R.E.B.E.L. EM – Post-Partum Hemorrhage

Definition: Blood loss > 500 ml after a delivery (or > 250 ml after an abortion). The management of post-abortion hemorrhage is similar to that of post-partum hemorrhage (PPH).

Causes

• Uterine atony (~ 50% of cases)
• Retained products of conception (POCs)
• Cervical lacerations
• Uterine perforation
• Uterine Inversion
• Abnormal placentation (accreta, increta, percreta)
• Coagulopathy

Background:

• Occurs in 1-2% of patients undergoing a first trimester surgical abortion
• Most common cause of abortion-related mortally in 2nd trimester
• Risk increases with increasing maternal age

Clinical Presentation

• Diagnosis
  • No exact definition but generally thought to be present when bleeding exceeds 500 ml
  • Should be suspected if bleeding “exceeds a clinician’s estimate of ‘normal’.” (Lew 2013)
  • Blood loss is not always brisk. Can be moderate, prolonged bleeding
  • Tachycardia and hypotension will be late findings
  • Look for signs of hypoperfusion
• Key Examination Pieces
  • Any abnormal vital signs should raise suspicion of PPH
  • Obtain history for bleeding disorders or anticoagulation use
  • Examination of placenta
    • Should be intact without “missing pieces”
    • Looking for retained products of conception as source of ongoing bleeding
  • Examination of fundus of uterus
    • Uterine atony (uterine muscles do not fully contract) is the most common cause of postpartum hemorrhage (~ 80% of cases) (Lew 2013)
    • Abdominal examination will reveal a “boggy” uterus. Can be confirmed on bimanual exam
  • Direct examination of vagina
    • Lacerations to genital tract during delivery can cause brisk blood loss
    • Examine for uterine inversion (displacement of uterus into vagina)
  • Examine sites where blood drawn/IVs started
    • Looking for oozing or ongoing bleeding that may signal the presence of disseminated intravascular coagulation (DIC)

Treatment

• Basic Supportive Care
  • Large bore IV X 2, supplemental O2 if hypoxic, cardiac monitor
  • Volume expansion to replace hemorrhage
    • Replace with blood products as soon as available
    • Give O negative until type specific products available
    • Can use crystalloid early if evidence of hypoperfusion but not ideal resuscitative fluid
  • Call obstetrics or surgical consultants early as patients frequently require surgical intervention
• 

  Fundal Massage (Robert’s + Hedges)

  Tranexamic Acid (TXA)

  • Largest study to date demonstrated reduction in death due to hemorrhage (1.9% vs 1.5%) without difference in hysterectomy rate (WOMAN trial 2017)
  • Dose
    • 1 gram over 10 minutes
    • Second dose given if continued bleeding after 30 minutes or recurrent bleeding within 24 hours
  • Full review of WOMAN trial found here
• Uterine Massage
  • First line treatment for uterine atony
  • Begin with firm massage of the uterine fundus through the abdominal wall
  • 

    Bimanual Uterine Massage (Robert’s + Hedges)

    Advance to bimanual uterine compression if bleeding continues 

    • External hand compresses and massages uterus
    • Hand placed internally in fist to massage anterior aspect of uterus
    • Avoid downward massage with internal hand (can cause uterine inversion or injure blood vessels)
• Uterotonic Medications 
  • Should be given concomitantly with uterine massage
  • Multiple medication options which increase uterine muscle tone

Drugs for the Management of Uterine Atony (Roberts + Hedges)

• Direct Uterine tamponade
  • Uterine packing: Uterus is packed with gauze or hemostatic dressings
  • Balloon tamponade
    • Device is placed into the uterus and balloon filled with saline or water
    • 

      Bakri Balloon

      Bakri Balloon

      • Commercially available device specifically for this indication
      • Balloon accommodates up to 800 ml but as little as 250-500 ml of inflation can stop bleeding
      • Can potentially obviate need for surgical management
    • Sengstaken-Blakemore Esophogastric tube
      • Has a maximum volume ~ 500 ml
    • Latex Condom (Georgiou 2009, Burke 2017)
      • Case reports + case series of condom secured to foley catheter and inflated
      • Volume: 250-300 ml
    • Do not use a single foley catheter for this indication
      • Balloon with only 80 ml volume at maximum
      • More likely to hide bleeding than to tamponade it
      • Case reports of placement of multiple foley catheters (Georgiou 2009)

Balloon Tamponade Options (Georgiou 2009)

• Uterine Inversion
  • Treatment involves reduction of the uterus back into position
  • Typically requires procedural sedation or general anesthesia to accomplish
  • Reduction can be facilitated with tocolytic agents (I.e. terbutaline or magnesium sulfate)
• Disseminated Intravascular Coagulation
  • Administer blood products and adjuncts based on clotting derangements that are present (See LITFL DIC Post)
  • Patients will often require hysterectomy to resolve DIC

Take Home Points

• Watch for continued bleeding in excess of 500 ml or bleeding that is “more than normal.” Call it postpartum hemorrhage and start resuscitation
• Call your obstetric and/or surgical consultants early as operative intervention is often required
• Replace intravascular volume with blood products
• Uterine atony is the most common cause of postpartum hemorrhage. Begin treatment with uterine massage and uterotonic medications
• Consider the development in DIC when patients continue to bleed despite appropriate management

For More on This Topic Checkout:

• Core EM: Episode 33.0 – Post-Partum Hemorrhage
• Core EM: TXA in Post-Partum Hemorrhage
• LITFL: Disseminated Intravascular Coagulation
• emDocs: EM@3AM – Disseminated Intravascular Coagulation

References:

1. Lew GH, Pulia MS: Emergency Childbirth, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 56:p 1155-82.
2. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartum hemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389(10084): 2105-16. PMID: 28456509
3. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG 2009; 116(6): 748-57. PMID: 19432563
4. Burke TF et al. Shock progression and survival after use of a condom uterine balloon tamponade package in women with uncontrolled postpartum hemorrhage. Int J Gynaecol Obstet 2017; 139(1): 34-8. PMID: 28675419

Post Peer Reviewed By: Salim R. Rezaie (Twitter: @srrezaie)