1. Postpartum Hemorrhage Christopher R. Graber, MD Salina Women’s Clinic 21 Feb 2012

2. Overview Background Etiology of postpartum hemorrhage – Primary – Secondary Risk factors Evaluation and management – Medical – Surgical

3. Background Severe bleeding is #1 worldwide cause of maternal death – 140,000 women die each year from hemorrhage – 1 every 4 minutes Other serious sequelae – ARDS, coagulopathy, shock, loss of fertility Hemorrhage frequently occurs without any warning

4. Background Physiologic changes during pregnancy – Increase in plasma volume by 40% – Increase red cell mass by 25% Definition of postpartum hemorrhage – 500 mL after vaginal delivery – 1000 ml after cesarean delivery

5. Etiology – Primary Hemorrhage Primary hemorrhage occurs in 1 st 24 hours Occurs in 4-6% of pregnancies Caused by The Four T’s – Tone – atony (80% of all cases) – Tissue – retained POC, accreta, uterine inversion – Trauma – cervical or vaginal laceration, rupture – Thrombic events – defects in coagulation Inherited or acquired

6. Etiology – Secondary hemorrhage Secondary hemorrhage occurs 24h to 6-12w Causes include: – Subinvolution of pacental site – Retained POC – Infection – Inherited coagulation defects

7. Risk Factors Prolonged labor (also augmented labor) Rapid labor History of postpartum hemorrhage Preeclampsia Distended uterus – Macrosomia, twins, polyhydramnios Chorioamnionitis Operative delivery

8. What to Do Next?!

9. Postpartum hemorrhage is a sign, not a diagnosis – find out what is causing bleeding Calmly work your way through the list of possible causes – If you get to the end of the list and don’t have an answer then start again at the top of the list Call for help if needed – Extra nurses, anesthesia, Ob/Gyn

10. Initial Evaluation Atony is the most common cause for bleeding – Pelvic exam, uterine massage, expel clots – Manual exam of the uterus Yes, put your whole hand and arm inside – Consider draining the bladder Examine for lacerations – Consider move to OR for lighting & exposure Ask about history of clotting disorders

11. Medical Management Uterotonic medications – Pitocin 10-40 units IV, continuous – Methergine (methylergonovine) 0.2mg IM Repeat q2-4h, avoid in hypertension – Hemabate (15-methyl PGF 2α ) 0.25mg IM Repeat q15min, avoid in asthma Higher risk of side-effects: diarrhea, fever, tachycardia – Cytotec (misoprostol, PGE 1 ) 800-1000mcg PR

12. Medical Management Uterine tamponade – Packing with guaze Can soak with thrombin – Intrauterine foley catheter One or more bulbs, 60-80ml of saline – Bakri tamponade balloon 300-500ml of saline

14. Surgical Management Consider surgical management when uterotonic agents (± tamponade) don’t work Uterine curettage Exploratory laparotomy – Hypogastric artery ligation – Bilateral uterine artery ligation (O’Leary sutures) – B-Lynch technique – Hysterectomy

15. Surgical Management

16. Other Considerations Placenta accreta – Risk factors: placenta previa, prior CD, Asherman’s syndrome, prior myomectomy – 40% risk if 2 prior CD + placenta previa – If known, consider delivery at tertiary center Arterial embolization – Not for acute cases

17. Other Considerations Uterine inversion – If occurs prior to placental delivery, do Not remove the placenta – Replace fundus with firm pressure upwards – Uterine relaxation may be required Terbutaline, nitroglycerine, anesthesia Consider activation of massive transfusion protocol

18. Review. Stay Calm! Tone, Tissue, Trauma, Thrombin Postpartum hemorrhage is a symptom, not a diagnosis – find a diagnosis Return to bedside if more than 1 dose of uterotonic medication is given by phone

19. Questions?