Post-Partum Hemorrhage

15 Jan
January 15, 2018

Definition: Blood loss > 500 ml after a delivery (or > 250 ml after an abortion). The management of post-abortion hemorrhage is similar to that of post-partum hemorrhage (PPH).

Causes

  • Uterine atony (~ 50% of cases)
  • Retained products of conception (POCs)
  • Cervical lacerations
  • Uterine perforation
  • Uterine Inversion
  • Abnormal placentation (accreta, increta, percreta)
  • Coagulopathy

Background:

  • Occurs in 1-2% of patients undergoing a first trimester surgical abortion
  • Most common cause of abortion-related mortally in 2nd trimester
  • Risk increases with increasing maternal age

Clinical Presentation

  • Diagnosis
    • No exact definition but generally thought to be present when bleeding exceeds 500 ml
    • Should be suspected if bleeding “exceeds a clinician’s estimate of ‘normal’.” (Lew 2013)
    • Blood loss is not always brisk. Can be moderate, prolonged bleeding
    • Tachycardia and hypotension will be late findings
    • Look for signs of hypoperfusion
  • Key Examination Pieces
    • Any abnormal vital signs should raise suspicion of PPH
    • Obtain history for bleeding disorders or anticoagulation use
    • Examination of placenta
      • Should be intact without “missing pieces”
      • Looking for retained products of conception as source of ongoing bleeding
    • Examination of fundus of uterus
      • Uterine atony (uterine muscles do not fully contract) is the most common cause of postpartum hemorrhage (~ 80% of cases) (Lew 2013)
      • Abdominal examination will reveal a “boggy” uterus. Can be confirmed on bimanual exam
    • Direct examination of vagina
      • Lacerations to genital tract during delivery can cause brisk blood loss
      • Examine for uterine inversion (displacement of uterus into vagina)
    • Examine sites where blood drawn/IVs started
      • Looking for oozing or ongoing bleeding that may signal the presence of disseminated intravascular coagulation (DIC)

Treatment

  • Basic Supportive Care
    • Large bore IV X 2, supplemental O2 if hypoxic, cardiac monitor
    • Volume expansion to replace hemorrhage
      • Replace with blood products as soon as available
      • Give O negative until type specific products available
      • Can use crystalloid early if evidence of hypoperfusion but not ideal resuscitative fluid
    • Call obstetrics or surgical consultants early as patients frequently require surgical intervention
  • Fundal Massage (Robert’s + Hedges)

    Tranexamic Acid (TXA)

    • Largest study to date demonstrated reduction in death due to hemorrhage (1.9% vs 1.5%) without difference in hysterectomy rate (WOMAN trial 2017)
    • Dose
      • 1 gram over 10 minutes
      • Second dose given if continued bleeding after 30 minutes or recurrent bleeding within 24 hours
    • Full review of WOMAN trial found here
  • Uterine Massage
    • First line treatment for uterine atony
    • Begin with firm massage of the uterine fundus through the abdominal wall
    • Bimanual Uterine Massage (Robert’s + Hedges)

      Advance to bimanual uterine compression if bleeding continues 

      • External hand compresses and massages uterus
      • Hand placed internally in fist to massage anterior aspect of uterus
      • Avoid downward massage with internal hand (can cause uterine inversion or injure blood vessels)
  • Uterotonic Medications 
    • Should be given concomitantly with uterine massage
    • Multiple medication options which increase uterine muscle tone

Drugs for the Management of Uterine Atony (Roberts + Hedges)

  • Direct Uterine tamponade
    • Uterine packing: Uterus is packed with gauze or hemostatic dressings
    • Balloon tamponade
      • Device is placed into the uterus and balloon filled with saline or water
      • Bakri Balloon

        Bakri Balloon

        • Commercially available device specifically for this indication
        • Balloon accommodates up to 800 ml but as little as 250-500 ml of inflation can stop bleeding
        • Can potentially obviate need for surgical management
      • Sengstaken-Blakemore Esophogastric tube
        • Has a maximum volume ~ 500 ml
      • Latex Condom (Georgiou 2009, Burke 2017)
        • Case reports + case series of condom secured to foley catheter and inflated
        • Volume: 250-300 ml
      • Do not use a single foley catheter for this indication
        • Balloon with only 80 ml volume at maximum
        • More likely to hide bleeding than to tamponade it
        • Case reports of placement of multiple foley catheters (Georgiou 2009)

Balloon Tamponade Options (Georgiou 2009)

  • Uterine Inversion
    • Treatment involves reduction of the uterus back into position
    • Typically requires procedural sedation or general anesthesia to accomplish
    • Reduction can be facilitated with tocolytic agents (I.e. terbutaline or magnesium sulfate)
  • Disseminated Intravascular Coagulation
    • Administer blood products and adjuncts based on clotting derangements that are present (See LITFL DIC Post)
    • Patients will often require hysterectomy to resolve DIC

Take Home Points

  • Watch for continued bleeding in excess of 500 ml or bleeding that is “more than normal.” Call it postpartum hemorrhage and start resuscitation
  • Call your obstetric and/or surgical consultants early as operative intervention is often required
  • Replace intravascular volume with blood products
  • Uterine atony is the most common cause of postpartum hemorrhage. Begin treatment with uterine massage and uterotonic medications
  • Consider the development in DIC when patients continue to bleed despite appropriate management

For More on This Topic Checkout:

References:

  1. Lew GH, Pulia MS: Emergency Childbirth, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 56:p 1155-82.
  2. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum hemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389(10084): 2105-16. PMID: 28456509
  3. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009; 116(6): 748-57. PMID: 19432563
  4. Burke TF et al. Shock progression and survival after use of a condom uterine balloon tamponade package in women with uncontrolled postpartum hemorrhage. Int J Gynaecol Obstet 2017; 139(1): 34-8. PMID: 28675419

Post Peer Reviewed By: Salim R. Rezaie (Twitter: @srrezaie)

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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at Bellvue/NYU
REBEL EM Associate Editor and Author
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1 reply
  1. Matt says:

    Great PPH post Dr. Swaminathan – an excellent and straightforward approach for such a scary condition.

    My last ditch low-resource effort would be external aortic compression, either manual or device, even though there’s low quality evidence for it. In the absence of definitive care, it could help temporize. For those interested in reading more about its use:

    Reham E. Adjuvant Effect of Aortic Compression and Carbetocin Injection in Management of Primary Atonic PPH to Improve Outcome. Integrata Ginecologia e obstetricia. 2017; 1: 13-16.

    Tunçalp Ö, Souza JP, Gülmezoglu M. New WHO recommendations on prevention and treatment of postpartum hemorrhage. International Journal of Gynecology & Obstetrics. 2013;123(3):254-256.

    Soltan MH, Sadek RR. Experience managing postpartum hemorrhage at Minia University Maternity Hospital, Egypt: No mortality using external aortic compression. Journal of Obstetrics and Gynaecology Research. 2011;37(11):1557-1563.

    Soltan MH, Faragallah MF, Mosabah MH, Al-adawy AR. External aortic compression device: The first aid for postpartum hemorrhage control. Journal of Obstetrics and Gynaecology Research. 2009;35(3):453-458.

    Keogh J, Tsokos N. Aortic Compression in Massive Postpartum Haemorrhage – An Old But Lifesaving Technique. The Australian and New Zealand Journal of Obstetrics and Gynaecology. 1997;37(2):237-238.

    Though I must confess that I’m considerably biased. I think it’s a worthwhile temporizing measure for life-threatening junctional hemorrhage too. http://rescuescience.org/tag/eac/

    Reply

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