Postpartum Hemorrhage
Matt Bogard, M.D.
Background
The physician who chooses to practice obstetrics engages in
a physiologic process that has occurred for thousands of years prior to the
advent of modern medicine. For the Family
Medicine Obstetrician, attending the deliveries of his or her patients further
expands on the concept of comprehensive care.
While laboring and vaginal delivery is often a positive
experience for patients and providers alike, it is a process wrought with
potential consequences that may be devastating to the mother, the fetus, or
both. The obstetrician must be vigilant
and suspicious of the potential for complications to develop, and must have at
his or her disposal appropriate medications, supplies, tools, and personnel for
necessary intervention.
The recent increase in alternative birthing centers,
including home deliveries, places the laboring patient in a precarious position
– in the event of a complication the attendant may lack the ability to
appropriately intervene. These
situations have led to recent legal challenges.1,2
Postpartum hemorrhage is a complication of labor that
requires immediate aggressive intervention to ensure maternal well-being. Postpartum hemorrhage is classically
considered to be blood loss of greater than 500mL during or following the third
stage of labor, and has an incidence of nearly 18%.3
Severe postpartum hemorrhage occurs with more than 1 liter of blood loss
and occurs in nearly 3% of vaginal deliveries.
Causes
There are many potential causes of postpartum
hemorrhage. Uterine atony is causative
in approximately 70% of PPH cases.4 The
second most common causative group, seen in 20% of cases, is urogenital trauma
in the form of laceration, hematoma, rupture, or uterine inversion. Retained tissue accounts for approximately
10% of postpartum hemorrhage occurrences.
A very small minority of hemorrhage is caused by coagulopathy or
bleeding diathesis.
Risk factors
There
are multiple risk factors a physician must consider when contemplating the
possibility of postpartum hemorrhage.
Anemia, easy bruising, clotting disorders, history of prior postpartum
hemorrhage, multiple gestation, prolonged third stage of labor, episiotomy, and
fetal macrosomia are all contributing factors.5 A retrospective study examining oxytoxin use
during labor and the incidence of PPH found women with severe PPH secondary to
uterine atony were exposed to significantly more oxytocin during labor when
compared to matched controls (10,054 mU AUC compared to 3762 mU AUC in
controls).6 This should prompt increased
suspicion for PPH in women after a lengthy induction or augmentation. Interestingly, regional epidural analgesia
was found to be a protective factor against severe blood loss in women with
postpartum hemorrhage.7
Initial resuscitation
Acute-onset hemorrhage is a situation with which every
physician should have comfort in the initial management. Evaluation of the ABCs of life support typically
centers on Circulation. Establishment of
vascular access via two large-bore peripheral IVs or one central line is
necessary and should be followed with immediate fluid resuscitation comprised
of isotonic fluids, either Lactated Ringer’s solution or Normal Saline. Oxygen therapy, typically via nonrebreather
mask, is initiated along with serial assessment of vital signs. Ongoing brisk bleeding may prompt ordering of
complete blood counts, coagulation profile, and type and cross donor blood
products in case transfusion later becomes warranted. In one hospital-based study, the prevalence
of severe PPH was 2.36%, and the rate of transfusion of blood and blood
products was 1.6%.8 In the same study,
transfusion of packed red blood cells and blood component therapy was
significantly more common in women after caesarean section, compared to those who
delivered vaginally. The provider must
also beware that blood counts take multiple hours to stabilize after resolved
hemorrhage and initial labs may not accurately portray the patient’s status.
Pneumonic Aids
There are two helpful pneumonic aids the astute
obstetrician should memorize to guide initial treatment strategies. A recent study9 examined use of the acronym
"HEMOSTASIS" in management of the patient with postpartum
hemorrhage. HEMOSTASIS includes: ask for
Help; Establish etiology; Massage the uterus; Oxytocin infusion and
prostaglandins; Shift to operating theater; Tamponade test; Apply compression
sutures; Systematic pelvic devascularization; Interventional radiology;
Subtotal/total abdominal hysterectomy.
Practitioners completing the ALSO course are taught to consider the four
causative T’s of the postpartum hemorrhage:
Tone, Trauma, Tissue, Thrombin.
Vaginal Delivery Postpartum Hemorrhage
Active Management, rather than Expectant Management, of the
third stage of labor is the single best approach to prevention of postpartum
hemorrhage.10 This involves administration of pitocin or other uterotonic
shortly after delivery of the anterior shoulder, uterine massage prior to and
after placental delivery, and controlled cord traction throughout the third
stage. When compared to Expectant
Management of the third stage, in which the placenta is allowed to separate
either spontaneously or aided only by gravity or nipple stimulation, the Number
Needed to Treat with Active Management to prevent one case of PPH is 12.11
Pitocin remains the primary uterotonic of choice in most
cases of Active Management of the third stage of labor, in part because it may
be given intravenous, intramuscular, or direct injection in the uterine
vein. Routine use of misoprostol plus pitocin
resulted in modest reductions of blood loss in the third stage of labor in one
study, but the effects did not reach statistical significance.12
When postpartum hemorrhage develops following a vaginal
delivery, the obstetrician should first assume uterine atony and begin
immediate massage, either abdominal massage or bimanual with one hand on the
abdomen and one in the vaginal vault compressing the uterus. The labor nurse should simultaneously
administer oxytocin. The physician may
reasonably elect to also administer 1mg of the Prostaglandin E1, misoprostol,
rectally.
Additional medications available include prostaglandin F-2α,
Hemabate, which may be given in patients without history of pulmonary disease,
and one of two ergot alkaloids, Methergine and Ergonovine, in patients without
underlying hypertension or preeclampsia.
As the uterus develops tone, a detailed inspection should
be undertaken looking for obvious or occult trauma. Dissolvable suture is employed to close any
lacerations discovered and achieve hemostasis.
A change in vital signs out of proportion to perceived blood loss
coupled with pain may represent hematoma formation. Large or enlarging hematomas should be
incised and the contained clot evacuated before applying hemostatic suture,
often a figure-of-eight.13
The third stage of labor has a mean length of 8-10 minutes
and the placenta is considered retained after 30 minutes.14 Umbilical vein injection of oxytocin may
accelerate the rate of placental separation.
If this fails, manual exploration with a gloved hand is typically the
next step, and much easier to complete in the patient with regional anesthesia. Finally, it may become necessary to perform
curettage of the uterine cavity.15
If the obstetrician fails to identify a cleavage plane
between placenta and uterus, one must suspect invasive placenta, whether it be
an accreta, increta, or percreta. The
usual treatment is hysterectomy and warrants urgent consultation with an
appropriate surgeon.16
Ongoing
uterine atony and hemorrhage may be treated with intrauterine balloon
tamponade. The Bakri Balloon is a
24-French catheter with a 500mL balloon that has multiple successful case
reports.
In a recent study, tamponade catheters
controlled postpartum hemorrhage in 18 of 20 cases (90%).17
Finally, less than 1% of postpartum hemorrhage cases is
caused by a coagulation disorder. In
these cases, treatment involves replacement of deficiencies via appropriate
blood products. Packed red blood cells,
platelets, and cryoprecipitate or clotting factors may become necessary.
Operative Postpartum Hemorrhage
The surgeon in a Cesarean Section has several additional
therapies at his or her disposal. The
surgeon is always appropriate to begin with the steps outlined for vaginal
deliveries; oxytocin administration, vigorous massage, prostaglandins, and
ergot alkaloids.
Uterine compression sutures running through the full
thickness of both anterior and posterior uterine walls are a newer operative
development for surgical management of uterine atony. Christopher B-Lynch was
the first to highlight this procedure. 18 Additional similar techniques have
also recently been described, such as the Hayman modification to the B-Lynch
procedure.19 Both the B-Lynch and Hayman
involve anchoring bilateral absorbable suture in the lower uterine segment and
looping over the fundus in an anterior-posterior direction.
A recent paper evaluated in a prospective observational
study the use of a "uterine sandwich" technique (B-Lynch uterine
compression sutures in association with Bakri intrauterine tamponade balloon)
in women with unsuccessful medical treatment for postpartum hemorrhage. The combined technique was successful in
avoiding hysterectomy in all studied cases and was without postpartum
morbidity.20
The next operative step in controlling postpartum
hemorrhage, particularly in cases with adequate uterine tone, is application of
bilateral O’Leary sutures to the uterine arteries with zero or number one
absorbable sutures.21
An additional potential treatment is bilateral embolization
of the uterine arteries, which appears to be an effective means by which to
control postpartum hemorrhage, especially when caused by with placenta accreta.22
In cases where all other medical or surgical methods have
been employed, total or subtotal hysterectomy is the ultimate solution.
Footnotes
[1] Jose Martinez.
“Midwife Who Starred In 'Business Of Being Born' Sued By Parents Who
Blame Her For Stillbirth.” New York
Daily Times. http://articles.nydailynews.com/2009-10-22/local/17934735_1_midwife-baby-birth.
2 “Midwife Charged in
Virginia With Involuntary Manslaughter.”
Fox News. http://www.foxnews.com/us/2011/04/20/midwife-charged-virginia-involuntary-manslaughter/.
3 The Prevention and
Management of Postpartum Haemorrhage. WHO
Report of Technical Working Group, 1990
4 Hossain N, Shah T, Khan
N, Shah N, Khan NH. Transfusion Of Blood
And Blood Component Therapy For Postpartum Hemorrhage At A Tertiary Referral
Center. J Pak Med Assoc. 2011
Apr;61(4):343-5.
5 Advanced Life Support in
Obstetrics Course Syllabus. American
Academy of Family Physicians. 2006.
6 Grotegut CA, Paglia MJ, Johnson LN, Thames B, James
AH. Oxytocin Exposure During Labor Among
Women With Postpartum Hemorrhage Secondary To Uterine Atony. Am J Obstet Gynecol. 2011 Jan;204(1):56.e1-6.
Epub 2010 Nov 3.
7 Driessen M, Bouvier-Colle MH, Dupont C, Khoshnood B,
Rudigoz RC, Deneux-Tharaux C. Postpartum
Hemorrhage Resulting From Uterine Atony After Vaginal Delivery: Factors
Associated With Severity. Obstet
Gynecol. 2011 Jan;117(1):21-31.
8 Hossain.
9 Varatharajan L, Chandraharan E, Sutton J, Lowe V,
Arulkumaran S. Outcome Of The Management
Of Massive Postpartum Hemorrhage Using The Algorithm
"HEMOSTASIS". Int J Gynaecol
Obstet. 2011 May;113(2):152-4. Epub 2011 Mar 10.
10 Janice M. Anderson, M.D.,
and Duncan Etches, M.D., “Prevention And Management Of Postpartum
Hemorrhage.” American Family Physician.
2007 Mar 15;75(6):875-882.
11 ALSO
12 Fawole AO, Sotiloye OS,
Hunyinbo KI, Umezulike AC, Okunlola MA, Adekanle DA, Osamor J, Adeyanju O,
Olowookere OO, Adekunle AO, Singata M, Mangesi L, Hofmeyr GJ. A Double-Blind, Randomized,
Placebo-Controlled Trial Of Misoprostol And Routine Uterotonics For The
Prevention Of Postpartum Hemorrhage. Int
J Gynaecol Obstet. 2011 Feb;112(2):107-11. Epub 2010 Dec 4.
13 Benrubi C, Neuman C,
Nuss RC, Thompson RJ. Vulvar and Vaginal
Heatomas: A Retrospective Study of Conservative Versus Operative
Management. South Med Journal. 1987; 80(8):991-94
14 ALSO
15 Anderson
16 ALSO
17 Dabelea V, Schultze PM,
McDuffie RS Jr. Intrauterine Balloon
Tamponade In The Management Of Postpartum Hemorrhage. Am J Perinatol. 2007 Jun;24(6):359-64. Epub
2007 Jun 13.
18 Allam MS, B-Lynch C. The B-Lynch And Other Uterine Compression
Suture Techniques. Int J Gynaecol Obstet. 2005 Jun;89(3):236-41. Epub 2005 Apr 19.
19 Ghezzi F, Cromi A,
Uccella S, Raio L, Bolis P, Surbek D. The Hayman Technique: A Simple Method To
Treat Postpartum Haemorrhage. BJOG. 2007
Mar;114(3):362-5.
20 Yoong W, Ridout A, Memtsa
M, Stavroulis A, Aref-Adib M, Ramsay-Marcelle Z, Fakokunde A.
Application Of Uterine
Compression Suture In Association With Intrauterine Balloon Tamponade
("Uterine Sandwich") For Postpartum Hemorrhage. Acta Obstet Gynecol
Scand. 2011 Apr 18. Doi: 10.1111/J.1600-0412.2011.01153.X.
21 ALSO
22 Jung Hn, Shin Sw,
Choi Sj, Cho Sk, Park Kb, Park Hs, Kang M, Choo Sw, Do Ys, Choo Iw.
Uterine Artery Embolization
For Emergent Management Of Postpartum Hemorrhage Associated With Placenta
Accreta. Acta Radiol. 2011 Mar 28.
Dr. Matthew Bogard, Iowa doctor, is an emergency medicine doctor primarily at the Lucas County Health Center in Chariton, Iowa. Presently, he is Board Certified in Family Medicine by the National Board of Physicians and Surgeons and the American Academy of Family Physicians.
