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Postpartum Hemorrhage

The following is a summary of the American College of Obstetrics and Gynecology (ACOG) bulletin on Post Partum Hemorrhage, published in 2017.

Definition

ACOG defines postpartum hemorrhage as cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process. 2 However, the WHO defines this as >500 ml blood loss. 4

Treatment

In order of preference once postpartum hemorrhage is identified.

  1. Fluids – Balanced solution bolus (NS, LR)
  2. Oxytocin
    • 10 units IM
    • 10-40 units diluted in 500-1000ml, infused at 500ml/hr (10-40 units/hr)
  3. Methergine (methylergonovine) 0.2 mg IM every 2-4 hours PRN
    • Avoid with hypertension
  4. Hemabate (Carboprost, prostaglandin) 250 mcg IM, repeat q15 min up to 8 doses
    • Avoid in asthma, caution with hypertension
  5. Misorpostol (Cytotec)
    • 800-1000 mcg PR
    • 600 mcg PO
    • 800 mcg sublingual
  6. Tranexamic Acid (TXA)
    • Mix 1 gram in 100ml and infuse over 10 min
    • May repeat x1 in 30 min
  7. Blood products – In escalating order
    • 2 units PRBCs
    • 2 units FFP
    • Massive transfusion porotocol (pRBCs, FFP, Platelets 1:1:1)
  8. Interventions
    • Bakri Balloon – insert under ultrasound, inflate with 300-500 ml sterile water or saline, secure to leg for traction.
    • Compression / B-lynch suture
    • Uterine artery ligation
    • Hysterectomy

Etiology

  • Tone – Atony is the most common cause. Treat with bimanual massage immediately.
  • Tissue – Consider retained products.
  • Trauma – Laceration
  • Thrombin – Coagulopathy (DIC) – transfusion

Epidemiology

Pregnancy related mortality in the US is increasing. Maternal hemorrhage remains the leading cause of maternal mortality worldwide. 2,3

Souce: CDC Pregnancy Mortality Surveillance System

Hemorrhage is the 4th leading cause of pregnancy related death.

Source: CDC Pregnancy Mortality Surveillance System

Considerable racial/ethnic disparities exist in this population.

Source: CDC Pregnancy Mortality Surveillance System

References

  1. Post-Partum Hemorrhage and Simulation, Carlson et al, ACOOG, 86th Annual Conference March 24-29, 2019 ,New Orleans
  2. Postpartum Hemorrhage, ACOG, Practice Bulletin, 2017
  3. Pregnancy Mortality Surveillance System, CDC
  4. WHO recommendations for the prevention and treatment of postpartum haemorrhage, WHO

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