REBEL Core Cast 44.0 – Postpartum Hemorrhage

Nov 11, 20
REBEL Core Cast 44.0 – Postpartum Hemorrhage

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

REBEL Core Cast 44.0 – Postpartum Hemorrhage

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, MD (Twitter: @srrezaie)

The post REBEL Core Cast 44.0 – Postpartum Hemorrhage appeared first on REBEL EM - Emergency Medicine Blog.

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