Postpartum Hemorrhage

Traditionally, postpartum hemorrhage (PPH) was defined as blood loss greater than 500 mL in a vaginal delivery and greater than 1000 mL in a cesarean delivery. However, studies have revealed that an uncomplicated delivery often results in blood loss of more than 500 mL without any compromise of the mother's condition (Pritchard et al., 1962). Clinically, these findings led some authors to adopt a broader definition for PPH. Any bleeding that results in signs and symptoms of hemodynamic instability, or bleeding that could result in hemodynamic instability if untreated, is considered PPH. The loss of these amounts within 24 hours of delivery is termed early or primary PPH, and such losses are termed late or secondary PPH if they occur 24 hours after delivery or later. This section focuses primarily on early PPH.

The most common causes of PPH are uterine atony and lacerations of the vagina and cervix. Other causes include retained placental fragments, lower genital tract lacerations, uterine rupture or inversion, placenta accreta, and hereditary coagulopathy. Causes of late PPH (24 hours to 6 weeks after delivery) include infection, placental site subinvolution, retained placental fragments, and hereditary coagulopathy (ACOG, 1998a).

Risk factors for uterine atony include uterine overdisten-tion secondary to hydramnios, multiple gestation, use of oxytocin, fetal macrosomia, high parity, rapid or prolonged labor, intra-amniotic infection, and use of uterine-relaxing agents (Combs et al., 1991). Uterine rupture occurs in approximately 1 in 2000 deliveries. Previous uterine surgery is a significant risk factor for uterine rupture, placenta accreta, and PPH. Other risk factors include obstructed labor, multiple gestations, abnormal fetal lie, and high parity.

Risk factors for hemorrhage at the time of cesarean delivery include preeclampsia, disorders of active labor, a history of previous hemorrhage, obesity, use of general anesthesia, and intra-amniotic infection.

Adequate intravascular access should be obtained in women who have significant risk factors for PPH. Active management of the third stage of labor has been shown to decrease the incidence of PPH. Early administration of oxy-tocin, early cord cutting and clamping, and controlled cord traction have been shown to decrease PPH by two-thirds (Soriano et al., 1996).

In the event of hemorrhage, supplemental oxygen should be administered to enhance cellular oxygen delivery. Heart rate and blood pressure should be monitored closely. Initial laboratory evaluation includes a complete blood count with platelet concentration. Blood type and crossmatch should be performed if not previously obtained. Fibrinogen, fibrin split products, prothrombin time, and partial thromboplas-tin time should be measured (ACOG, 1998a).

Excessive vaginal bleeding after placental delivery should prompt vigorous fundal massage while the patient is rapidly given 10 to 30 units of oxytocin in 1 L of IV fluid. If the fundus does not become firm, uterine atony is the presumed (and most common) diagnosis. Uterine atony should be initially managed by bimanual uterine massage and compression in addition to the oxytocin. If IV or IM oxytocin proves ineffective, other uterotonic agents, such as methylergonovine and prostaglandin derivatives (15-methyl PGF2a), may be used as second-line treatment (ACOG, 1998a). Methylergono-vine may be administered in a dose of 0.2 mg IM every 2 to 4 hours. Methylergonovine can cause cramping, headache, and dizziness. This agent is contraindicated in hypertensive disease states because it induces vasoconstriction, which can lead to severe hypertension.

15-Methyl prostaglandin F2a (Hemabate), may be given in a dose of 0.25 mg IM every 15 to 90 minutes (no more than eight doses). PGF2a may also be given by intramyome-trial injection at cesarean delivery or transabdominally after vaginal delivery. Prostaglandin E2 can cause vasodilation and exacerbation of hypotension; therefore, 15-methyl PGF2a is preferred. Because oxygen desaturation has been reported with use of PGF2a, patients should be monitored by pulse oximetry.

Continuing hemorrhage in a patient with a firm uterine fundus can indicate a hidden vaginal or cervical laceration. This type of injury is usually easy to identify and repair with adequate lighting, exposure, and assistance. If no laceration is present and the fundus is firm, the uterus requires gentle but thorough manual exploration for retained placenta, which should be removed. Uterine rupture is occasionally evident and requires immediate surgery.

An occult uterine inversion might also be discovered on vaginal examination, or it can manifest frankly. Uterine inversion is somewhat more common in primiparas and has no clear association with the mismanagement of labor. Because uterine inversion can quickly lead to shock, the physician should order brisk IV hydration and grasp the uterus in the palm, with the thumb anterior. The uterus is then firmly pushed back up into the abdominal cavity and held in place for several minutes (Brar et al., 1989). Magnesium sulfate, 0.25 mg IV, has been reported to assist in the repositioning of the uterus (Catanzarite et al., 1986).

If uterine and vaginal exploration is nondiagnostic, if uterine inversion is excluded, and if the fundus is firm, rarer causes of hemorrhage should be considered. Puerperal hematomas typically cause a vulvar or vaginal mass, and an occult retroperitoneal hematoma can manifest with severe abdominal pain and shock after delivery. The diagnosis is confirmed on laparotomy. Visible hematomas less than 4 cm and not expanding may be managed with ice packs and observation. Larger or expanding hematomas must be

The complete reference list is available online at www.expertconsult.com.

www.guidelines.gov

U.S. federal health guidelines; contains links to a variety of medical care and evidence-based guidelines for many clinical problems, in addition to obstetrics. www.ahrq.gov/

Agency for Healthcare Research and Quality; contains clinical information, research findings, survey data, and funding opportunities. www.uptodate.com

Subscription program offering clinical information focused on primary care but also including a variety of other clinical specialties.

incised, irrigated, and packed, and any obvious bleeding vessels must be ligated. If venipuncture sites are oozing, coagu-lopathy should be considered.

Surgical intervention is undertaken for direct indications, such as uterine curettage for suspected retained placental tissue or for hemostasis if medical therapy fails. The most common indications for emergency hysterectomy include uterine atony, placenta accreta, uterine rupture, and the extension of a low-transverse uterine incision.

KEY TREATMENT

Uterotonic agents should be the first-line treatment for postpartum hemorrhage caused by uterine atony (SOR: C).

Management of PPH may vary greatly among patients, depending on etiology and available treatment options, and often a multidis-

ciplinary approach is required (SOR: C).

When uterotonics fail following vaginal delivery, exploratory laparotomy is the next step (SOR: C).

In the presence of conditions known to be associated with placenta accreta, the obstetric care provider must have a high clinical suspicion and take appropriate precautions (SOR: C).

Data from ACOG, 2006.

www.marchofdimes.com/peristats/

Excellent source of free access to national, state, and city maternal and infant health data; includes graphs, quick facts, maps, and state summaries. www.aafp.org

American Academy of Family Physicians; includes continuing medical education (CME) opportunities, clinical information, and links to the American Family Physician, Family Practice Management, and the Annals of Family Medicine.

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