Postpartum Hemorrhage and Meds

Question 1

How can PPH be minimized?

Answer 1

• correction of anemia prenatally
• elimination of routine episiotomies
• avoid genital tract lacerations
• uterotonic agent in 2nd stage

Question 2

What is second-line tx of PPH?

Answer 2

• methergine
• prostaglandin analogue
• tranexamic acid

Question 3

early/primary PPH

Answer 3

w/in first 24h PP

Question 4

late/secondary PPH

Answer 4

after 24h and up to 6wks PP

Question 5

What are major causes of PPH?

Answer 5

1) uterine atony (~70%)
2) tissue (i.e. retained placenta) (20%)
3) trauma (e.g. episiotomy, lacerations) (10%)
4) thrombin/coagulopathies (<1%)

Question 6

What are risk factors for uterine atony?

Answer 6

• overdistended uterus d/t large fetus, multiple gestation, poly
• prolonged labor
• rapid labor
• oxytocin induced or augmented labor
• high parity
• hx PPH
• chorioamnionitis
• poorly perfused myometrium 2/2 hypotension
• meds (e.g. mag sulfate, nifedipine, general anesthetics)
• uterine abnormalities (e..g. fibroids)

Question 7

Describe steps in management of PPH

Answer 7

1) fundal massage
2) R/O bleeding from laceration
3) catheterize bladder
4) administer uterotonic agent

Question 8

Describe management of continued PPH

Answer 8

1) start 2nd IV w/ NS to prep for blood transfusion
2) call physician
3) initiate bimanual compression
4) perform intrauterine exploration if suspected retained products of conception
5) pain management PRN
6) calculate total blood loss
7) repeat Hgb/Hct and assess sx during first 24-72h

Question 9

oxytocin (Pitocin)

Answer 9

augment labor; bleeding management

dose:
- 10U IM (lasts 2-3h) - start large bore IV
- 10-80U in 250-500mL NS or LR; 125 OR 250mL/h
- 10-40U in 1000mL at 500mL/h; titrate to uterine tone
* *do not give IV push**
- increase dose to 40U w/ active bleeding

onset: 2-3mins; effective in 15-30mins

SE: cramping, hypo-Na w/ large doses

Question 10

Methergine

Answer 10

alpha adrenergic agonist; control of PPH via vascular smooth muscle constriction; second-line if oxytocin does not work

dose: 0.2mg IM; may repeat in 5 mins, then q2-4h
* * do NOT give IV**

onset: 2-5mins
contraindications: HTN, PEC

SE: cramping, N/V, HTN, seizure, headache

Question 11

Hemabate (carboprost tromethamine)

Answer 11

prostaglandin; control of PPH via induction of contractions; second-line if oxytocin + fundal massage has not worked

dose: 250mcg IM; may repeat q15-90mins x 8 doses
contraindications: asthma, active cardiac/pulmonary/renal/hepatic disease

SE: bronchospasm, N/V/D, pyrexia

Question 12

misoprostil (Cytotec)

Answer 12

prostaglandin; induces uterine contractions; second-line that can be used w/ HTN

dose:
- 600-800mcg sublingual x1 = faster onset
- 800-1000mcg rectally x1; peak conc = 1.5h –> use as long-term agent after initial PPH is controlled

longer duration of action

SE: N/V/D, abdominal pain, pyrexia w/ higher doses, shivering

Question 13

What is the best PPH preventative strategy?

Answer 13

active management in 3rd stage of labor!

• administration of uterotonic agent (Pitocin IM) during or immediately following labor
• +/- uterine massage after placental expulsion
• nipple stimulation/breastfeeding

Question 14

postpartum hemorrhage

Answer 14

blood loss of >/= 1000mL

OR

blood loss + s/sx hypovolemia w/in 24h PP