Postpartum hemorrhage (PPH) is classically defined as > 500 cc of blood loss after standard vaginal delivery or >1000 cc after a C-section. However, most recently ACOG redefined PPH as >1000 cc of blood loss OR signs and symptoms of hypovolemia in the setting of bleeding within the first 24 hours. It is an incredibly common event, occurring in almost 1 in 5 postpartum mothers and is the most frequent cause of maternal morbidity in the developed world.
The 4 T's of Postpartum Hemorrhage
Tone: uterine atony accounts for 70-80% of PPH. Blood flow can reach up to 500-900 ml/min during delivery. Key presentation is the "soft, boggy uterus." The predisposing risk factors are
impaired contraction from local inflammation or acidosis of uterine tissue (chorioamnionitis)
down regulation of oxytocin receptions (prolonged labor)
diminished actin-myosin interaction from enlarged uterus (macrosomia, multiple gestations)
Actions:
Bimanual massage: Manually massage the uterus, with one hand internally inside the vagina and pressing against the uterus from below, while applying external pressure with the other hand above the fundus of the uterus. Avoid downward massage by the internal hand as it can cause injury to the blood vessels and potentially cause uterine inversion
Uterotonics: there are several available medications that can increase uterine tone, of which the most important the most crucial is oxytocin. Oxytocin is endogenously excreted and induces uterine contraction. It can be given 40 mg IV in a 1 L normal saline bolus and then continued at 200 ml/hr until uterus is firm. Alternatively, it can be given as 10 mg IM x 2. Oxytocin is first-line and should be given in all patients with uterine atony. Other medications can be added as needed, see below:
Misoprotsol (Cytotec): a prostaglandin adjunct that stimulates uterine contraction. It can be given as 1000 mcg (usually 5 tablets) rectally or sublingually and has no contraindications in an emergent setting
methylergonovine (Methergine): induces smooth muscle contraction. for PPH should be given as 0.2 mg IM every 2-4 hours until max of 5 doses. This should NOT be given IV as it induces severe hypertension and can precipitate CVA and is contraindicated in patients with hypertension
Carboprost: a synthetic prostaglandin that induces myometrial contraction and vasoconstriction through smooth muscle contraction. It's given 250 mcg IM or injected into the myometrium, and can be in 15-90 minute intervals for a max dose of 2 mg. Similarly, this should NOT be given IV as it can induce hypertension and severe bronchospasm, and is contraindicated in patients with asthma or HTN
Our resuscitation bay has a PPH pharmacy kit! It hands out in the fridge in room 52 and comes with a handy slip with all the dosages, route, frequency and contraindications! Go check it out!
Trauma: Genital tract trauma is the second most common cause of PPH. up to 80% of traumas are minor and occur in the vagina or perineum. However consider harder to reach areas such as cervical Any ongoing bleeding that does not stop with tamponade should be repaired via suturing. Other options include tamponade with a bark balloon, visualized below. Often we don't have these in the emergency room, so consider using a Blakemore tube (fold the distal tip back, inflate the esophageal balloon).
External aortic compression can also be used as an emergency maneuver, where you apply direct firm pressure with a closed fist over the aorta just above the umbilicus. This is obviously a temporizing maneuver and should be used as a bridge to a more permanent solution or during transport to OR, but it remains fairly effective.
Tissue: refers to retained products of conception. any retained products prevents induction of uterine contraction that occurs after disruption of the placenta. Examine the placenta to see if it's intact. If possible, attempt to retrieve products that are visible and within reach via manual or curettage. If it cannot be reached, they required OR.
Thrombin: both inherited and acquired coagulopathies should be considered. There are obviously many different ways to treat coagulopathies that are tailored to specific clinical pictures, of which I will briefly cover and not go through the mechanisms. Consider DIC and hypofibrinogenemia in placental abruptions and amniotic fluid embolism.
If giving MTF, you should also give FFP and platelets in a 1:1:1 ratio
For von Willebrand, give DDAVP
for DIC, given cryoprecipitate
for hemophilia, give factor replacement therapy
A word on TXA: previous recommendations suggest IV TXA. However, the WOMAN trial in 2017 showed no benefit. That being said, there is much debate on the metrics of how this trial was performed, that the exclusion criteria excluded the sickest patients, there are other studies showing benefits of TXA etc. etc. Long story short, evidence is mixed, and since TXA has little adverse events, giving 1 gram IV isn't going to hurt anyone.