Postpartum Hemorrhage

Question 0

Definition of postpartum hemorrhage?

Answer 0

Greater than 500 mL blood loss and vaginal delivery or greater than 1000 mL during C-section

Question 1

Patient with postpartum hemorrhage – next step?

Answer 1

1. IV oxytocin

2. If ineffective, IM prostaglandin F2-Alpha OR rectal misoprostol

Question 2

Uterine atony?

Answer 2

Lack of myometrial contractions

Question 3

Methylergonovine maleate (Methergine)? Treatment for? Countraindicated if?

Answer 3

Ergot alkaloid agent that induces myometrial contractions

Uterine atony

Hypertension

Question 4

Prostaglandin F2-Alpha – causes? Contraindicated in? (Why?)

Answer 4

Smooth muscle contraction; asthmatic patients (Bronchial constriction)

Question 5

Most common cause of early postpartum hemorrhage? Most common cause if contracted uterus? Other causes?

Answer 5

Uterine atony

Genital tract lacerations (firm, contracted uterus)

1. Uterine invasion
2. Placenta creta or retained placenta
3. Coagulopathy

Question 6

Risk factors for uterine atony?

Answer 6

1. Magnesium
2. Oxytocin
3. Rapid labor/delivery
4. Over distention of the uterus (macrosomia, multifetal pregnancy, hydramnios)
5. Chorioamnionitis
6. Prolonged labor
7. High parity

Question 7

Early versus late postpartum hemorrhage?

Answer 7

Within 24 hours postpartum versus after 24 hours

Question 8

Best initial management for uterine atony?

Answer 8

1. Uterine massage
2. Bimanual compression
3. IV oxytocin

Question 9

If uterine massage with bimanual compression and oxytocin fails to reduce uterine atony, consider?

Answer 9

1. uterotonic agents (Methergine, prostaglandin F2-Alpha, misoprostol)
2. Surgery – exploratory laparotomy with interruption of blood vessels to the uterus (uterine artery/cardinal ligament ligation or internal iliac artery ligation)
3. Hysterectomy

Question 10

Causes of late postpartum hemorrhage? (Time after delivery?)

Answer 10

1. Subinvolution of the placental site (10 to 14 days

2. Retained products of conception

Question 11

Subinvolution of the placental site? Tx?

Answer 11

Eschar over the placental bed falls off, lack of myometrial contraction leads to bleeding

Ergot alkaloids

Question 12

Signs of retained products of conception? Tx?

Answer 12

1. Uterine cramping and bleeding
2. Fever
3. Foul-smelling Lochia

Antibiotics and curettage

Question 13

In patients with postpartum hemorrhage – can ligate what arteries? (effects on childbearing)

Answer 13

1. Internal iliac (hypogastric) – no hysterectomy

2. Cardinal ligaments (Tutoring artery) – hysterectomy necessary