Postpartum Hemorrhage in Emergency Medicine

Defining postpartum hemorrhage (PPH) is problematic and has been historically difficult. Waiting for a patient to meet the postpartum hemorrhage criteria, particularly in resource-poor settings or with sudden hemorrhage, may delay appropriate intervention. Postpartum hemorrhage is traditionally defined as blood loss greater than 500 mL during a vaginal delivery or greater than 1,000 mL with a cesarean delivery. However, significant blood loss can be well tolerated by most young healthy females, and an uncomplicated delivery often results in blood loss of more than 500 mL without any compromise of the mother's condition.

The addition of "a 10% drop in hemoglobin" to the definition provides an objective laboratory measure. However, this is not helpful in acute situations since it can take hours for losses to create laboratory changes in red blood cell measurements. Signs and symptoms of hypovolemia (lightheadedness, tachycardia, syncope, fatigue and oliguria) are also of limited utility as they can be late findings in a young and otherwise healthy female. As a result, any bleeding that has the potential to result in hemodynamic instability, if left untreated, should be considered postpartum hemorrhage and managed accordingly.

Postpartum hemorrhage can be divided into 2 types: early postpartum hemorrhage, which occurs within 24 hours of delivery, and late postpartum hemorrhage, which occurs 24 hours to 6 weeks after delivery. Most cases of postpartum hemorrhage, greater than 99%, are early postpartum hemorrhage. Notably, most women are still under the care of their delivering provider during this time. With many women delivering outside of hospitals and early postpartum hospital discharge being a growing trend, postpartum hemorrhage that presents to the emergency department may be either early or late.

Within this combined population, emergency medicine providers are likely to receive patients that fall into 1 of 3 categories:

• Those that are too close to delivery to be transferred to another location (the facility's labor and delivery suite or to another facility)

• Women who delivered at home, at a nonhospital facility, or en route to the hospital and are too hemodynamically unstable to be transferred to a labor and delivery floor within the facility or at another location

• Patients who were discharged home after delivery in stable condition, but had concerning bleeding that prompted an emergency department visit

At term, the uterus and placenta receive 500-800 mL of blood per minute through their low resistance network of vessels. This high flow predisposes a gravid uterus to significant bleeding if not well physiologically or medically controlled. By the third trimester, maternal blood volume increases by 50%, which increases the body's tolerance of blood loss during delivery.

Following delivery of the fetus, the gravid uterus is able to contract down significantly given the reduction in volume. This allows the placenta to separate from the uterine interface, exposing maternal blood vessels that interface with the placental surface. After separation and delivery of the placenta, the uterus initiates a process of contraction and retraction, shortening its fiber and kinking the supplying blood vessels, like physiologic sutures or "living ligatures."

If the uterus fails to contract, or the placenta fails to separate or deliver, then significant hemorrhage may ensue. Uterine atony, or diminished myometrial contractility, accounts for 80% of postpartum hemorrhage. The other major causes include abnormal placental attachment or retained placental tissue, laceration of tissues or blood vessels in the pelvis and genital tract, and maternal coagulopathies. An additional, though uncommon, cause is inversion of the uterus during placental delivery.

The traditional pneumonic "4Ts: tone, tissue, trauma, and thrombosis" can be used to remember the potential causes. Here, a 5th is added; “T” for uterine inversion that will be called “traction.”

The incidence of postpartum hemorrhage is about 1 in 5 pregnancies, but this figure varies widely due to differential definitions for postpartum hemorrhage.

The prognosis depends on the cause of the PPH, its duration, the amount of blood loss, comorbid conditions, and the effectiveness of treatment. Prompt diagnosis and treatment are essential to achieving the best outcome for any given patient. Most reproductive-age women will do well if managed promptly in a setting with operative and blood-product resources available.

Consequences include the sequelae of hemorrhage; aggressive fluid resuscitation; blood-product exposure; and procedures done to control uterine, cervical, vaginal, or peritoneal hemorrhage. 

Mortality

Although accountable for only 8% of maternal deaths in developed countries, postpartum hemorrhage is the second leading single cause of maternal mortality, ranking behind preeclampsia/eclampsia.[1]  Globally, postpartum hemorrhage is the leading cause of maternal mortality. The condition is responsible for 25% of delivery-associated deaths,[2]  and this figure is as high as 60% in some countries. International initiatives to improve outcomes have invested in training birth attendants (traditional or otherwise) and nurse midwives on the active management of the third stage of labor (the period immediately after delivering of the infant). Most efforts focus on uterine atony, which is the primary cause of postpartum hemorrhage. This has included education on manual techniques to increase uterine contraction-retraction and making pharmacologic uterotonic agents (oxytocin and misoprostol) more available.[3, 4, 5]

Morbidity

Postpartum hemorrhage is a potentially life-threatening complication of both vaginal and cesarean delivery. Associated morbidity is related to the direct consequences of blood loss as well as the potential complications of hemostatic and resuscitative interventions.

Consequences of uncontrolled hemorrhage

Hypovolemic shock and associated organ failure including renal failure, stroke, myocardial infarction may occur.

Postpartum hypopituitarism (Sheehan syndrome) may occur. Acute blood loss and/or hypovolemic shock during and after childbirth can lead to hypoperfusion of the pituitary and subsequent necrosis. Although often asymptomatic, it may present with an inability to breastfeed, fatigue, hypogonadism, amenorrhea, and hypotension.

Death secondary to hypovolemic shock may occur.

Consequences of fluid resuscitation

Fluid overload can lead to extremity edema and pulmonary edema. The latter is less common in young healthy women, but it should be suspected in the setting of large fluid and blood product resuscitation.

Dilutional coagulopathy occurs when crystalloids and/or serum-poor blood products are given in large volume.

Risks from exposure to blood products

The following may develop as a result of exposure of blood products:

• Allergic or febrile reactions have an incidence of about 1 case per 333 population.[6]

• Anaphylactic reactions occur in 1 in 20,000 to 1 in 47,000 blood products transfused.[7]

• Transfusion-related acute lung injury (TRALI) occurs in 1 out of every 5,000 transfusions, but more often with high plasma containing products like fresh frozen plasma (FFP) and platelets. It often starts within 1-2 hours of the transfusion, but it can happen anytime up to 6 hours after a transfusion. The symptom complex includes severe bilateral pulmonary edema, severe hypoxemia, tachycardia, cyanosis, hypotension, and fever.[8]

• Acute immune hemolytic reaction, though rare, is the most serious type of transfusion reaction. Symptoms are associated with red blood cell hemolysis. Patients may have fevers, chills, chest and lower back pain, nausea, renal failure, and death if the transfusion is not stopped.

• Delayed hemolytic reaction: This type of reaction happens when the body slowly attacks antigens (other than ABO antigens) on the transfused blood cells. Symptoms occur days to weeks after a transfusion. Affected patients are either asymptomatic or have mild symptoms, which may include jaundice, low-grade fever, and a low hemoglobin or hematocrit.[9]

• Infection: Hepatitis is the most common disease transmitted by blood transfusions. According to the American Red Cross, about 1 blood transfusion in 205,000 transmits a hepatitis B infection, and 1 blood transfusion in about 2 million transmits hepatitis C. Other rare but potential infections include HIV (risk of 1 in 2.5 million), Lyme disease, babesiosis, and malaria. Donors are screened for potential exposure so transmission is very rare. Rarely, blood may be contaminated with tiny amounts of skin bacteria during donation. Platelets are the most likely blood product to be affected by contamination from skin flora.

• Metabolic reactions: With large volume and rapid transfusions, patients are at risk of encountering 3 metabolic reactions: hypothermia, hyperkalemia, and citrate toxicity. Hypothermia results from the transfusion of unwarmed crystalloid or colloid that drops the body temperature. Hypothermia inhibits coagulation and can worsen postpartum hemorrhage. Citrate is a blood product additive that binds serum calcium and can cause hypocalcemia with large-volume transfusions. Hemolysis occurs with red blood cell storage releasing increasing amounts of intracellular potassium with time. Transfusions of older red blood cells increase the risk of hyperkalemia.

Risks associated with surgical intervention

The following may result following surgical intervention:

• Intubation and anesthesia complications: Pregnant women have an increased risk for aspiration, failed intubation, and death from failed ventilation when compared with nonpregnant patients. Respiratory injury or infection, myocardial infarction, myocardial arrhythmia, stroke, or allergic reactions to anesthetic medications may also rarely occur.

• Bleeding: Continued bleeding from the genital tract or a bleeding complication from the surgery may occur.

• Infection: Sepsis, wound infection, or pneumonia is possible.

• Deep venous thrombosis and/or pulmonary embolism: Risk is increased due to postpartum and postoperative associated hypercoagulability as well as from relative immobility in the operative and postoperative period.

Need for permanent sterilization to control bleeding

If the bleeding cannot be controlled conservatively (removal of products of conception, suturing disrupted tissues, application of pressure) then surgical intervention may be necessary. In severe cases, the following may occur:

• Hysterectomy

• Asherman syndrome, which is secondary (non-hormone mediated) amenorrhea due to uterine scarring that develops after infection and/or curettage performed to remove placental fragments

Postpartum hemorrhage can be a frightening experience for patients. It is important to provide reassurance and communicate through each step of emergency care. Make patients aware of what to anticipate through their clinical course including expected procedures; transport; and the indication, risks, and benefits of interventions.

The clinical history should be taken as a primary survey (ABCs) of the patient. This should include collecting an initial set of vital signs to guide the patient’s management, as the patient is positioned to begin the physical examination. Keep in mind, that if the bleeding is very brisk, the patient’s mental status may wane. As a result, this first set of questions should include queries about signs and symptoms that are most crucial in managing potential circulatory collapse, identifying the cause of postpartum hemorrhage (PPH), and selecting appropriate therapies.[10]

Severity of bleeding

Consider the following:

• Is the placenta delivered?

• What has been the duration of the third stage of labor?

• How long has the bleeding been heavy?

• Was initial postdelivery bleeding light, medium, or heavy?

• Are symptoms of hypovolemia present such as dizziness/lightheadedness, changes in vision, palpitations, fatigue, orthostasis, syncope or presyncope?

• If evaluating a patient with delayed postpartum hemorrhage, what has been the bleeding pattern since delivery?

Intervention guides

Obtain the following information:

• Is there a history of transfusion? What was the reason for transfusion? Is there a history of a transfusion reaction?

• Past medical history (particularly cardiovascular, pulmonary, or hematologic conditions)

• Allergies

Predisposing factors and potential etiology

Obtain the following information:

• History of postpartum hemorrhage

• Gravity, parity, length of most recent pregnancy, history of multiple gestations

• Number of fetuses for the most recent pregnancy

• Pregnancy complications (polyhydramnios, infection, vaginal bleeding, placental abnormalities)

• If the placental was delivered, was it spontaneous, or was manual delivery required?

• Current and past history of vaginal delivery versus cesarean delivery

• If cesarean delivery, was it planned in advance, decided upon after a failed vaginal delivery attempt, or performed emergently?

• Other uterine surgeries such as myomectomy (transvaginal vs transabdominal), uterine septum removal

• Personal or family history of bleeding disorder

• Medications such as prescribed, over the counter, diet supplements, or vitamins (with particular attention to anticoagulants, platelet inhibitors, uterine relaxants, and antihypertensives)

• Vaginal penetration since delivery (tampons, finger, other foreign object, vaginal intercourse)

• Signs or symptoms of infection such as uterine pain or tenderness, fever, tachycardia, or foul vaginal discharge

• Information helpful for continued management

• When and where was the delivery?

• Who assisted the delivery?

• Where and with whom was prenatal care?

• Healthy infant(s) delivered (any complications or concerns before, during, or after delivery)?

• Past surgical history

As mentioned earlier, patients with postpartum hemorrhage (PPH) should be managed like all emergency department resuscitation situations, with the history and physical examination occurring simultaneously while following acute life support algorithms.

The physical examination should focus on determining the cause of the bleeding. The patient may not have the typical hemodynamic changes of shock early in the course of the hemorrhage due to physiologic maternal hypervolemia.

Important organ systems to assess include the pulmonary system (evidence of pulmonary edema), the cardiovascular (heart murmur, tachycardia, strength of peripheral pulses), and neurological systems (mental status changes from hypovolemia).The skin should also be checked for petechiae or oozing from skin puncture sites, which could indicate a coagulopathy, or a mottled appearance, which can be indicative of severe hypovolemia.

Looking for occult postpartum hemorrhage—in the form of a pelvic, vaginal, uterine, or abdominal wall hematoma, or intra-abdominal or perihepatic bleeding—is always an important consideration when unstable hemodynamic findings are present without evidence of excessive vaginal blood loss.

Having a gynecologic examination bed is helpful but not necessary. The patient's pelvis can always be elevated on an inverted bedpan (thick-side toward the patient's feet) cushioned with towels and a sheet for comfort.

Ensure that good lighting and suction are available before beginning the following evaluations:

• Abdominal examination: Pain and tenderness (concerning for retained placenta tissue, rupture, or endometritis), distension, boggy or grossly palpable uterus (at or above the umbilicus) is suggestive of atony. Palpation of an overdistended bladder may indicate a barrier to adequate uterine contraction.

• Perineal examination: A brisk bleed should be visible at the introitus; identify any perineal lacerations.

• Speculum examination: Gently suction blood, clots, and tissue fragments as needed to maintain the view of the vagina and cervix. Careful inspection of the cervix and vagina under good light may reveal the presence and extent of lacerations.

• Bimanual examination: Bimanual palpation of the uterus may reveal bogginess, atony, uterine enlargement, or a large amount of accumulated blood. Palpation may also reveal hematomas in the vagina or pelvis. Assess if the cervical os is open or closed.

• Placental examination: Examine the placenta for missing portions, which suggest the possibility of retained placental tissue.

The 4Ts of postpartum hemorrhage (PPH) +1: tone, trauma, tissue, thrombosis, and traction. More than one of these can cause postpartum hemorrhage in any given patient.

Uterine atony

"Tone"

Atony is by far the most common cause of postpartum hemorrhage. Uterine contraction is essential for appropriate hemostasis, and disruption of this process can lead to significant bleeding. Uterine atony is the typical cause of postpartum hemorrhage that occurs in the first 4 hours after delivery.

Risk factors for atony include the following:

• Overdistended uterus (eg, multiple gestation, fetal macrosomia, polyhydramnios)

• Fatigued uterus (eg, augmented or prolonged labor, amnionitis, use of uterine tocolytics such as magnesium or calcium channel blockers)

• Obstructed uterus (eg, retained placenta or fetal parts, placenta accreta, or an overly distended bladder)

Laceration or hematoma

"Trauma"

Trauma to the uterus, cervix, and/or vagina is the second most frequent cause of postpartum hemorrhage. Injury to these tissues during or after delivery can cause significant bleeding because of their increased vascularity during pregnancy. Vaginal trauma is most common with surgical or assisted vaginal deliveries. It also occurs more frequently with deliveries that involve a large fetus, manual exploration, instrumentation, a fetal hand presenting with the head, or spontaneously from friction between mucosal tissue and the fetus during delivery. Cervical lacerations are rarer now that forceps-assisted deliveries are less common. They are more likely to occur when delivery assistance is provided before the cervix is fully dilated.

Risk factors for trauma include the following:

• Delivery of a large infant

• Any instrumentation or intrauterine manipulation (eg, forceps, vacuum, manual removal of retained placental fragments)

• Vaginal birth after cesarean section (VBAC)

• Episiotomy

Retained placenta

"Tissue"

Retained placental tissue is most likely to occur with a placenta that has an accessory lobe, deliveries that are extremely preterm, or variants of placenta accreta. Retained or adherent placental tissue prevents adequate contraction of the uterus allowing for increased blood loss.

Risk factors for retained products of conception include the following:

• Prior uterine surgery or procedures

• Premature delivery

• Difficult or prolonged placental delivery

• Multilobed placenta

• Signs of placental accreta by antepartum ultrasonography or MRI

Clotting disorder

"Thrombosis"

During the third stage of labor (after delivery of the fetus), hemostasis is most dependent on contraction and retraction of the myometrium. During this period, coagulation disorders are not often a contributing factor. However, hours to days after delivery, the deposition of fibrin (within the vessels in the area where the placenta adhered to the uterine wall and/or at cesarean delivery incision sites) plays a more prominent role. In this delayed period, coagulation abnormalities can cause postpartum hemorrhage alone or contribute to bleeding from other causes, most notably trauma. These abnormalities may be preexistent or acquired during pregnancy, delivery, or the postpartum period.

Potential causes include the following:

• Platelet dysfunction: Thrombocytopenia may be related to preexisting disease, such as idiopathic thrombocytopenic purpura (ITP) or, less commonly, functional platelet abnormalities. Platelet dysfunction can also be acquired secondary to HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count).

• Inherited coagulopathy: Preexisting abnormalities of the clotting system, as factor X deficiency or familial hypofibrinogenemia

• Use of anticoagulants: This is an iatrogenic coagulopathy from the use of heparin, enoxaparin, aspirin, or postpartum warfarin.

• Disseminated intravascular coagulation (DIC): This can occur, such as from sepsis, placental abruption, amniotic fluid embolism, HELLP syndrome, or intrauterine fetal demise.

• Dilutional coagulopathy: Large blood loss, or large volume resuscitation with crystalloid and/or packed red blood cells (PRBCs), can cause a dilutional coagulopathy and worsen hemorrhage from other causes.

• Physiologic factors: These factors may develop during the hemorrhage such as hypocalcemia, hypothermia, and acidemia.

Uterine inversion

"Traction": The traditional teaching is that uterine inversion occurs with an atonic uterus that has not separated well from the placenta as it is being delivered, or from excessive traction on the umbilical cord while placental delivery is being assisted. Studies have yet to demonstrate the typical mechanism for uterine inversion. However, clinical vigilance for inversion, secondary to these potential causes, is generally practiced. Inversion prevents the myometrium from contracting and retracting, and it is associated with life-threatening blood losses as well as profound hypotension from vagal activation.

Complete blood count (CBC)

The hemoglobin and hematocrit are helpful in estimating blood losses. However, in a patient with acute hemorrhage, several hours may pass before these levels change to reflect the blood loss and platelet count.

If the white blood cell count is elevated, suspect endometritis or toxic shock syndrome.

Assess for thrombocytopenia.

Coagulation laboratory studies

Elevations of the prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) can indicate a present or developing coagulopathy.

Electrolyte levels

Check for complicating electrolyte derangements such as a hypocalcemia, hypokalemia, and hypomagnesemia. Use this first set as a baseline for comparison during and after fluid and/or blood resuscitation.

BUN/creatinine levels

These measurements can be helpful in identifying renal failure as a complication of shock. If the BUN level rises during or after resuscitation with blood products, consider red blood cell hemolysis as a complication.

Type and crossmatch

Begin the process of finding appropriately matched blood for resuscitation in the event that it is needed.

Fibrinogen level

Levels are normally elevated to 300-600 mg/dL in pregnancy. Normal or low values raise concerns for a consumptive coagulopathy.

Liver function tests (LFTs), amylase, lipase

These studies can be helpful in considering other abdominal pathology, such as HELLP syndrome, if there is abdominal pain in addition to, or instead of, uterine tenderness.

Lactate level

Consider ordering this if the initial electrolyte study shows an anion gap or septic or hypovolemic shock is suspected as a concomitant diagnosis.

Studies to be considered with vaginal bleeding and decreasing red blood cell counts in the postpartum patient include ultrasonography (U/S), computed tomography (CT), or magnetic resonance imaging (MRI).

Ultrasonography is a fast and helpful modality for imaging pelvic structures and should be the first-line study for pelvic pathology.

Ultrasonography

In a hemodynamically unstable patient, a bedside ultrasonography can be performed by an experienced emergency medicine provider as an extension of the physical examination. In general, a dedicated pelvic ultrasonography (transabdominal and/or transvaginal) is helpful in identifying large retained placental fragments, hematomas, or other intrauterine abnormalities. Retained placenta and hematoma can look ultrasonographically identical. Using a Doppler ultrasound to look for vascularity can help to differential between the two, with clots being avascular and retained placenta often receiving persistent blood flow from the uterus.

The abdominal views of the focused assessment with sonography in trauma (FAST) examination are helpful in identifying fluid within the peritoneum that may be the result of hemorrhage. This study is designed to identify intra-abdominal and pericardial fluid that requires early operative intervention in trauma patients. However, the abdominal views are useful in any patient with suspected intra-abdominal free fluid. These include views of the right upper quadrant (RUQ)/Morison's pouch area (the most dependent area of a supine patient's peritoneal cavity), the left upper quadrant (LUQ) spleno-renal recess, and views of the pelvis (sagittal and coronal views of the uterus and pouch of Douglas). This study can detect 250-500 mL of fluid in the peritoneum, but it is a poor study for identifying retroperitoneal or paravaginal hemorrhage (extra-peritoneal bleeding).

Ultrasonography cannot reliably differentiate between blood, urine, or ascites; however, in the setting of suspected hemorrhage, any fluid in the abdomen should prompt further investigation.

More stable patients can have their abdominal and/or pelvic ultrasonography confirmed with an official study performed by a radiologist.

Computed tomography

In the event that ultrasonography is not diagnostic, CT is a helpful follow-up study. This may also be the first-line study when a pelvic hematoma or abscess is suspected, which may be missed with a sonogram. The traditional teaching is that pelvic CT is a less than ideal study for pelvic structures, due to artifact from the surrounding pelvic bones that reduces the image quality. However, this is generally not the case with modern multidetector CT studies. When enhanced with intravenous (I+) and intra-intestinal (O/R+...either oral or rectal contrast), CT can detail pelvic hematomas, cesarean delivery wound dehiscence, and retained placental tissue.

Magnetic resonance imaging

MRI is a time consuming study that is rarely performed from the ED in these patients. It can be helpful in delineating tissue planes to determine if a fluid collection (hematoma or abscess) is intrauterine or extrauterine when this is not clear from ultrasonography or CT. It can also help to distinguish a placenta accreta from simple retained products of conception.

Limited literature is available on abdominopelvic imaging in postpartum hemorrhage since the presentation of significant bleeding prompts rapid resuscitation and immediate intervention based on the clinical picture rather than documented imaging. Nonetheless, all 3 imaging modalities can assist in the evaluation of a bleeding source, but ultrasonography is usually sufficient for emergent situations.

If a patient is brought to a hospital without obstetric services, the emergency medicine providers should initiate resuscitation and transfer the patient as quickly as possible to a hospital with obstetric services for definitive care. Discuss an en route resuscitation plan with the emergency medical services (EMS) transport team, and make the receiving hospital aware of what the patient's status was upon departure from the emergency department (ED) so that the appropriate resources are mobilized before her arrival. Be sure to adhere to patient transfer laws set by the transferring facility, city, EMS transport organization, and state.

A 2014 Cochrane review of ten randomized trials for the treatment for primary postpartum hemorrhage found that oxytocin infusion was more effective and caused fewer side effects than misoprostol when used as first-line therapy.[11] However, after administration of prophylactic uterotonic agents, oxytocin and misoprostol infusions worked similarly. Although there was insufficient evidence in the review for assessing tranexamic acid (TXA), an antifibrinolytic agent, and compression methods,[11]  in other studies TXA appears to show promise for the prevention and treatment of postpartum hemorrhage after both vaginal and cesarean delivery, particularly in high doses.[12, 13]

A randomized double-blind, placebo-controlled trial by the WOMAN Trial Collaborators reported that tranexamic acid significantly reduced death due to bleeding in women with postpartum hemorrhage when compared to the placebo group (155 [1.5%] of 10,036 patients, vs 191 [1.9%] of 9985 patients in the placebo group). The study also found that the effects of tranexamic acid was greater when given within 3 hours of giving birth (89 [1·2%] vs 127 [1·7%] in the placebo group. Adverse events did not differ significantly in the two groups.[14]  The WOMAN Trial studied TXA for advanced hemorrhages in resource-limited settings. The benefit of TXA in higher resource environments, and with specific diagnoses (such as DIC) have yet to be evaluated. Currently, ACOG recommends adding TXA when first-line measures to treat PPH have failed.[15]

Another randomized controlled study by Quibel et al found that the addition of misoprostol to oxytocin did not prevent postpartum hemorrhage and increased the risk for adverse events. The rate of postpartum hemorrhage was 8.4% (68/806) in the misoprostol in addition to oxytocin group and 8.3% (66/797) in the placebo group. Fever and shivering were significantly higher in the misoprostol group compared to the placebo group (30.4% vs 6.3% for fever and 10.8% vs 0.6% for shivering).[16, 17]

 

For any obstetric emergency medical services (EMS) field call, emergency medical technicians (EMTs) should be vigilant and prepared for postpartum hemorrhage (PPH) as a potential complication. After delivery, there are two patients to assess: the mother and the baby. Their intervention needs should be prioritized according to the airway, breathing, and circulation (ABCs) of acute life support.

A primary survey of the mother should be performed by obtaining vital signs and doing a brief physical examination focused on the ABCs: If she is able to speak her A irway is intact. Consider providing supplemental oxygen to augment her B reathing and oxygen delivery; in addition to evaluating heart rate and blood pressure, include a perineal examination for sources of bleeding as part of the assessment of C irculation.

Once the primary survey is completed, immediate interventions include the following:

• Gentle massage of the uterine fundus to encourage bleeding control and delivery of the placenta (which normally takes up to 15-30 min)

• Fluid resuscitation with crystalloids, particularly if bleeding continues: This situation should be managed like that of any patient at risk of hemorrhagic shock.

• Visible perineal lacerations may be packed with sterile gauze to tamponade bleeding during transport.

• Some EMS systems are equipped with oxytocin in the prehospital setting. An infusion of oxytocin may be started in accordance with standing orders or with the agreement of the online medical control physician. (For dosing information, see the Medication section).

Do only what is needed at the scene to stabilize the mother and the baby for transport and further care in a more resourced setting. Transport should be to the nearest appropriate hospital with preference for those with obstetric services. In rural areas, the patient may need to be stabilized in a smaller community hospital ED, followed by transport to a second facility with higher-level obstetric care capabilities.

ACOG tips on preparing for OB/GYN clinical emergencies

By some estimates, the incidence of PPH has increased by as much as 114% in the United States over the past decade. The American College of Obstetrics and Gynecologists (ACOG) has released tips on how to prepare for PPH and other clinical emergencies in obstetrics and gynecology practices and departments.[18, 19] Recommendations include the following:

• Appropriate emergency supplies should be maintained on a “crash” cart or kit to eliminate the need to search for such supplies during emergency situations

• A rapid response team should be designated and trained and should undergo regular drills and simulations

• All staff members should be trained in the use of a formal standardized communication tool, such as the Situation-Background-Assessment-Recommendation tool (SBAR)

• Many emergencies can be avoided by watching for changes in patients’ clinical status that may indicate the need for intervention; recognition of these types of triggers can be incorporated into protocols, such as the United Kingdom’s Modified Early Obstetric Warning System

Management in the emergency department (ED)

The patient with suspected or obvious postpartum hemorrhage should be managed like any other hemorrhaging patient. Resuscitation measure should be started with the history and physical examination according to acute life support algorithms. Have someone call a consultant obstetrician/gynecologist (OB/GYN) immediately as care for the patient is initiated in order to make the patient's transition from resuscitative care to definitive care with the OB/GYN team smooth and early.

Primary survey (ABCs)

Perform the A irway assessment evaluating it for patency. Assess B reathing adequacy and provide supplementation with 100% oxygen as needed. Assess the C irculatory status (including peripheral pulses, heart rate, blood pressure, and a perineal examination). Support circulation to vital organs by putting the patient into the Trendelenburg position, placing at least 2 large-bore IVs, starting a rapid crystalloid infusions through both IVs, and establishing continuous vital sign monitoring to guide continued management.

Laboratory studies

Obtain samples for laboratory testing. Consider blood cultures if the patient is febrile or the vaginal blood/discharge is malodorous, as endometritis may be a complicating factor. See Laboratory Studies for more detail.

Secondary survey

Perform a focused physical examination (see Physical Examination). Also, consider a bedside ultrasonography (a FAST examination to look for intra-abdominal fluid and/or a pelvic ultrasound) as an adjunct to the physical examination. See Imaging Studies for more detail.

Interventions

Address the "4Ts plus 1" starting with "tone" since it is the most common cause of postpartum hemorrhage.

Tone

Uterine atony should always be treated empirically in the early postpartum period. Uterine massage will stimulate uterine contractions and frequently stops uterine hemorrhage. The examiner's gloved hand can be placed into the lower uterus, extracting any large clots or tissue that prevent adequate contractions.

Do not apply excessive pressure on the fundus of the uterus as this may increase the risk of inversion. Note that massaging a hard, contracted uterus can actually impede detachment of the placenta and increase bleeding.

With a boggy uterus, continue to massage and administer uterotonics to increase uterine contraction. Give oxytocin, an analogue of the identically named endogenous hormone, 20-40 units in 1 L lactated Ringer (LR) at 600 mL/h to maintain uterine contraction and to control hemorrhage. Ergotamines (eg, ergonovine, methylergonovine [Methergine]) can be used instead of, or with the failure of oxytocin, to facilitate uterine contraction.[20] Other alternatives include 15-methyl-prostaglandin, also known as carboprost (Hemabate) (0.25 mg IM), and misoprostol (1 mg PR), which is an inexpensive prostaglandin E1 analogue that has been used in several trials with good success in controlling postpartum hemorrhage in cases refractory to oxytocin. In settings in which oxytocin use is not feasible, misoprostol might be a suitable treatment alternative for postpartum hemorrhage.[21] See the Medication section for more details.

Uterine rupture

If uterine rupture is suspected, consider performing a FAST examination to look for intra-abdominal fluid, a bedside pelvic ultrasonography to evaluate the myometrial tissue for continuity and an upright kidneys, ureters, bladder (KUB) to look for peritoneal free air. Consider giving broad-spectrum antibiotics and plan for an emergent laparotomy with an OB/GYN or a general surgeon for repair.

Trauma

If lacerations or hematomas are found, direct pressure may help control bleeding. Actively bleeding perineal, vaginal, and cervical lacerations should be repaired. If brisk bleeding comes from the uterus, it may be urgently slowed by packing the uterine cavity. This may be accomplished by introducing a long vaginal pack into the cavity with dressing forceps. Alternatively (and usually more easily), a Bakri or Blakemore balloon may be introduced into the uterus and inflated. The balloon should be filled with as much saline as possible to produce adequate tamponade. It is important that the pack is placed into the uterus itself rather than into the vagina. If these devices are not available, a Foley catheter with a large balloon (30 mL or more) may be introduced into the lower uterine segment.

In a retrospective multicenter study, that evaluated maternal outcomes following uterine balloon tamponade in the management of primary postpartum hemorrhage after standard treatment had failed, Martin et al found an overall success rate of 65%.[22]  Of 17 failures, surgery was required in 16 cases, including hysterectomy in 11, and uterine artery embolization in one case. The investigators concluded that balloon tamponade is effective, safe, and accessible for treating primary postpartum hemorrhage, and it may reduce the need for invasive procedures.[22]

In a separate study that evaluated whether the timing of balloon tamponade and uterine artery embolization is associated with morbidity among women with postpartum hemorrhage, Howard and Grobman reported that earlier use of balloon tamponade among women experiencing postpartum hemorrhage is associated with decreased maternal morbidity.[23]

Hematomas should not be disrupted if they are unruptured. However, steady pressure may be applied to prevent expansion. If there is no other cause of blood loss, resuscitate the patient and admit her to the hospital with a plan to monitor the hematoma for expansion and follow her hemoglobin and hematocrit levels.

Tissue

If retained placental tissue is identified, plan for manual extraction. This may be performed by wrapping gauze around one hand, then inserting it through the vagina to the uterus in order to gently sweep the inner wall and very carefully remove adherent placental tissue fragments. This is often a difficult procedure to perform and very painful for the patient. Before starting, provided analgesia to assist with the patient's tolerance. If the bleeding is severe or accreta is suspected, it is more prudent to pack the bleeding uterus and transfer the patient to an operating room. In the operating room, the surgeon can use suction evacuation or, if needed, laparotomy, to manage the bleeding in a more controlled environment.

Traction

If uterine inversion occurs, gently push the uterus back into position. Do this by pressing the fingers of the dominant hand together to form a tear drop shape. Enter the vagina with the tips of the fingers. Once contact is made with the fundus, use an outward to inward motion of the fingers along with gentle upward pressure to move the uterus through the cervix. If the uterus has contracted down in an inverted position, the patient may be treated with nitroglycerin (50-100 mcg IV) to relax the myometrium and allow uterine replacement. Emergency surgical intervention is indicated if initial replacement attempts fail.

Thrombosis

Evaluate the CBC and coagulation study results for evidence of clotting disorders. Providing blood products will be necessary if the bleeding is profuse or initial laboratory results show hemoglobin drop >10% from the patient's prior value or from the midpoint of the normal range with continued bleeding.

For anemia, transfuse type-specific blood (or O- blood if unable to wait). Using blood warmers that permit rapid infusion is highly recommended as long as this does not delay transfusion.

For thrombocytopenia, particularly if platelets are less than 50,000, consider transfusing a pack of platelets.

Fresh frozen plasma (FFP) may also be necessary in the setting of a coagulopathy (prolonged PT or PTT or INR >1.3). In the event of massive hemorrhage, plasma transfusion should be initiated with the replacement of red blood cells to avoid a dilutional coagulopathy by adding back a proportional amount of clotting factors.[24]

If transfusing more than 6 units of pRBCs occurs or is anticipated, give 4 units of FFP, 1 unit of platelets, and 1 unit of cryoprecipitate to avoid a transfusion-related dilutional coagulopathy. The effects of any anticoagulant medications that the patient may have on board should be reversed (aspirin with platelets, low molecular weight heparin [LMWH] or heparin with protamine, warfarin with vitamin K or FFP).

Also see the American College of Obstetricians and Gynecologists for guidelines on the treatment of postpartum hemorrhage.[15]

For all cases, do the following:

• Obstetrics and gynecology: Immediate consultation with an OB/GYN is vital for the appropriate care of a patient with postpartum hemorrhage. As mentioned above, an OB/GYN should be consulted as the assessment of the patient is initiated or upon arrival of the patient in the ED. If no OB/GYN is available, consult a general surgeon.

• Blood bank: Direct contact with the blood bank is essential in assuring timely arrival of any blood products ordered.

For cases of extreme hemorrhage or when it is not possible to identify the source of the bleeding after the secondary survey, consider an urgent transfer of the patient to an operating room with the OB/GYN or general surgery consulting team and perform the following.

• Obstetric and gynecology: Recontact the OB/GYN consultant to notify him or her of the situation and discuss the appropriateness of the location change. Solicit advice from the OB/GYN consultant on how best to temporize the patient in the interim.

• Operating room: Notify the appropriate OR of the urgent arrival.

• Anesthesiology: Make the anesthesia service aware so that they can evaluate the patient and prepare their staff for the case.

• Blood bank: Notify the blood bank when the patient is being moved so that products are sent to the appropriate location.

• Interventional radiology: In centers where rapid arterial embolization can be achieved, consultation with interventional radiology should be obtained. Studies report over a 90% success rate in stopping bleeding, which can prevent hysterectomy. The decision to embolize should be made in conjunction with the OB/GYN consultant.

The active management of the third stage of labor has been shown to decrease the incidence and severity of postpartum hemorrhage (PPH). This includes the administration of oxytocin or misoprostol, uterine massage, gentle traction on the umbilical cord, and prompt placental delivery. Women with a known uterine scar or suspected placental abnormalities should be delivered and managed in a hospital setting, and instrumentation should be avoided, when possible, during vaginal delivery.

For further information, see the World Health Organizations recommendations on the prevention of postpartum hemorrhage.[25]

FIGO guidelines

The International Federation of Gynecology and Obstetrics (FIGO) has published guidelines on the prevention and management of postpartum hemorrhage (PPH). Highlights of the guidelines include the following[26] :

Prevention of PPH

To prevent PPH, a uterotonic drug should be routinely administered during the third stage of labor in all births. The preferred choice is oxytocin (either intravenous [IV] or intramuscular [IM]); if oxytocin is unavailable, other injectable uterotonics (eg, ergometrine/methylergometrine), oral misoprostol, or carbetocin (IM or IV) can be used.

For the early detection of uterine atony, abdominal uterine tonus assessment is warranted after all births.

To prevent PPH after cesarean delivery, administration of oxytocin (IV or IM) and controlled cord traction are recommended for removal of the placenta.

Management of PPH

The first-line uterotonic drug for the management of PPH is IV oxytocin. IM ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (eg, sublingual misoprostol) can be used if IV oxytocin is unavailable or if oxytocin fails to control the bleeding.

In addition, IV tranexamic acid should be administered as soon as PPH is diagnosed but within 3 hours of either vaginal birth or cesarean delivery. A second dose is recommended if bleeding continues after 30 minutes or if bleeding restarts within 24 hours of the first dose.

Uterine massage should be included in the management of PPH. In addition, bimanual uterine compression or external aortic compression can be used to treat PPH that results from uterine atony following vaginal birth.

Uterine balloon tamponade is a nonsurgical treatment option if PPH fails to respond to uterotonic drugs or if these drugs are not available. Another conservative management option is uterine artery embolization.

If uterotonic agents and conservative measures fail to control PPH, surgical interventions are recommended, such as the use of compression sutures, uterine and hypogastric artery ligation, and hysterectomy.

Medications used to control postpartum hemorrhage (PPH) are in the category of uterotonic drugs. These drugs stimulate contraction of the uterine muscle, helping to control PPH.

Class Summary

These agents are useful in the treatment and prophylaxis of PPH. The information below applies only following delivery of the fetus (the dosing, indications, and contraindications will vary prior to delivery).

Oxytocin (Pitocin)

Produces rhythmic uterine contractions, can stimulate the gravid uterus, and has vasopressive and antidiuretic effects. Can be used to control postpartum bleeding or hemorrhage. Some suggest its prophylactic use in the third stage of labor; one study of 1000 deliveries revealed a 32% reduction in the rate of PPH.

Methylergonovine (Methergine)

Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding and shortens the third stage of labor. Administer IM or intramyometrially during puerperium, during delivery of placenta, or after delivering anterior shoulder.

Carboprost (Hemabate)

Prostaglandin similar to F2-alpha, but it has a longer duration and produces myometrial contractions that induce hemostasis at the placentation site, which reduces postpartum bleeding.

Misoprostol (Cytotec)

Synthetic prostaglandin E 1 analog.

Ergonovine (Ergotrate Maleate)

Used to prevent and treat PPH due to uterine atony by producing firm contraction of the uterus within minutes. Although it is intended primarily for IM administration, a faster response can be achieved with IV use. Compared with IM route, IV route has a higher incidence of adverse effects; IV use should be reserved for emergencies (eg, excessive uterine bleeding). Severe uterine bleeding may require repeated doses, but it seldom requires more than one injection q2-4h.

Recombinant factor VIIa (NovoSeven)

Man-made activated protein that promotes thrombosis.