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.
- Fluids – Balanced solution bolus (NS, LR)
- Medical Therapy – see table below
- Blood products – In escalating order
- 2 units PRBCs
- 2 units FFP
- Massive transfusion protocol (pRBCs, FFP, Platelets 1:1:1)
- 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
Medication | Dosage | Considerations |
First Line Agent | ||
Oxytocin | • 10-40 units diluted in 500 1000 mL NS IV at 500 mL/hr (10-40 units/hr) OR • 10 units IM | •Contraindications are few •Adverse effects may include nausea or vomiting •Hyponatremia can occur with prolonged dosing •IV push may cause hypotension |
Second Line Agent | ||
Methylergonovine | • 0.2 mg IM q2-4h as needed | •Avoid in patients with hypertension, pre-eclampsia, cardiovascular disease, or hypersensitivity to this medication •Avoid IV administration, which may cause severe hypertension •Adverse effects may include nausea or vomiting |
Carboprost (Hemabate®) | • 250 mcg IM | •Contraindicated in patients with asthma •Use with caution in patients with hypertension or with active cardiac, pulmonary, or hepatic disease •Adverse effects may include nausea, vomiting, headache, fever, chills, bronchospasm, or hypertension |
Misoprostol (Cytotec®) | • 800-1000 mcg PR OR • 600 mcg PO OR • 800 mcg SL | •Avoid use in patients with hypersensitivity to prostaglandins nausea, vomiting, diarrhea, headache, or fever |
Tranexamic acid | • 1 g in 100 mL NS IV administered over 10 min • May repeat once after 30 min | •Maximum benefit if administered within 3 hours of delivery |
Abbreviations: IM, intramuscular; IV, intravenous; NS, normal saline; q, every; PO, by mouth; PR, rectally; SL, sublingually. | ||
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. 3,4
Hemorrhage is the 4th leading cause of pregnancy related death.
Considerable racial/ethnic disparities exist in this population.
Further Reading
Maternal Hemorrhage and Severe Hypertension/Pre-eclampsia: Identification and Management in the Emergency Department Date Release: Sep 2021 This course reviews evidence-based recommendations to improve care and outcomes for pregnant and postpartum patients with hemorrhage or severe hypertension. Emergency Medicine Practice and Pediatric Emergency Medicine Practice subscribers receive this content & CME Credit absolutely free!
References
- Ashoo S. Maternal hemorrhage and severe hypertension/pre-eclampsia: identification and management in the emergency department. Emerg Med Pract. 2021 Sep 15;23(Suppl 9):1-19. PubMed
- Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-e186. doi: 10.1097/AOG.0000000000002351. PubMed, PDF
- Pregnancy Mortality Surveillance System, CDC
- WHO recommendations for the prevention and treatment of postpartum haemorrhage, WHO
- Tranexamic Acid – Drug Summary. Prescribers’ Digital Reference. Accessed September 1, 2021.
Last Updated on January 25, 2023
Sam Ashoo, MD, FACEP, is board certified in emergency medicine and clinical informatics. He serves as EB Medicine’s editor-in-chief of interactive clinical pathways and FOAMEd blog, and host of EB Medicine’s EMplify podcast. Follow him below for more…
