Obstetrical Hemorrhage

Question 1

What is obstetrical hemorrhage?

Answer 1

Excessive bleeding at time of delivery. Normal blood loss is 500cc for vaginal delivery and 1000cc during a cesarean section.

Question 2

What are the clinical features of obstetrical hemorrhage?

Answer 2

1. Hypovolemic shock
2. Fetal distress
3. Associated with massive hemorrhage (low platelets, coagulation factor depletion, hypocalcemia, hyperkalemia, acid/base alterations, hypothermia)

Question 3

What is the differential diagnosis for obstetrical hemorrhage?

Answer 3

1. Uterine atony
2. Vaginal or cervical tears
3. Retained placental fragments
4. Placenta previa/accreta
5. Placental abruption
6. Uterine rupture
7. bleeding disorder
8. DIC

Question 4

What are the risk factors for uterine atony?

Answer 4

Multiple gestation
Grand multiparity
Fetal macrosomia
Polyhydramnios
Prolonged labor
Chorioamnionitis

Question 5

What is the management of obstetrical hemorrhage?

Answer 5

1. Assess need for airway management and initiation of CPR
2. Call for assistance and potential need for neonatal resuscitation
3. Factor replacement
4. Notify blood bank/Transfuse
5. Treat uterine atony
6. C-section/hysterectomy may be necessary for placenta previa/accreta/abruption or uterine rupture.
7. Consider need for invasive monitors and rapid transfusion devices
8. Minimize hypothermia
9. Labs
10. Assess for component therapy
11. Follow and treat calcium and potassium levels
12. Consider factor VIIa

Question 6

What are the treatments/interventions for uterine atony?

Answer 6

• bimanual uterine compression/massage
• oxytocin
• methylergonovine
• PGF 2-alpha (carboprost, hemabate)
• uterine vessel embolization/ligation
• hysterectomy

Question 7

What is another name for carboprost/hemabate?

Answer 7

15-methyl PGF 2-alpha