Postpartum Hemorrhage

Question 1

Postpartum hemorrhages

Answer 1

> 500cc for vaginal delivery

> 1000cc for C-section

Timing definition

• 1st - 24hrs = primary or early
• 24hrs - 6 weeks = secondary or late

Is an obstetrical emergency

Pathophysiology:

• *disturbance in one of two mechanisms (or both)**
  1) contraction of the myometrium to compress the blood vessels supplying the placental bed
  2) local decidual hemostatic factors cause clotting

Question 2

Causes of PPH

Answer 2

Uterine aTony = #1
- makes up 50% of PPH

Trauma: uterine rupture, surgical incision, lacerations

Retained placenta

Uterine inversion

Coagulopathies

Multiparty

Large fibroids

Macrosomia

BMI > 40

Anemia

Chorioamnionits

Use of oxytocin longer than 24 hrs

Use of magnesium sulfate during pregnancy

Question 3

Risk factors for PPH

Answer 3

Retained placenta/membranes

Failure to progress during the second stage of labor (prolonged labor)
- #1 risk factor

Lacerations present

Instrumental delivery (assisted delivery)

Macrosomia

HTN disorders present

Induction of labor

Prolonged 1st or 2nd stage of labor

Question 4

Highest risk conditions

Answer 4

Abnormal placenta (previa, accreta, percreta, etc) 
- highest risk condition associated with PPH 

Placental abruption

Severe preeclampsia

Intrauterine fetal demise

Question 5

Most important risk factor for Placenta Accreta spectrum (PAS)

Answer 5

Placenta previa or low lying placenta after a prior C-section
- all of these patients must be screened via ultrasound or MRI during pregnancy for PAS

Pathogenesis of PAS = placental implantation at an area of defective decidualization caused by preexisting damage to the endometrial-myometrial interface

Question 6

Prevention of PPH

Answer 6

Active management of 3rd stage of labor

• uterotonic (misoprostal, carboprost, etc) after delivery of anterior shoulder or after delivery of neonate
• control cord traction
• induce uterine massage (Brandt-andrews maneuver)

Large bore IV and have blood types and crossed for high risk patients ahead of time

If the patient is actively bleeding = must do manual removal of the placenta and control stage 3 of labor

**DONT use carboprost if the patient is an asthmatic

Question 7

Uterine inversion

Answer 7

Life threatening side effect of massive PPH and hypotension

Causes the uterus to invert out of the vagina

must manually replace the uterus into he vagina ASAP

Question 8

PPH treatment goals

Answer 8

Restore or maintain adequate circulatory volume to prevent hypoperfusion of vital organs

Restore or maintain adequate tissue oxygenation

Reverse or prevent coagulopathy If present

Eliminate the obstetric cause of PPH

Question 9

Laceration repair

Answer 9

Always start above highest part of the laceration and do a running suture
- this gives vessels a chance to fix themselves

if the broad ligament is involved = abdominal surgery usually