Postpartum Hemorrhage in Emergency Medicine Treatment & Management

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]