1. Postpartum Hemorrhage: Evaluation, Management and Pearls
Annie Siewert, MD MS FACOG
South Dakota Perinatal Association Annual Meeting.
September 22, 2017

2. Objectives: Identify stages of postpartum hemorrhage
Discuss new treatment techniques for postpartum hemorrhage
Management of stages of postpartum hemorrhage

3. PPH: Who is at Risk? Risk Factors History of PPH
Asian or Hispanic ethnicity
Overdistended uterus
Twins, macrosomnia, polyhydraminos
Preeclampsia
Prolonged labor
Augmented labor
Rapid labor
Episiotomy
Especially mediolateral
Operative delivery
Chorioamnionitis

4. Situational Awareness: Assessing the Risk on Admission
Low Risk: Type and Screen Recommended; BB Hold (Minimum)
No prior uterine incision
Singleton
<4 Vaginal deliveries
No history of PPH
No bleeding disorder.
Negative Antibody screen on PN lab

5. Situational Awareness: Assessing the Risk on Admission
Prior C/S or uterine surgery
Multiple gestations
>4 vaginal deliveries
H/O PPH
Large uterine fibroids
EFW> 4k
BMI>35
Medium Risk: Type and Screen

6. Situational Awareness: Assessing the risk on admission
High Risk: Type and Cross for 2 U PRBCs
Placenta Previa, Low-lying placenta
Suspected Accreta/Increta/Percreta
Hct<30 AND other RF
Plt < 100k
Active Bleeding
Known Coagulopathy

7. Situational Awareness: Assessing the Risk
Prolonged 2nd stage
Prolonged Oxytocin use
Active bleeding
Chorioamnionitis
Magnesium Sulfate treatment
On-going Risk Assessment:

8. Postpartum Hemorrhage
Causes
Uterine atony
Retained Placenta
Lacerations
Abnormal placentation
Other

9. PPH: Definition Vaginal Delivery Cesarean section Decline in Hct by
500cc
Cesarean section
1000cc
Decline in Hct by
10%
Vital sign changes
Tachycardia
Hypotension
Oliguria

10. Visual Estimates of PPH
UpToDate Management of Postpartum Hemorrhage at Vaginal Delivery

11. PPH: Definition of Unstable VS
HR > 110
BP < 85/45
O2 Sat < 95%
VS >15% change

12. Postpartum Hemorrhage
Management
Prevention
Conservative Measures
Medications
Surgical Measures

13. PPH Management
PREVENTION!

14. Active Management of the Third Stage
After delivery of anterior shoulder
Has not been shown to increase retained placenta
Oxytocin mU in cc q hr X 2 hrs IV or 10 U IM
DO NOT PULL TOO HARD
Decreases risk of retained placenta
Gentle cord traction/ Controlled Traction (+/-)
Cord clamping within 1-3 minutes of delivery.
Fundal Massage.

15. Active Management of the Third Stage
2015 Cochrane Review
Defined active management as uterotonic administration, early cord clamping, cord traction.
7 studies, 8247 woman
Decreased risk of 1˚ PPH with RR
Significant decrease in EBL>500cc, transfusion, use of uterotonics in third stage
Also demonstrated decreased birth weight and increases in maternal diastolic BP, vomiting, pain, use of pain meds,
Begley, et al. Active versus expectant management for women in third stage of labour. The Cochrane Collaboration

16. Active Management of the Third Stage
Controlled Cord Traction
2015 Cochrane Review
No difference in amount of blood loss ≥1000cc
Decreased risk of manual placental removal
Decreased risk of blood loss ≥500cc (10cc!)
No change in uterotonic administration, transfusion, morbidity, operative procedures.
Duration of Third Stage
Secondary analysis of 7,121 women at Washington Univ
Mean duration of 3rd stage: 5.46
90%ile: 9 min, 95%ile: 13 min, 99%ile: 28 min
3rd stage > 90%ile had increased risk of PPH: 13.2% vs 8.3%
PPH risk increases after 20 min (15.9% vs 8.5%)
Hofmeyr, et al. Controlled Cord Traction for the third stage of labor. The Cochrane Collaboration
Frolova, et al. Duration of Third Stage of Labor and Risk of Postpartum Hemorrhage. Obstet Gynecol

17. Conservative Measures
PPH Management
Conservative Measures
Call for help
Examine patient
Empty bladder
Bimanual massage
Manual evacuation of uterus

18. Bimanual massage

19. Manual Exam of the Uterus
Conservative Measures
MEU
Manual Exam of the Uterus
It’s cheap.
It’s effective!
It can hurt.

20. Conservative Measures
Population based cohort study patients with PPH due to atony after SVD in 106 hospitals aimed at studying factors contributing to severe PPH
Factors independently associated with severe PPH
Delay call for help had a 1.6x higher risk for severe PPH
Oxytocin started late or not at all in 24.5% with PPH
PPH risk 1.4X higher in women when oxytocin was started min after PPH diagnosis, and almost 2X higher if started greater than 20 min
MEU was late or not done in 33.2 %
PPH risk 1.8X higher when MEU performed >20 min after diagnosis
Driessen, et al. Postpartum Hemorrhage Resulting from Uterine Atony after Vaginal Delivery. Obstet Gynecol

21. PPH Management Medications Uterotonics Tranexamic acid
Recombinant Factor VIIa

22. PPH Medications: Uterotonics
Drug*
Dose/Route
Frequency
Comment
Oxytocin (Pitocin)
IV: 10–40 units in 1 liter normal saline or lactated Ringer's solution IM: 10 units
Continuous
Avoid undiluted rapid IV infusion, which causes hypotension.
Methylergonovine (Methergine)
IM: 0.2 mg
Every 2–4 h
Avoid if patient is hypertensive.
15-methyl PGF2α (Carboprost) (Hemabate)
IM: 0.25 mg
Every 15–90 min, 8 doses maximum
Avoid in asthmatic patients; relative contraindication if hepatic, renal, and cardiac disease. Diarrhea, fever, tachycardia can occur.
Dinoprostone (Prostin E2)
Suppository: vaginal or rectal 20 mg
Every 2 h
Avoid if patient is hypotensive. Fever is common. Stored frozen, it must be thawed to room temperature.
Misoprostol (Cytotec, PGE1)
800–1,000 mcg rectally

23. PPH Medications
Tranexamic acid and Factory VIIa

24. PPH Medications Tranexamic Acid (TXA)
Inhibits ability of plasmin to form fibrin degradation productions
Inhibition of fibrinolysis
Half life: 2 hours
Metabolized by kidney
TXA

25. PPH Medications: Tranexamic Acid (TXA)
OB hemorrhage results in increased fibrinolytic activity
Placental disruption leads to increase in tPA
Increased D-dimer levels postpartum increase fibrinolytic activity

26. PPH Medications: Tranexamic Acid (TXA)
Endothelial injury or hypoperfusion secondary to trauma
Increased tPA
Decreased tPA inhibition by protein C activation from thrombin-thrombomodulin interaction
TXA
Plasminogen activates plasmin=fibin degradation and bleeding
Increased D-dimer and fibrin degradation products
Adapted from Pacheco. Obstet Gynecol. 2017

27. PPH Medications: Tranexamic Acid (TXA)
CRASH-2 trial
RCT in trauma
TXA given within 3 hours of trauma decreased mortality
TXA given ≥ 3 hours after event did not improve outcome or survival
TXA administration is also standard of care in cardiac surgery and ortho
CRASH-2 trial collaborators. Effects of Tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage. (CRASH-2): a randomized placebo controlled trial. Lancet. 2010; 376:

28. PPH Medications: Tranexamic Acid (TXA)
WOMAN trial
Effects of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum hemorrhage (WOMAN): an international, randomized, double-blind, placebo controlled trial. Lancet May 2017.
20,060 woman with diagnosed PPH enrolled from 193 hospitals in 21 countries
Significant decrease in death due to bleeding
Hysterectomy rates did not change
Death from all causes did not decrease
No increase in adverse outcomes with TXA (ie VTE)
WOMAN trial collaborators. Effects of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum hemorrhage (WOMAN): an international, randomized, double-blind, placebo controlled trial. Lancet May 2017

29. PPH Medications: TXA
Tranexamic Acid for the Management of Obstetric Hemorrhage. Current Commentary. Obstet. Gynecology. PAP 2017.
Diagnosed PPH
TXA 1g IV within 3 hours of delivery
If continued bleeding, administer second dose within 24 hours
Dose not to exceed 2g in 24 hours
Risk of renal cortical necrosis
Seizure
PPH Prophylaxis
May be prior to delivery given to patients with hemophilia, vWD and platelet disorders.
Can also be given postpartum to prevent bleeding
1g po TID
Insufficient evidence to give for primary prevention
Does cross placenta and is found in breast milk, but no adverse neonatal outcomes have been demonstrated.
Pacheco et al. Tranexamic Acid for the Management of Obstetric Hemorrhage. Current Commentary. Obstet. Gynecology. PAP Sept

30. PPH Medications: Recombinant Factor VIIa
Vitamin K-dependent glycoprotein, promotes hemostasis by activating the extrinsic pathway of the coagulation cascade.
It replaces deficient activated coagulation factor VII allowing conversion of Factor X
When complexed with other factors, coagulation factor Xa converts prothrombin to thrombin, a key step in the formation of a fibrin-platelet hemostatic plug

31. PPH Medications: Recombinant Factor VIIa
Administration can cause improvement in up to 80% PPH patients
Low risk of adverse outcomes
Quality evidence is still lacking
Very expensive! Cost between 9,000-18,000 depending on patient’s weight and how many doses needed
Alfirevic et al. Use of Recombinant Activated Factor VII in Primary Postpartum Hemorrhage. Obstet. Gynecol. 2007; 110:

32. PPH Management Surgical Measures D&C Bakri balloon
Uterine Artery Embolization
Exploratory laparotomy
B-Lynch suture
O’Leary stitch
Hysterectomy

33. Ultrasound diagnosis of Retained POCs

34. Surgical Measures: Bakri Balloon
Fill to cc Sterile Saline
Antibiotics
Leave in hours
No need for slow release of pressure

35. Surgical Management: Uterine Artery Embolization
Case review study demonstrated UAE successful in 89.6% of patients
Adverse outcomes
Fertility rate 70-80%
No increased risk of IUGR
Higher risk of abnormal placentation
Patient MUST be stable!
Labarta et al. Eur J of Obstet Gynecol and Reprod Bio. 206; Nov
Soro et al. Eur Radiol Feb; 27(2):

36. PPH: Surgical Measures

37. B-Lynch Suture

38. Blood Component Therapy
PPH Management
Blood Component Therapy

39. Blood Component Therapy
Product
Volume (mL)
Contents
Effect (per unit)
Packed red cells
240
Red blood cells, white blood cells, plasma
Increase HCT 3%,
Hb by 1 g/dL
Platelets 50
Platelets, red blood cells, white blood cells, plasma
Increase platelet count 5,000–10,000/mm3 per unit
Fresh frozen plasma
250
Fibrinogen, antithrombin III, factors V and VIII
Increase fibrinogen by 10 mg/dL
Cryoprecipitate 40
Fibrinogen, factors VIII and XIII, von Willebrand factor

40. Massive Transfusion Protocols
Purpose:
Structured system-wide process for early and efficient delivery of specific ratios of blood product,
4 U PRBCs/4U FFP/ 1 Aphoresis pack PLT

41. PPH Management
Stages of PPH
Stage 1
Stage 2
Stage 3

42. PPH Stages Stage 1 EBL>500cc vaginal or > 1000cc cs Stage 2
Continued bleeding or Unstable VS or EBL > 1500 cc
Stage 3
EBL>1500cc, > 2U PRBCs given, unstable vs or Suspect DIC

43. STAGE I Hemorrhage: EBL>500cc vaginal or > 1000cc cs
IV access
On-going assessment: ARE VS UNSTABLE??
Calculating blood loss
TYPE and CROSS (if BB Hold, will delay minutes)
Keep patient warm and oxygenated
Place a foley
Nursing interventions
Find cause for bleeding
MANUAL EXAM OF UTERUS: if you cannot reach the fundus, CALL LABORIST
Give medications
TYPE and CROSS
ARE VS UNSTABLE???:
MD/CNMW

44. Stage I Hemorrhage: Medications
Methergine 0.2 mg IM
Usually first line—onset action within 5 minutes
Contraindicated with HTN
Little or no response to 1st dose then MOVE ON
Hemeabate 0.25 mg IM
Usually works within 2 doses
Contraindicated in ASTHMA/HTN**
No response after the 2nd dose then MOVE ON
Cytotec mcg pr
Onset of action usually minutes PR
SL dose 400mcg-600mcg onset within 11 minutes

45. STAGE 2: Continued bleeding or Unstable VS or EBL > 1500 cc
D&C, Laceration repair
Bakri Balloon
Interventional radiology
Vaginal Delivery
B-Lynch
O’Leary stitches
Uterine/internal iliac ligation
Bakri Balloon placement
Cesarean Section

46. STAGE 2: Continued bleeding or Unstable VS or EBL > 1500 cc
Request Laborist/OB consult if not present
Move patient to OR
Notify Anesthesia
Nursing interventions
Move to OR
Continued uterotonic use
Request anesthesia
1500 CC EBL with ongoing bleeding---Start transfusing (do not wait for lab results)
MD/CNM interventions

47. Stage 3: EBL>1500cc, > 2U PRBCs given, unstable VS or Suspect DIC
Continued monitoring of EBL
SUGGEST MTP activation
Manage activation of MTP
Nursing interventions:
Consider CVP or Art line
Manage Blood products
Anesthesia interventions

48. Stage 3: EBL>1500cc, > 2U PRBCs given, unstable VS or Suspect DIC
MTP activation
Call in back-up OR Gyn Onc
Transfuse 2 U FFP
Keep transfusion ration 4:4:1 (PRBCS:FFP:PLT)
Laparotomy/Gyn Onc
B-Lynch
Uterine/ internal iliac artery ligation
Hysterectomy
OB MD interventions

49. Resources
UpToDate Management of Postpartum Hemorrhage at Vaginal Delivery
Begley, et al. Active versus expectant management for women in third stage of labour. The Cochrane Collaboration
Hofmeyr, et al. Controlled Cord Traction for the third stage of labor. The Cochrane Collaboration
Frolova, et al. Duration of Third Stage of Labor and Risk of Postpartum Hemorrhage. Obstet Gynecol
Driessen, et al. Postpartum Hemorrhage Resulting from Uterine Atony after Vaginal Delivery. Obstet Gynecol
CRASH-2 trial collaborators. Effects of Tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage. (CRASH-2): a randomized placebo controlled trial. Lancet. 2010; 376:
WOMAN trial collaborators. Effects of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum hemorrhage (WOMAN): an international, randomized, double-blind, placebo controlled trial. Lancet May 2017
Pacheco et al. Tranexamic Acid for the Management of Obstetric Hemorrhage. Current Commentary. Obstet. Gynecology. PAP Sept
Alfirevic et al. Use of Recombinant Activated Factor VII in Primary Postpartum Hemorrhage. Obstet. Gynecol. 2007; 110:
Labarta et al. Eur J of Obstet Gynecol and Reprod Bio. 206; Nov
Soro et al. Eur Radiol Feb; 27(2):
California Maternal Quality Care Collaborative
ACOG Practice Bulletin No. 76 Postpartum Hemorrhage

50. PPH: Definition Primary Secondary or Delayed
Occurring within first 24 hours
Atony
Retained placenta
Coagulation problems
Uterine inversion
Secondary or Delayed
Occurring >24 hours
Subinvolution
Retained POCs
Infection
Inherited coagulation defects