II. Definition

  1. Postpartum Hemorrhage (2006 definition)
    1. Change in Hematocrit of 10% or greater between Labor and Delivery Admission and postpartum period or
    2. Need for postpartum bleeding requiring pRBC transfusion
    3. Previously diagnosed at blood loss >500 cc
  2. Primary Postpartum Hemorrhage (Early Postpartum Hemorrhage)
    1. Blood loss within 24 hours
  3. Secondary Postpartum Hemorrhage (Late Postpartum Hemorrhage)
    1. Blood loss after 24 hours and before 6 weeks
    2. Due to placental eschar slouphing, Retained Placenta

III. Epidemiology

  1. Incidence: 5% of all deliveries
  2. Increased risk if prior history Postpartum Hemorrhage
    1. Relative Risk increases 2-3 fold

IV. Causes: Mnemonic: 4T's

  1. Tone diminished
    1. Uterine Atony represents 70% Postpartum Hemorrhage
  2. Tissue
    1. Retained Placenta
    2. Placenta accreta
  3. Trauma
    1. Uterine Inversion
    2. Uterine Rupture
    3. Cervical Laceration
    4. Vaginal hematoma
  4. Thrombin
    1. Coagulopathy

V. Pathophysiology: Uterine Atony

  1. Uterus fails to contract despite being empty
    1. Unable to control bleeding at placental site
  2. Predisposing Causes
    1. Excessive Uterine distension
      1. Twin Gestation
      2. Fetal Macrosomia
      3. Polyhydramnios
    2. Multiparity
      1. Fibrosis in uterine muscle
    3. Prolonged labor (uterine inertia)
    4. Labor augmented with Oxytocin
    5. General Anesthesia
    6. Placenta Previa
      1. Lower segment does not contract
    7. Abruptio Placentae
      1. "Couvelaire" Uterus may not contract

VI. Risk Factors

  1. Grand Multipara
  2. Prolonged labor (especially prolonged third stage)
  3. Chorioamnionitis
  4. Multiple Gestation
  5. Magnesium Sulfate infusion
  6. Prolonged Pitocin infusion
  7. Episiotomy
  8. Fetal Macrosomia

VII. Examination

  1. Inspect Vagina and Cervix for bleeding source

VIII. Labs

  1. Complete Blood Count with platelets
  2. ProTime (PT)
  3. Partial Thromboplastin Time (PTT)
  4. Type and cross for 2-4 units of pRBC

IX. Management: Active Management of the Third Stage of Labor

  1. Pitocin administered on delivery of anterior Shoulder
    1. Reduces Incidence from 16.5% to 3.8% of deliveries
    2. See Third Stage of Labor
  2. Controlled cord traction
  3. Limit the third stage to <10 minutes
    1. Delayed placental delivery >10 min doubles bleed risk
  4. Early cord clamping and cutting
    1. Initially recommended due to lower Hemorrhage risk
    2. Consider 60 second wait to reduce newborn Anemia

X. Management: Four T's (see Above)

  1. Tone (Soft, boggy Uterus)
    1. Bimanual uterine massage
      1. Bimanual massage between vagina and uterine fundus
      2. Empty the Bladder!
    2. Uterotonic Medications
      1. Oxytocin 20 IU per Liter NS
        1. Infuse 250 cc/h (Max: 500 cc/10 min)
      2. Methergine 0.2 mg IM q2-4 hours
        1. Contraindicated in Hypertension
      3. 15-Methyl PGF2-alfa
        1. Hemabate 0.25 mg IM q15 min to maximum 2 mg or
        2. Carboprost
      4. Misoprostol (Cytotec, PGE1)
        1. Misoprostel 1000 mcg per Rectum or
        2. Misoprostel 400 mcg per Rectum after placenta delivery and 100 mcg at 4 hours and 8 hours
      5. Dinoprostone (PGE2)
        1. Caliskan (2002) Am J Obstet Gynecol 187:1038-45
  2. Trauma (Genital Laceration, Uterine Inversion)
    1. Inspect Vagina and Cervix for bleeding source
      1. Suture Lacerations if present
      2. Drain large hematomas (>3 cm)
    2. Evaluate Uterus
      1. Consider exploring Uterus
      2. Replace Uterine Inversion
  3. Tissue (Retained Placenta)
    1. Inspect placenta for missing segments
    2. Manually remove Retained Placenta
    3. Consider curettage
  4. Thrombin (Clotting disorder)
    1. Obtain labs as above
    2. Replace Coagulation Factors
      1. Fresh Frozen Plasma
      2. Platelet Transfusion
      3. Factor VIIa

XI. Management: Resuscitation

  1. Indications
    1. Brisk bleeding
    2. Hypotension and Tachycardia
  2. Initial Management
    1. Large Bore (14-16 gauge) Intravenous Access (2 sites)
    2. Close hemodynamic monitoring
    3. Supplemental Oxygen
    4. Patient in Trendelenburg
  3. Massive Hemorrhage Management
    1. Transfuse pRBC, platelets, factors as indicated
    2. Uterine packing and tamponade
    3. Surgical interventions
      1. Vessel embolization
      2. Ligation of Uterine and Hypogastric arteries
      3. Hysterectomy

Images: Related links to external sites (from Google)

Ontology: Postpartum Hemorrhage (C0032797)

Definition (NCI) Hemorrhage defined as a blood loss in excess of 500 mL after vaginal delivery or more than 1000 mL after a cesarean delivery.
Definition (MSH) Excess blood loss from uterine bleeding associated with OBSTETRIC LABOR or CHILDBIRTH. It is defined as blood loss greater than 500 ml or of the amount that adversely affects the maternal physiology, such as BLOOD PRESSURE and HEMATOCRIT. Postpartum hemorrhage is divided into two categories, immediate (within first 24 hours after birth) or delayed (after 24 hours postpartum).
Concepts Pathologic Function (T046)
MSH D006473
ICD9 666
ICD10 O72
SnomedCT 156243000, 156239004, 47821001, 200033009
English Hemorrhage, Postpartum, HEMORRHAGE POSTPARTUM, POSTPARTUM HEMORRHAGE, Hemorrhage after delivery of fetus, NOS, Postpartum hemorrhage, NOS, BLEEDING POSTPARTUM, Postpartum haemorrhage NOS, Postpartum hemorrhage NOS, Haemorrhage after delivery of foetus, NOS, Heavy post-partum bleeding, Postpartum haemorrhage, NOS, Post-partum hemorrhage, HEMORRHAGE TERM, postpartum hemorrhage (diagnosis), postpartum hemorrhage, 8-34 POSTPARTUM HEMORRHAGE, Postpartum haemorrhage NOS (disorder), Postpartum haemorrhage (disorder), Post-partum haemorrhage, Hemorrhage postpartum, Haemorrhage after delivery of foetus, Haemorrhage after delivery of fetus, Postpartum hemorrhage NOS (disorder), Postpartum Hemorrhage [Disease/Finding], Bleeding;postpartum, hemorrhage postpartum, post-partum haemorrhage, postpartum bleed, Haemorrhage;postpartum, bleeding postpartum, post-partum bleeding, post-partum hemorrhage, Haemorrhage postpartum, Postpartum hemorrhage, Bleeding postpartum, PPH - Postpartum haemorrhage, PPH - Postpartum hemorrhage, Postpartum haemorrhage, Hemorrhage after delivery of fetus, Postpartum hemorrhage (disorder), Post-partum bleeding, hemorrhage; postpartum, postpartum; hemorrhage, Postpartum Hemorrhage, Hemorrhage;postpartum, postpartum bleeding, postpartum haemorrhage
Dutch bloeding postpartum, hemorragie postpartum, postpartum hemorragie NAO, postpartumhemorragie, Hevig bloedverlies post-partum, Post-partum bloedverlies, bloeding; post partum, post partum; bloeding, postpartumbloeding, Bloeding post partum, Bloeding, post partum
French Hémorragie postpartum, Hémorragie post-partum, Hémorragie postpartum SAI, Saignement severe post-partum, Hémorragie du postpartum, Hémorragie du post-partum, Hémorragie de la délivrance
German Blutung postpartal, postpartale Blutung, postpartale Blutung NNB, starke Blutung im Wochenbett, Blutung, postpartale, Postpartale Blutung, Hämorrhagie, postpartale
Italian Emorragia postpartum NAS, Sanguinamento postpartum, Grave sanguinamento post-partum, Emorragia postpartum
Portuguese Hemorragia pós-parto NE, Hemorragia importante pos-parto, Hemorragia pós-parto, Hemorragia Pós-Parto, Hemorragia Puerperal
Spanish Sangrado postpartum, Hemorragia postparto NEOM, Postpartum haemorrhage, Postpartum haemorrhage NOS, Postpartum hemorrhage, Hemorragia importante postparto, hemorragia después del parto del feto, Postpartum hemorrhage NOS, hemorragia de postparto, SAI (trastorno), hemorragia de postparto, SAI, hemorragia después del alumbramiento del feto, hemorragia posparto, hemorragia postparto (trastorno), hemorragia postparto, Hemorragia postparto, Hemorragia Posparto, Hemorragia Puerperal
Japanese 分娩後出血NOS, ブンベンゴシュッケツNOS, ブンベンゴシュッケツ, 産褥出血, 分娩後出血, 出血-分娩後
Czech hemoragie poporodní, Poporodní krvácení NOS, Krvácení po porodu, Poporodní krvácení
Finnish Synnytyksenjälkeinen verenvuoto, RUNSAS SYNNYTYKSEN JALKEINEN VERENVUOTO
Danish Kraftig blodning efter fodsel
Hungarian eros gyermekagyi verzes, Postpartum haemorrhagia, Postpartum vérzés, Haemorrhagia post partum, Postpartum vérzés k.m.n.
Korean 분만후 출혈
Polish Krwotok poporodowy, Krwawienie maciczne poporodowe