Here are some very-quick and easy-to-read pearls to remember for the dangerous immediate postpartum complication of postpartum hemorrhage.
Most common causes
- Uterine atony (by far)
- Trauma (i.e. lacerations, surgical incisions, uterine rupture)
- Coagulopathy (persistent heavy bleeding can lead to consumption of clotting factors)
Management
- Uterine massage. Tamponade bleeding from uterine cavity.
- Two large-bore IV lines. Make airway preparations. Make blood bank preparations. Alert appropriate consultants.
- Start fluid resuscitation (SBP >90)
- Blood products transfusion if hemodynamics do not improve with 2-3 L isotonic crystalloid
- Uterotonic drugs
- Oxytocin – 40 U in 1 L NS, then 40 mU/min (expect rapid response); or 10 U IM (response within 3-5 min)
- Other supplemental agents: Methylergonovine/Ergonovine, Carboprost
- Repair any vaginal or cervical lacerations. Evacuate retained POC. Replace uterus if inverted.
- Arrange for transarterial embolization if patient stable and IR available
- Arrange for laparotomy (can ligate bleeding sites, ligate uterine artery, or perform hysterectomy if needed)
Additional pearls
- Bleeding may not be visible. Boggy and dilated uterus may contain significant amount of blood.
- Young patients may not show altered hemodynamics at the outset.
- HCT/HGB drop may be delayed and not representative of blood loss.
- Most significant risk factors: retained placenta/membranes, failure to progress during the 2nd stage of labor (Sheiner E, et al. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Matern Fetal Neonatal Med. 2005;18(3):149)
Also check out Megha and Brendan’s EMdocs post on Postpartum Emergencies: http://www.emdocs.net/postpartum-within-1st-month-emergencies-and-their-management/
