When the obstetrician is faced with a postpartum hemorrhage, an organized care plan needs to be set in motion to minimize further bleeding and associated morbidity and mortality. Table 3-4 lists the components of such a care plan.
TABLE 3-4.Postpartum Hemorrhage Care Plan ||Download (.pdf) TABLE 3-4. Postpartum Hemorrhage Care Plan
|B ||Blood loss needs |
|L ||Loss estimation |
|E ||Etiology |
|E ||EBL replacement |
|D ||Drug therapy |
|I ||Intraoperative management |
|N ||Nonobstetrical services |
|G ||General complication assessment |
When faced with a postpartum hemorrhage, the first priority that a clinician should assess is his or her blood loss needs. Appropriate intravenous (IV) access is critical. This includes two large-bore (16-gauge) IV catheters. In addition, the patient’s blood type should be confirmed and held for possible cross matching needs. The patient should be provided supplemental oxygen and attempts should be made to keep the patient warm (eg, Bair Hugger warming unit). Finally, need for ancillary support should be assessed. This support may include additional nursing assistance, operating room staff, physician assistance, and an anesthesiology team.
Many instances of hemorrhage result in compounded morbidity secondary to an inadequate blood loss estimation on the part of the obstetrician. At the onset of a postpartum hemorrhage, it is important for the clinician to realistically estimate the amount of blood loss that has occurred. At this time, baseline laboratory evaluations of hemoglobin, hematocrit, platelet count, fibrinogen, prothrombin time, and partial thromboplastin time should be taken. If timely laboratory assessment is unavailable, drawing 5 mL of maternal blood into an empty red top tube and observing for clot formation will provide the clinician a rough estimate of the patient’s coagulopathy. If a clot is not visible within 6 minutes or forms and lyses within 30 minutes, the fibrinogen level is usually less than 150 mg/dL.
After assessing blood loss needs and estimation, a rapid yet thorough exploration for the hemorrhage etiology must be undertaken. A poorly contractile uterus suggests uterine atony. If atony is not the source of bleeding, further exploration should occur. This exploration should begin with the most superior aspect of the genital tract and progress inferiorly since heavy downward blood flow may make visualization of the more inferior landmarks difficult.
Initial assessment should focus on the uterus. The most common uterine source of bleeding other than atony is retained products of conception. Figure 3-2 demonstrates proper manual exploration of the uterine cavity in order to remove retained products of conception.38 Wrapping the examination hand with moist gauze can facilitate removal of retained amniotic membranes. If manual access to the uterine cavity is difficult or limited due to maternal body habitus or inadequate pain relief, transabdominal ultrasound may be used to assess for retained placental fragments. Once fragments are identified, appropriate removal may be undertaken via manual extraction and/or uterine curettage. Besides assessing for retained products of conception, a proper uterine examination can assess for evidence of invasive placentation, uterine rupture, and uterine inversion.
Manual uterine exploration.
Once a uterine source has been excluded, attention should be focused on identifying a lower genitourinary tract laceration. Cervical and/or vaginal fornix lacerations are often difficult to repair due to their location. In these situations, it is best to have early assistance for retraction in order to visualize the laceration and provide adequate repair. In some instances, moving to an operating room to provide more adequate pain relief, pelvic relaxation, and visualization will save time and subsequent bleeding since a proper repair can be instituted more efficiently. In addition, lacerations that involve sites near the urethra and/or bowel may be challenging from the technical as well as visual perspectives. In these circumstances, employing additional instrumentation (eg, transurethral catheter) may protect uninjured entities and allow for a better repair.
After the most common etiologies of postpartum hemorrhage are excluded, other sources of bleeding should be assessed. Being aware of the risk factors for these etiologies will decrease diagnostic time and allow for more timely intervention.
Estimated Blood Loss Replacement
Understanding the patient’s requirements for fluid and blood component therapy is critical to providing adequate care to the bleeding patient. Estimated blood loss (EBL) replacement begins with appropriate fluid resuscitation. Warmed crystalloid solution in a 3:1 ratio to EBL will provide the initial volume necessary to stabilize a bleeding patient. Once appropriate volume resuscitation has occurred, additional blood component therapy may be tailored to the individual patient’s needs and blood loss. It is important for the clinician to understand the expected clinical response to the blood product therapy that is given (see Chap. 2).
In the past, there was no consensus regarding optimal blood product replacement. However, newer data from military experience suggest improved outcomes when the ratio of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets is 1:1:1.39,40,41,42,43, 44 In addition, hospital-based massive transfusion protocols have been successful in consumptive coagulopathy management due to postpartum hemorrhage. Stanford University Medical Center has incorporated a fixed protocol of 6:4:1 for PRBC to FFP to apheresed platelets.45 Other centers have added 6 to 10 units of thawed cryoprecipitate to this regimen.46
Uterotonic medications represent the mainstay of drug therapy for postpartum hemorrhage due to uterine atony. Table 3-5 lists available uterotonic agents, their dosage, side effects, response time, and contraindications.46,47
TABLE 3-5.Uterotonic Therapy ||Download (.pdf) TABLE 3-5. Uterotonic Therapy
|Agent ||Dose ||Route ||Dosing interval ||Response time ||Side effects ||Contraindications |
|Oxytocin (Pitocin) ||10-80 units in 1000 mL crystalloid solution || |
First line: IV
Second line: IM or IU
|Continuous ||1-5 min ||Nausea, emesis, water intoxication ||None |
|Misoprostol (Cytotec) ||200-1000 mcg || |
First line: PR
Second line: PO or SL
|Single dose ||40-60 min for PR 30 min for SL ||Nausea, emesis, diarrhea, fever, chills ||None |
|Methylergonovine (Methergine) ||0.2 mg || |
First line: IM
Second line: IU or PO
|Every 2-4 h ||2-5 min ||Hypertension, hypotension, nausea, emesis ||Hypertension, scleroderma, Raynaud’s |
|Prostaglandin F2α(Hemabate) ||0.25 mg || |
First line: IM
Second line: IU
|Every 15-90 min (maximum of 8 doses) ||15-30 min ||Nausea, emesis, diarrhea, flushing, chills ||Active cardiac, pulmonary, renal, or hepatic disease |
|Prostaglandin E2 (Dinoprostone) ||20 mg ||PR ||Every 2 h ||10 min ||Nausea, emesis, diarrhea, fever, chills, headache ||Hypotension |
When atony is due to tocolytic therapy that impairs calcium entry into the cell (magnesium sulfate, nifedipine), an additional agent to employ is calcium. Given as an intravenous push, one ampule of calcium chloride or calcium gluconate can effectively improve uterine tone and minimize bleeding due to atony.
Intraoperative management encompasses simple conservative techniques to hysterectomy. The main objective that a clinician must keep in mind when embarking upon an operative course is to proceed efficiently with those techniques that he or she finds easy, and avoid those that are either technically difficult or excessively time consuming.
Along with concurrent drug therapy, uterine atony should initially be managed with gentle bimanual massage. Figure 3-3 demonstrates the proper technique for bimanual massage.38 Care must be taken to avoid aggressive massage that can injure the large vessels of the broad ligament.
If retained products of conception are the cause of postpartum hemorrhage and manual extraction is unsuccessful, uterine curettage should be undertaken. While this may be performed in a delivery room, excessive bleeding mandates that an operating room be used for the procedure. Not only does moving the patient to the operating room remove potential distractions for efficient therapy, but it also allows for improved visualization, patient relaxation, ancillary support, and further operative management if the curettage is unsuccessful. A large Banjo (blunt) curette should be employed with gentle traction in order to avoid uterine perforation. Transabdominal ultrasound guidance may be helpful in assisting the clinician with removal of retained placental fragments.
If uterine inversion is the source of bleeding, rapid replacement of the uterus to its proper orientation will resolve the hemorrhage. This is best accomplished in an operating room with the assistance of an anesthesiologist. The uterus and cervix should be initially relaxed with a tocolytic agent (eg, magnesium sulfate, terbutaline), nitroglycerin, or a halogenated anesthetic. Once adequate relaxation is accomplished, gentle pressure should be applied to the uterine fundus in order to revert it back into its proper abdominal location. Once the uterus has been replaced, uterotonic therapy should be given to assist with uterine contraction and prevent future inversion. On rare occasions, this conservative approach for uterine repositioning is unsuccessful and alternative therapy with hydrostatic reduction and/or surgical repair by laparotomy must be performed.
Tamponade techniques are conservative approaches that may avoid further surgery or treat surface bleeding while EBL replacement is underway. A variety of techniques are available, including packing and balloon devices. Packing typically entails the use of continuous gauze (eg, Kerlix) within a sterile plastic bag or impregnated with thrombin 5000 units in 5 mL.46 The pack is left in place for approximately 12 to 24 hours while close attention is paid to the patient’s vital signs, laboratory parameters, and urine output. Transurethral Foley catheter placement and prophylactic antibiotic use should be considered to prevent urinary retention and infection, respectively.
Several balloon devices are available for uterine tamponade, including the Bakri tamponade balloon, BT-Cath, and the Glenveigh Ebb complete tamponade system. Tamponade balloons can be used in isolation for postpartum hemorrhage control or in conjunction with other procedures (ie, surgery or selective arterial embolization). The Bakri tamponade balloon (Cook Urological, Bloomington, Indiana) is placed within the uterus either manually or under ultrasound guidance (Fig. 3-4). Once properly located, the balloon is filled with saline until bleeding stops. The balloon can hold 500 mL of saline and withstand a pressure of 300 mm Hg. Surveillance of persistent bleeding is possible as the balloon catheter drains into a collection bag. After bleeding has slowed, the balloon can be gradually deflated and subsequently removed. The BT-Cath is similar to the Bakri balloon in that it is a silicone device with a double lumen catheter for saline filling and uterine drainage; however, it is shaped like an inverted pear. The Glenveigh Ebb complete tamponade system incorporates both intrauterine and intravaginal tamponade (Fig. 3-5).38 Both balloons are made of strong yet malleable polyurethane, allowing for better conformation to the uterine and vaginal shapes. In addition, the uterine balloon can be rapidly inflated from a saline bag to a larger volume of 750 mL for circumstances in which the smaller balloons are inadequate (multiple gestations). Finally, like the other balloons, this system has a drainage port to assess for ongoing bleeding; however, unlike the others, it also has an infusion port to irrigate the uterus.
Placement of SOS Bakri tamponade balloon.
Glenveigh Ebb complete tamponade system. (Reproduced with permission from Francois K, Foley MR. Antepartum and postpartum hemorrhage. In: Gabbe SG, Niebyl JR, Simpson JL, Landon MB, Galan HL, Jauniaux ERM, Driscoll D, eds. Obstetrics: Normal and Problem Pregnancies. 6th ed. Philadelphia, PA: Elsevier Saunders;) 2012.
When bleeding continues despite conservative therapy, surgical management via laparotomy must be considered. Interventions include arterial ligation, uterine compression sutures, and hysterectomy.
The goal of arterial ligation is to decrease uterine perfusion and subsequent bleeding. Success rates have varied from 40% to 95% in published literature depending upon which arteries are ligated.47,48,49,50, 51 Arterial ligation may be performed on the uterine, utero-ovarian (Fig. 3-6), and hypogastric arteries. Hypogastric artery ligation can be technically challenging and is not recommended unless the obstetrician is extremely skilled in performing the procedure. Bakri has described a bilateral looped uterine suture technique that compresses the uterine vessels against the entire thickness of the lateral uterine wall (Fig. 3-7). It is recommended that a tamponade balloon be placed with the suture placement to ensure adequate hemorrhage control.52
Bakri balloon-looped uterine vessels (BB-LUVs).
Uterine compression sutures are simple, effective techniques to reduce bleeding and avoid hysterectomy. Several techniques have evolved over the past 15 years, including the B-Lynch suture, Hayman vertical sutures, Pereira transverse and vertical sutures, and multiple square sutures.53,54,55,56,57, 58 Figures 3-8,3-9,3-10, 3-11 demonstrate these techniques. Compression sutures are best used for cases of uterine atony controlled by bimanual massage and focal invasive placentation with desire for future fertility.
Pereira transverse and vertical sutures.
Multiple square compression sutures.
Hysterectomy provides definitive therapy in cases of refractory bleeding. Since blood flow may be torrential, it is prudent for the clinician to consider performing a supracervical hysterectomy in some situations. This is especially important when the patient is unstable. Also, assistance from other surgical specialties may be necessary and a delay in consultation should be avoided.
Nonobstetrical services that are particularly useful in postpartum hemorrhage management include interventional radiology, the pharmacy, and an intensive care team. Selective arterial embolization has gained success and popularity for postpartum hemorrhage management. The technique involves pelvic angiography to visualize the bleeding vessels and placement of Gelfoam (gelatin) pledgets into the vessels for occlusion. Reported success rates approximate 90% to 95%.59,60,61, 62 Advantages to embolization include selectivity, uterine/fertility preservation, minimal morbidity, and ability to forego or delay surgical intervention. Reported disadvantages include postembolization fever, infection, ischemic pain, and tissue necrosis. Unfortunately, a lack of rapid availability may limit its usefulness in some facilities.
In addition to interventional radiology, another nonobstetrical service that may be critical in successful postpartum hemorrhage management is the pharmacy. Recombinant activated factor VIIa, RiaSTAP, and hemostatic agents can be extremely effective pharmaceutical agents in postpartum hemorrhage management. Recombinant activated factor VIIa is given as an intravenous bolus over a few minutes in average doses of 60 to 100 μg/kg.63,64,65,66,67,68, 69 In conjunction with other blood component therapy, recombinant activated factor VIIa can achieve rapid hemostasis within 10 to 40 minutes. Unfortunately, the half-life of the agent is relatively short (2 hours) so repeated dosing may be necessary in some cases.67,68, 69
Besides recombinant activated factor VIIa, another promising pharmaceutical agent for coagulopathy management is RiaSTAP, or fibrinogen concentrate. RiaSTAP is an intravenous therapy of fibrinogen made from human plasma. Recently approved by the Food and Drug Administration (FDA), RiaSTAP has been successfully used in Europe for the treatment of massive hemorrhage due to consumptive coagulopathy (trauma, surgery, gastrointestinal hemorrhage) and congenital fibrinogen deficiency.70
Hemostatic agents include fibrin sealants (eg, Tisseal), topical thrombin (eg, Thrombogen and CoStasis), hemostatic matrices (eg, Floseal), gelatin sponges (eg, Gelfoam), oxidized regenerated cellulose (eg, Surgicel), and microfibrillar collagen, (eg, Avitene).71 While each of these agents has different clotting factors and mechanisms of action, they are all effective either singly or in combination for control of bleeding surfaces. These agents are particularly helpful in situations of consumptive coagulopathy associated with diffuse low-volume bleeding.
A final nonobstetrical service line to consider is an intensive care team. The patient who endures a severe postpartum hemorrhage is at risk of multiple comorbidities as noted in the following section. These comorbidities can often be avoided or dealt more efficiently with the assistance of an intensive care team that is accustomed to the hemodynamic challenges of massive hemorrhage and transfusion.
General Complication Assessment
Once a postpartum hemorrhage has successfully been treated, the patient is still at risk for complications related to the blood loss, the therapy, or both. It is important for the obstetrician to critically assess the patient for general organ system complications. These complications include hypoperfusion injuries to the brain, heart, and kidneys; infection; persistent coagulopathy; acute lung injury due to massive transfusion requirements; and pituitary necrosis. By being aware of these potential complications, the physician can ensure that proper posthemorrhage care and consultation are available in a timely fashion so that further morbidity can be avoided.