Postpartum Hemorrhage

Question 1

PP Hemorrhage definition

Answer 1

• NSVD > 500cc EBL

- C/S > 1000cc EBL

Question 2

Types of PPHemorrhage

Answer 2

• Primary = w/in 24 hours of delivery

- Secondary = 24h - 12w after delivery

Question 3

Causes of primary pphemorrhage

Answer 3

• uterine atony
• genital tract lacerations
• urethral or bladder lacerations
• retained POC
• invasive placentation
• uterine rupture or inversion
• coagulopathy

Question 4

Causes of secondary pphemorrhage

Answer 4

• infection
• retained POC
• placental site sub-involution
• coagulopathy

Question 5

Evaluation of pphemorrhage

Answer 5

• PE (uterine tone, lacs?)
• US for retained products
• labs: CBC, PT/INT, ptt, fibrinogen, type & cross

Question 6

Management of pphemorrhage_initial steps

Answer 6

• place foley catheter (distended bladder can contribute to uterine atony)
• manual evacuation of uterine cavity if retained products

Question 7

Medications therapy for PPH

Answer 7

• oxytocin (pitocin) => routine use during 3rd stage => decreased incidence of PPH
• misoprostol
• methlyergonovine (methergine)
• prostoglandin (Hemavate)
• Dinoprostone (Prostaglandin E2)

Question 8

Oxytocin: dose, routes, frequency, side effects, contraindications

Answer 8

• dose: 20-40U/1L crystalloid
• route: IV (or IM/IU)
• frequency: continuous
• SE: N/V, emesis, water intoxication
• contra: none

Question 9

Misoprostol: dose, routes, frequency, side effects, contraindications

Answer 9

• dose: 600-1000ug
• route: PR or PO
• frequency: single dose
• SE: N/V, diarrhea, fever, chilles
• contra: none

Question 10

Methergine (Methylergonovine): dose, routes, frequency, side effects, contraindications

Answer 10

• dose: .2mg
• route: IM (or IU)
• frequency: q2-4H
• SE: HTN, Hypotension, N/V
• contra: HTN, Pre-E

Question 11

Hemabate (Prostaglandin F2a): dose, routes, frequency, side effects, contraindications

Answer 11

• dose: 0.25mg
• route: IM (or IU)
• frequency: q15-90min (8 dose max)
• SE: N/V, diarrhea*, flushing, chills
• contra: active cardiac, pulm (asthma), renal, or hepatic dz

Question 12

Dinoprostone (Prostoglandin E2): dose, routes, frequency, side effects, contraindications

Answer 12

• dose: 20mg
• route: PR
• frequency: q2h
• SE: N/V, diarrhea, fever, chills, HA
• contra: hypotension

Question 13

Procedural therapies for PPH

Answer 13

• uterine massage
• manual extraction
• D&C
• uterine tamponade
• uterine compression sutures
• uterine a. embolization
• ex lap
• hysterectomy

Question 14

Rapidly acting meds for PPH

Answer 14

• oxytocin (IV or IM)

- methergine (IM)