal vital signs r7
    • May vary depending on capabilities of obstetric unit

    Recommendations for specialist referral

    • Refer to obstetrician-gynecologist to evaluate and manage source of bleeding
    • Refer to hematologist, anesthesiologist, and/or critical care specialist to manage hemostatic resuscitation
    • Refer stable patients who present with unexplained secondary postpartum hemorrhage to a hematologist for evaluation and management of possible coagulopathy

    Treatment Options

    Primary postpartum hemorrhage

    • Simultaneous efforts must be made to maintain or restore hemodynamic stability, control source of bleeding, replace lost blood and fluids, and address coagulopathy if present; protocols have been published and their use improves outcomesr7
    • Ensure patent airway r12
      • Consider intubation if airway or level of consciousness is compromised; provide supplemental oxygen
    • Obtain additional IV access with large-bore cannula and infuse crystalloids pending availability of blood products
    • Place a urinary catheter to decompress bladder (allowing easier examination and uterine compression) and to monitor urine output (goal, greater than 30 mL/hour) r11
    • Control source(s) of bleeding
      • Placenta has not been expelled r2
        • Massage uterus to stimulate contraction
        • Apply controlled traction to cord
        • If necessary, remove placenta manually
      • Placenta has been expelled
        • Massage and compress uterus to expel remaining clots
      • Suspected uterine atony
        • Initiate or supplement uterotonic administration (eg, oxytocin, carboprost, methylergonovine, misoprostol)
          • For initial use as primary treatment of postpartum hemorrhage, oxytocin is superior to misoprostol and is considered first line therapyr24r25 where available r23
          • Second line uterotonics include methylergonovine and carboprost; selection depends on availability and contraindications r25
            • Methylergonovine is contraindicated in the setting of hypertension, preeclampsia, or recent use of vasoconstrictive drugs
            • Carboprost has been associated with hypertension and bronchospasm and must be used with caution in patients with asthma, cardiovascular disease, or hepatic disease
          • Misoprostol should be considered for patients with asthma and hypertension; contraindicated with known hypersensitivity to the drug r25
            • California Maternal Quality Care Collaborative does not recommend otherwise, due to side effects and inconsistent efficacy r25
        • Consider administration of tranexamic acid if uterotonics are ineffective r2r26
          • Results from the WOMAN trial (World Maternal Antifibrinolytic Trial) showed that 20,000 women with postpartum hemorrhage who were given tranexamic acid demonstrated a small but statistically significant reduction in death caused by bleeding, especially if administered within 3 hours of onset;r8 however, its use is not universally endorsedr27
        • If bleeding continues, consider uterine tamponader28 (Bakri balloon), uterine artery embolization, compression (B-lynch) sutures, or uterine artery ligation r24
          • Bimanual compression, external aortic compression, and use of nonpneumatic antishock trousers may be needed temporarily while more definitive treatment is arranged r9r24
          • Hysterectomy may be necessary in refractory cases r24
          • Gauze packing of the uterine cavity is controversial; WHOr9 and FIGOr24 recommend against it, while ACOGr2 recommends packing when balloon tamponade is unavailable
      • Repair identified lacerations or tears
      • It is suggested that no more than 30 minutes elapse before resorting to the next step in management (eg, primary measures to control bleeding, secondary interventions, hysterectomy) r10
      • Recognize that there may be more than 1 source of blood loss r10
    • Hemostatic resuscitation
      • Transfusion is indicated for patients with ongoing bleeding who have an estimated blood loss of at least 1500 mL or who have abnormal vital signs r2
      • A balanced combination of blood, platelets, and fresh frozen plasma is recommended r2
      • Cryoprecipitate or fibrinogen infusion is recommended in cases complicated by consumptive coagulopathy (eg, disseminated intravascular coagulation) r2r6
      • Some experts recommend administering recombinant factor VIIa r14
        • Efficacy data are limited and there is an associated risk of thromboembolism r29
        • Current guidelines by the American College of Obstetricians and Gynecologists recommend its use only in extreme cases unresponsive to standard transfusion management r2
      • Keep patient as close to normothermic as possible; hemostasis is less effective in hypothermia
      • Correct hyperkalemia, hypocalcemia, and pH as needed
        • Hypocalcemia may be avoided by giving calcium gluconate r12
      • Many hospitals maintain massive transfusion protocols to expedite prompt and continuous preparation and delivery of blood products r7r30

    Secondary postpartum hemorrhage r2

    • Treatment is aimed at underlying cause
      • Uterotonic agents (eg, oxytocin, carboprost, misoprostol, methylergonovine) are recommended when subinvolution is the likely cause (ie, no evidence of retained products, coagulopathy, or infection)
      • Antibiotics are indicated for endometritis
      • Dilation and curettage is recommended when the suspected cause is retained products of conception or if medical therapy with antibiotics or uterotonics is ineffective
      • Refer stable patients with suspected coagulopathy to a hematologist for evaluation and management
    • When bleeding is severe and patient is hemodynamically unstable, management is the same as for primary postpartum hemorrhage

    Drug therapy

    • Uterotonic agents
      • None of the available agents has proven superior when oxytocin has been given prophylactically during the third stage of labor; for initial use as primary treatment of postpartum hemorrhage, oxytocin is superior to misoprostol r23
        • Oxytocin c96
          • Intramuscular
            • Oxytocin Solution for injection; Adults: 10 units IM as a single dose after delivery of the placenta.
          • Intravenous
            • Oxytocin Solution for injection; Adults: 10 to 40 units in 500 to 1,000 mL of dextrose or electrolyte solution continuous IV infusion; adjust infusion rate to sustain uterine contraction and control uterine atony.
        • Methylergonovine c97
          • Methylergonovine Maleate Solution for injection; Adults: 0.2 mg IM as a single dose after delivery of the anterior shoulder or placenta or during the puerperium; may repeat dose every 2 to 4 hours as needed.
        • Carboprost c98
          • Intramuscular
            • Carboprost Tromethamine Solution for injection; Adults: 250 mcg IM every 15 to 90 minutes as needed, although unlikely additional doses will be of benefit if no response after 3 doses. Max: 2 mg.
          • Intramyometrial
            • Carboprost Tromethamine Solution for injection; Adults: 250 mcg by intramyometrial injection every 15 to 90 minutes as needed, although unlikely additional doses will be of benefit if no response after 3 doses. Max: 2 mg.
        • Misoprostol c99
          • Oral
            • Misoprostol Oral tablet; Adults: 600 mcg PO as a single dose.
          • Sublingual
            • Misoprostol Oral tablet; Adults: 800 mcg SL as a single dose.
    • Hemostatic agents
      • Tranexamic acid c100
        • Tranexamic Acid Solution for injection; Adults: 1 g IV as a single dose, initially, within 3 hours of hemorrhage recognition; may give a second dose of 1 g IV if bleeding continues after 30 minutes or stops and restarts within 24 hours of the first dose.
      • Recombinant factor VIIa c101c102
        • Note: serious arterial and venous thrombotic events after administration of factor VIIa (recombinant) have been reported r31
        • For best effect, the following parameters should be met before administration: r32
          • Platelet count greater than 50,000/μL
          • Fibrinogen level of 50 to 100 mg/dL
          • Body temperature above 32 °C
          • pH greater than 7.2
          • Serum calcium level within reference limits
        • Coagulation Factor VIIA Recombinant Human Solution for injection; Adults: 35 to 90 mcg/kg IV as a single dose.
    • Calcium gluconate c103
      • Calcium Gluconate Solution for injection; Adults: 300 mg (approximately 1.4 mEq elemental calcium) IV for each 100 mL of citrated blood infused.

    Nondrug and supportive care

    Fluid administration

    • Crystalloids (eg, normal saline, Ringer lactate solution) are preferred and should be warmed if possible r9c104c105c106
      • Some authorities favor Ringer lactate solution over normal saline owing to possible chloride-induced renal vasoconstriction r30
    • Administer enough to maintain circulation pending availability of blood, but avoid overhydration to prevent hemodilution and clot disruption; a systolic blood pressure goal of 80 to 100 mm Hg is appropriate r14

    Transfusion of blood products r14

    • Packed RBCs, fresh frozen plasma, and platelets are typically administered in a ratio of 1:1:1, although more complex regimens have been proposed r2c107c108c109
    • Additionally, cryoprecipitate or fibrinogen is recommended if fibrinogen levels remain low after fresh frozen plasma infusion r2r6c110
      • Guidelines differ in levels at which fibrinogen replacement is indicated, ranging from 1 to 2 g/L (100 to 200 mg/dL) r6
      • Usual dose of 10 units of cryoprecipitate will raise fibrinogen levels by 100 mg/dL r30
      • Recommended dose of fibrinogen concentrate is 2 to 3 g r30
    • Blood products should be warmed if possible r33
    • Goal laboratory parameters include: r7
      • Hematocrit above 24%
      • INR less than 1.5 c111
      • Platelet count more than 50,000/μL c112
      • Fibrinogen more than 100,000 mg/dL c113
    Procedures
    Laceration repair r34c114
    General explanation
    • Wound edges are approximated and a continuous suture is placed from the upper apex of the wound to the lower
    • Techniques vary with location and depth of wound and involvement of associated structures (eg, anal sphincter)
    Indication
    • Presence of laceration or tear with excessive bleeding
    Complications
    • Chronic pain, dyspareunia
    • Incontinence
    • Fistula formation
    Reversal of inversion r2
    General explanation
    • Placing the fingertips circumferentially around the inverted fundus, pressure is exerted upward to restore the uterus to proper position
    • Relaxation of the uterus may be necessary to achieve repositioning; general anesthesia, terbutaline, magnesium sulfate, or nitroglycerin have been used
    Indication
    • Inversion of the uterus
    Complications
    • Recurrence
      • Placement of a tamponade balloon may prevent further recurrences, but open surgical correction may be required
    Uterine tamponade c115
    General explanation
    • Pressure is applied to the myometrium by filling the uterine cavity r2
      • May be achieved by multiple techniques:
        • Placement of a specially designed balloon (eg, Bakri balloon) that is then filled with water
        • Placement of multiple Foley catheter balloons filled with water
        • Thrombin-soaked gauze packing is laid from one cornu to the other, back and forth, until the uterus is packed and gauze extends through the cervical os
    Indication
    • Postpartum hemorrhage caused by atony and refractory to medical therapy
    Interpretation of results
    • Bleeding is controlled in approximately 75% of patients r2
    Uterine artery embolization r35c116
    General explanation
    • Fluoroscopically guided catheter placement for embolization into the bleeding vessel r2
    Indication
    • Hemodynamically stable patient with persistent bleeding despite medical and mechanical measures
    Complications
    • May result from mechanical injury or from high dose of radiation sustained during fluoroscopy
      • Uterine or bladder wall necrosis
      • Vaginal fistula
      • Transient ovarian failure
      • Peripheral neuropathy
      • Deep vein thrombosis and/or pulmonary embolism
      • Placenta accreta in subsequent pregnancies r36
      • Infertility
    Interpretation of results
    • Bleeding is controlled in up to 90% of patients r37r38
    Uterine artery ligation c117
    General explanation
    • Through a laparotomy incision, sutures are placed around the uterine arteries bilaterally, sometimes including vessels within the utero-ovarian ligaments as well r2
    Indication
    • Postpartum hemorrhage refractory to noninvasive measures
    Complications
    • Unintentional ureteral ligation
    Interpretation of results
    • Bleeding is controlled in greater than 90% of patients r2
    Uterine compression sutures
    General explanation
    • Through a laparotomy incision, large sutures are wrapped around the uterus from cervix to fundus r2
    Indication
    • Postpartum hemorrhage caused by atony and refractory to medical therapy
    Complications
    • Uterine necrosis
    • Entrapment of bowel when suture loops loosen as uterus involutes; use of soluble suture material is recommended to prevent this complication
    Interpretation of results
    • Bleeding is controlled in approximately 60% to 75% of cases r2
    Hysterectomy c118
    General explanation
    • Surgical removal of the uterus via abdominal approach
    Indication
    • Postpartum hemorrhage refractory to other measures
    Complications
    • Infection
    • Infertility
    • Bowel, bladder, or ureter injury
    Uterine curettage c119
    General explanation
    • "Banjo" curette is inserted through the cervical os and retained tissue and clots are gently debrided and retrieved
    Indication
    • Secondary postpartum hemorrhage, retained tissue
    Complications
    • Perforation of uterus
    • Asherman syndrome (uterine adhesions)

    Comorbidities

    • Preexisting coagulopathies increase risk of hemorrhage during delivery c120
      • Anticipatory infusion of coagulation factors may prevent excessive bleeding

    Monitoring

    • During acute care
      • Vital signs every 5 minutes r7c121
      • Urine output r33c122
      • Pulse oximetry r33c123
      • Periodic auscultation of lung bases r33c124
      • Periodic laboratory studies r33
        • CBC c125
        • INR, prothrombin time, and fibrinogen levels c126
        • Serum chemistry (eg, electrolyte and BUN levels) c127
    • Postpartum follow-up r18
      • Check hemoglobin level at first postpartum visit c128
        • Provide supplemental iron at a dose of 60 mg/day to all patients for 3 months
        • For patients with a hemoglobin level below 11 g/dL, give 60 mg twice daily for 3 months

    Complications and Prognosis

    Complications

    • Disseminated intravascular coagulation r35c129
    • End-organ damage r35
      • Renal failure c130
      • Hepatic failure c131
      • Respiratory distress syndrome c132
    • Loss of further reproductive potential
      • May result from uterine synechiae or from surgical intervention to control bleeding
      • Uterine artery ligation or embolization and uterine compression are selected, when feasible, to spare reproductive potential
    • Death c133
      • Causes approximately 25% of all maternal deaths and is most common cause of maternal death in developing countries r9

    Prognosis

    • Life-threatening complication of pregnancy
      • Most common cause of pregnancy-related death r6
      • Mortality rates vary greatly among developing and industrialized countries
        • In 1 surveillance study, the death rate among patients with postpartum hemorrhage was 0.3%, with 1.8% considered near-misses r39
        • Death rates of 5% or higher have been reported among patients with postpartum hemorrhage after delivery in hospital r40
    • Uterine-sparing procedures for treatment of severe postpartum hemorrhage do not appear to adversely affect subsequent fertility and pregnancy outcomes in most patients; however, available data are limited r41
    • Subsequent pregnancies may be at increased risk for postpartum hemorrhage, placental disorders, fetal growth restriction, and need for cesarean delivery r42

    Screening and Prevention

    Screening

    At-risk populations

    • All patients presenting for labor and delivery care c134

    Screening tests

    • Screening at admission has been proposed to assess risk and initiate blood banking procedures if appropriate r7c135
      • Low-risk criteria: singleton pregnancy, unscarred uterus, no previous postpartum hemorrhage, 4 or fewer previous vaginal deliveries, no known bleeding disorder
      • Medium-risk criteria: previous postpartum hemorrhage, previous cesarean delivery or other uterine surgery, 5 or more previous vaginal deliveries, multiple gestations, large fibroids, chorioamnionitis, indication for magnesium sulfate
        • Obtain blood for type and screen
      • High-risk criteria: placenta previa or accreta; hematocrit level less than 30% plus other risk, bleeding on admission, platelet count less than 100,000/μL, known coagulation defect
        • Obtain blood for type and crossmatch
      • Patients with 2 risk criteria in any category are moved to the next risk category

    Prevention

    • Active management of the third stage of labor is recommended to reduce risk of hemorrhage r2r43c136c137
      • Administer prophylactic uterotonic agents; this may be done with delivery of the anterior shoulder or after full delivery of the infant r44
        • Oxytocin by IV bolus or intramuscularly is recommended r2
          • A Cochrane review found oxytocin reduces incidence of postpartum hemorrhage and is associated with fewer adverse effects than other uterotonic agents r45c138
        • WHO recommends use of other injectable uterotonics or oral misoprostol if oxytocin is not available r46
        • A Cochrane review concluded that use of misoprostol had no impact on maternal morbidity or mortality, but was associated with an increased incidence of fever r47c139c140c141
        • Another systematic review examining only cesarean deliveries concluded that misoprostol and oxytocin were equivalent in reducing intraoperative and postoperative hemorrhage and that oxytocin plus misoprostol was superior to oxytocin alone r48c142
      • Undertake controlled cord traction after clamping and cutting umbilical cord (1 to 2 minutes after delivery) r49c143
        • During contractions, pull umbilical cord down and out with gentle but constant force while maintaining upward pressure on the uterus with the other hand to prevent inversion
        • If placenta cannot be delivered over the course of 30 minutes, remove manually c144
      • Uterine massage may also be performed
        • In patients who have received oxytocin, it is not clear that uterine massage provides additional benefit r50c145
    • Folate supplementation during pregnancy reduces risk of abruptio placentae, a risk factor for postpartum hemorrhage r51c146
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