#183 Postpartum Hemorrhage Flashcards by Angela Nolin

What is the definition of maternal hemorrhage?

Cumulative blood loss of greater than or equal to 1,000mL or blood loss accompanied by signs or symptoms of hypovolemmia within 24 hours after birth process

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What is the leading cause of maternal mortality worldwide?

Hemorrhage

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What secondary sequelae from maternal hemorrhage exist?

ARDS, shock, DIC, acute renal failure, loss of fertility, and pituitary necrosis (Sheehan syndrome)

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What is rate (% of total mortalities and per 100,000 live births) of maternal mortality from hemorrhage?

Slightly more than 10% of maternal mortality due to hemorrhage. 1.7 deaths per 100,000 live births (in 2009)

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How does definition of postpartum hemorrhage change based on mode of delivery?

It does not. 1,000mL for both.

Traditionally was 500cc for vaginal, 1000cc for CS

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Definition of PPH for vaginal delivery is 1000cc blood loss or greater, previously was 500cc. Is blood loss of 500-1000cc after vaginal delivery normal?

No. Should be considered abnormal and should serve as an indication for provider to investigate the increased blood deficit

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What decrease in hematocrit has been used to define postpartum hemorrhage? What are limitations of this?

Decrease of 10%. Measurements of hematocrit concentrations are often delayed, may not reflect current hematologic status, and are not clinically useful in acute setting

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At what level of blood loss (mL and % total volume), would you expect a healthy postpartum patient to start developing tachycardia and hypotension?

1,500mL or more of blood, about 25% of total blood volume.

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What is the definition of secondary postpartum hemorrage?

Excessive bleeding that occurs more than 24 hours after delivery and up to 12 weeks postpartum

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What are the etiologies of primary (within 24h) postpartum hemorrhage?

Uterine atony, lacerations, retained placenta, abnormally adherent placenta (accreta), defects of coagulation (eg, DIC), uterine inversion

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What are the etiologies of secondary (>24h, <12wks) postpartum hemorrhage?

Subinvolution of the placental site, retained POCs, infection, inherited coagulation defects

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What percent of cases of postpartum hemorrhage are caused by uterine atony?

70-80%

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What is the most common cause of postpartum hemorrhage?

Uterine atony, 70-80% of cases

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What are risk factors for postpartum uterine atony leading to postpartum hemorrhage?

Prolonged use of oxytocin, high parity, chorioamnionitis, general anesthesia, over-distended uterus (twins or multiple gestation, polyhydramnios, macrosomia), uterine inversion (excessive umbilical cord traction, short umbilical cord, fundal implantation of placenta)

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What are risk factors for genital tract trauma leading to postpartum hemorrhage?

Episiotomy, operative vaginal delivery, precipitous delivery, cervical, vaginal, and perineal lacerations, uterine rupture

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What are risk factors for retained placental tissue leading to postpartum hemorrhage?

Retained placenta, succenturiate placenta, placenta accreta, previous uterine surgery, incomplete placenta at delivery

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What are risk factors for abnormalities of coagulation leading to postpartum hemorrhage?

Preeclampsia, inherited clotting factor deficiency (von Willebrand, hemophilia), severe infection, amniotic fluid embolism, excessive crystalloid replacement, therapeutic anticoagulation, fetal death, placental abruption, hemorrhage

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How accurate are risk assessment tools at identifying patients who will experience a significant obstetrical hemorrhage? What percentage does it identify that does not experience hemorrhage?

Identify 60-85% who had hemorrhage. Identified more than 40% of women who did not experience hemorrhage as high risk.

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What components make up active management of third stage of labor?

Oxytocin administration
Uterine massage
Umbilical cord traction

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What is the dosing of oxytocin (IV and IM) for prophylaxis during third stage of labor?

Dilute IV infusion (bolus dose of 10u), or IM injection of 10u

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When should prophylactic oxytocin be administered during third stage of labor to help prevent postpartum hemorrhage?

Timing has not been adequately studied or found to be associated with difference in the risk of hemorrhage.

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Does nipple stimulation or breastfeeding decrease the risk of postpartum hemorrhage?

Per Cochrane review, it does not

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What treatment options are available for management of postpartum hemorrhage due to uterine atony?

Administration of uterotonics or pharmacologic agents, tamponade of the uterus (eg, intrauterine balloon), surgical techniques to control bleeding (eg, B-Lynch pro3-25%cedure), embolization of pelvic arteries or, ultimately, hysterectomy

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After uterine atony is identified in setting of postpartum hemorrhage, what are the first steps?

Empty bladder, bimanual pelvic exam, removal of intrauterine clots, uterine massage

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How often is a second uterotonic (after oxytocin) required during a postpartum hemorrhage?

3-25% of cases

Which uterotonic is most effective?

According to 2015 systematic review, lack of evidence that suggests which additional uterotonics are most effective (after oxytocin)

What is the initial management of lower uterine segment dilation and atony (fundus firm)?

Manually remove any clots and use bimanual compression to reduce blood loss while waiting for the uterotonic agents to work

Are genital tract lacerations more commonly venous or arterial bleeding?

Venous

How do you manage a post vaginal delivery patient with suspected uterine artery laceration?

Interventional radiology or surgical exploration and ligation

What signs/symptoms may make you concerned for a genital tract hematoma after vaginal delivery if you're unable to see it?

Labial, rectal, pelvic pressure or pain, vital sign deterioration. Also need to consider possible retroperitoneal or intraperitoneal bleeding.

What are risk factors for a genital tract hematoma formation during vaginal delivery?

Precipitous delivery or operative delivery

How do you manage a genital tract hematoma after delivery?

Most can be managed conservatively. If rapidly expanding or vital sign deterioration > interventional radiology arterial embolization vs exploration with suturing and packing

True or false, you should inspect the placenta for completeness after all deliveries?

True, but even if appears intact, may be additional remaining POCs (eg, succenturiate lobe)

How do you diagnose retained placental tissue at time of delivery?

Ultrasonography or intrauterine manual examination

How should you remove retained palcenta at the time of delivery?

First step is attempt manual removal. Then either a "banjo" curette or large oval forceps (Sopher or Bierer) can be used.

How does placental abruption typically lead to postpartum hemorrhage?

Often associated with uterine atony 2/2 extravasation of blood into myometrium (Couvelaire uterus), and DIC and hypofibrinogenemia.

How does placental abruption classically present?

Vaginal bleeding, frequent uterine contractions (tachysystole; high-frequency, low-amplitude ctx), and pain.

What % of postpartum hemorrhage cases that require massive transfusion are caused by placental abruption?

17%

Is amniotic fluid embolism common?

Is amniotic fluid embolism predictable?

Is amniotic fluid embolism preventable?

What triad makes up amniotic fluid embolism?

hemodynamic and respiratory compromise in addition to strictly defined DIC

What are the uterotonic medications?

oxytocin, methylergonovine, 15-methyl prostaglandin F2, and misoprostol

Can you use all uterotonics in rapid succession or do they need to be spaced out?

Can be used in rapid succession

What is dosing of oxytocin for management of postpartum hemorrhage?

IV: 10-40 units per 500-1000mL continuous infusion IM: 10 units

What are contraindications to use of oxytocin for postpartum hemorrhage?

Hypersensitivity to medication

What are adverse effects from oxytocin use, in setting of postpartum hemorrhage?

Nausea, vomiting, hyponatremia w/ prolonged dosing. Hypotension from IV push (which is not recommended)

What is the dosing and route of methylergonovine?

0.2mg IM

How often can you redose methylergonovine?

every 2-4 hours

What are contraindications to methylergonovine use in postpartum hemorrhage?

HTN, PEC, cardiovascular disease, hypersensitivity to drug

What are adverse effects from methylergonovine administration?

Nausea, vomiting, severe hypertension particularly when given IV (not recommended)

What is the dosing and route of administration for 15-methyl prostaglandin F2?

0. 25mg IM | 0. 25mg intramyometrial

How often can you dose 15-methyl prostaglandin F2? For how many doses?

Every 15-90 minutes. Eight doses maximum.

What are contraindications to 15-methyl prostaglandin F2 administration?

Asthma, relative contraindication for hypertension, active hepatic, pulmonary, or cardiac disease

What adverse effects are associated with 15-methyl prostaglandin F2 administration?

Nausea, vomiting, diarrhea, fever (transient), headache, chills, shivering, hypertension, bronchospasm

What is the dosing and route of misoprostol for postpartum hemorrahge? How frequently can you give it?

600-1000mcg oral, sublingual, or rectal. Administer once

What are contraindications to misoprostol use for postpartum hemorrhage?

Hypersensitivity to medication or to prostaglandins

What adverse effects are associated with misoprostol administration for postpartum hemorrahge?

Nausea, vomiting, diarrhea, shivering, fever (transient), headache

What type of medication is transexamic acid?

Antifibrinolytic agent

How is transexamic acid administered?

Either IV or orally

When is transexamic acid administration most beneficial for patient with postpartum hemorrhage?

Prophylactically or within 3 hours from time of delivery

How much of what type of fluid do you put in a Bakri balloon?

300-500mL of saline

Describe an ebb uterine tamponade system.

Double balloon with uterine and vaginal balloon. Maximum recommended fill volumes 750cc uterine, 300cc vaginal

How do you perform uterine packing during a postpartum hemorrhage?

4-inch gauze, which can be soaked with 5,000 units of thrombin in 5mL of saline then insert from one cornua to the other with ring forceps

What percent of women will need additional intervention after intrauterine balloon placement for postpartum hemorrhage?

75-86% do not need further treatment

What are alternatives for intrauterine balloon tamponade for postpartum hemorrhage (other methods for tamponade)?

Pack uterus with gauze. Multiple large Foley catheters.

Who are candidates for uterine artery embolization in setting of postpartum hemorrhage?

Typically hemodynamically stable, appear to have persistent slow bleeding and have failed less invasive therapy

What is the success rate of uterine artery embolization for postpartum hemorrhage?

Median success rate 89% (58-98%)

What percent of women who get UAE for postpartum hemorrhage wind up requiring subsequent hysterectomy?

15% according to largest series available (114 UAE procedures)

What is rate of infertility after UAE?

Reported in up to 43%

What are risks to subsequent pregnancy after UAE for postpartum hemorrhage?

Risk appear to be similar to general obstetric population. Preterm birth (5-15%) and fetal growth restriction (7%)

What is the common first approach to surgical vascular ligation for postpartum hemorrhage?

Bilateral uterine artery ligation (O'Leary sutures)

What is the goal of bilateral uterine artery ligation for postpartum hemorrhage?

Reduce blood flow to the uterus and diminish the pulse pressure to blood flow to uterus

After bilateral uterine artery ligation (O'Leary sutures), what is another option to decrease blood flow?

Sutures can also be placed across the vessels within the utero-ovarian ligaments

What is the effectiveness of uterine compression sutures as a secondary treatment for uterine atony unresponsive to medical management?

Approximately 60-75%

Why is it important to use a rapidly absorbed suture for B-lynch sutures?

Prevent risk of bowel herniation through a persistent loop of suture after uterine involution

What uterine compression sutures are there?

B-Lynch, Hayman, Cho https://www.oatext.com/to-b-or-not-to-b-compression-sutures-what-a-patient-needs-to-know-after-the-bleeding-is-controlled-a-review.php#gsc.tab=0

What are the risk of ureteral injuries and bladder injuries during hysterectomy for postpartum hemorrhage?

Ureteral injury 0.4-41% and bladder injuries 6-12%. Based on six small studies

What is the risk of placenta accreta with number of cesarean deliveries (first through sixth cesarean section) [all comers, not just previa]?

``` First cesarean: 0.2% Second: 0.3% Third: 0.6% Fourth: 2.1% Fifth: 2.3% Sixth: 6.7% ```

What is the risk of placenta accreta with placenta previa and no prior cesarean section?

What is the risk of placenta accreta with placenta previa and one prior cesarean section [2nd CS]?

11%

What is the risk of placenta accreta with placenta previa and two prior cesarean section [3rd CS]?

40%

What is the risk of placenta accreta with placenta previa and three prior cesarean section [4th CS]?

61%

What is the risk of placenta accreta with placenta previa and four prior cesarean section [5th CS]?

67%

Can you conserve the uterus in the setting of a focal accreta?

Conservative efforts may work, however hysterectomy may still be needed

What is the risk of emergency hysterectomy and major morbidity with attempts at uterine conservation with placenta accreta?

40% risk of emergency hysterectomy, 42% of women suffered major morbidity

What is the risk of abnormally adherent placenta after prior abnormally adherent placenta?

Approximately 20%

What is the incidence of uterine inversion at the time of vaginal delivery and at cesarean delivery?

1 in 3,700 to 20,000 at vaginal delivery. 1 in 1,860 at cesarean delivery.

What is the risk of uterine version at time of delivery in woman with previous uterine inversion?

1 in 26 subsequent deliveries

If uterine inversion occurs prior to detachment of placenta, is it recommended to detach placenta prior to or after replacement of uterus?

In general, do not remove placenta prior to replacement, as could lead to additional hemorrhage

How do you manually replace the uterine corpus during uterine inversion?

Place palm of hand against fundus as if holding a tennis ball, with the fingertips exerting upward pressure circumferentially or using closed fist.

What medications (category and specifics) may be necessary to help replace uterine inversion?

Uterine relaxant may be necessary: terbutaline, magnesium sulfate, halogenated general anesthetics, and nitroglycerin

If uterine inversion cannot be reduced manually, what is the next step?

Laparotomy with Huntington procedure or Haultain procedure

What is the Huntington procedure?

Procedure to return uterine corpus to abdominal cavity after inversion. Progressive upward traction on the inverted corpus using Babcock or Allis forceps

What is the Haultain procedure?

Procedure to return uterine corpus to abdominal cavity after inversion. Incising the cervix posteriorly, which allows for digital repositioning, with subsequent repair of the incision

What is the risk of delayed postpartum hemorrhage (>24h, <12wks postpartum)?

1% of pregnancies

What is the treatment for postpartum endometritis?

Broad antibiotic coverage, clindamycin and gentamicin is a common choice, although other combinations are also used

When during a postpartum hemorrhage should you transfuse blood?

Women with ongoing bleeding that equates to blood loss of 1500mL or more or in women with abnormal vital signs (tachycardia, hypotension)

What is the definition of massive transfusion?

Transfusion of 10 or more units of pRBCs within 24 hours, transfusion of 4 units of pRBCs within 1 hour when ongoing need for more blood is anticipated, or replacement of a complete blood volume

During massive transfusion protocol what is the recommended initial ratio for pRBC: FFP: Platelets?

1:1:1. Designed to mimic replacement of whole blood.

What is the risk of maternal mortality from obstetric hemorrhage in patients who refuse blood products compared to those who accept blood products?

44-fold to 130-fold higher risk

What risks are associated with massive transfusion?

Hyperkalemia from pRBCs, citrate toxicity (preservative in blood) that will worsen hypocalcemia. [combo of acidosis, hypocalcemia, and hypothermia > worsening coagulopathy and increased morbidity]. Pulmonary edema. Transfusion febrile nonhemolytic reactions (0.8 per 1,000 units transfused), acute hemolytic transfusion reaction (0.19 per 1,000 units transfused), acute transfusion reactions related lung injury (TRALI, 0.1 per 1000 units transfused). Transfusion-associated infections are relatively rare

What are prothrombin complex concentrates and what is it used for?

Human plasma-derived concentrates of vitamin K-dependent clotting factors (Factors II, IX and X or factors II, VII, IX, and X). First-line tretment for urgent reversal of acquired coagulation factor deficiency induced by vitamin-K antagonists (eg, warfarin)

What is the only FDA approved indication for recombinant factor VII?

Treatment of patients with hemophilia A and B

Is there a role for recombinant factor VII in postpartum hemorrhage? What's the risk?

Reserved for extenuating circumstances after multiple rounds of standard massive transfusion agents and in consultation with local or regional expert. Risk is life-threatening thrombosis in range of 2-9%

Is there a role for prothrombin complex and fibrinogen concentrates during postpartum hemorrahge?

Only after multiple rounds of the standard massive transfusion agents and in consultation with local or regional expert.

At what hemoglobin level should you consider a blood transfusion in a postpartum patient? How many units should you start with?

Less than 7 g/dL. American Association of Blood Banks recommends starting with 1 unit and then reassessing in a stable patient.

Is oral or IV iron better at improving H&H short term, long term?

Short term (posttreatment day 14), IV is modestly better. At posttreatment day 40-42, no difference

True or false, multidisciplinary simulation-based team training, including postpartum hemorrhage scenarios, have been associated with improved safety culture and outcomes in obstetrics?

True