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Overviewofpostpartumhemorrhage

OfficialreprintfromUpToDate
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Overviewofpostpartumhemorrhage
Author
MichaelABelfort,MBBCH,MD,
PhD,FRCSC,FRCOG

SectionEditors
CharlesJLockwood,MD,MHCM
DeborahLevine,MD

DeputyEditor
VanessaABarss,MD,FACOG

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Feb2016.|Thistopiclastupdated:Feb24,2016.
INTRODUCTIONPostpartumhemorrhage(PPH)isanobstetricalemergency.Itisamajorcauseof
maternalmorbidity,andoneofthetopthreecausesofmaternalmortalityinbothhighandlowpercapita
incomecountries,althoughtheabsoluteriskofdeathfromPPHismuchlowerinhighincomecountries(1in
100,000deliveriesintheUnitedKingdomversus1in1000deliveriesinthedevelopingworld).Withtimely
diagnosis,appropriateresources,andappropriatemanagement,however,PPHmaybethemostpreventable
causeofmaternalmortality.
Thistopicwillpresentanoverviewofmajorissuesrelatingtopostpartumhemorrhage,includingmanagement
ofsecondarypostpartumhemorrhage.SpecificissuesinmanagementofPPHdependonthesetting,vaginalor
cesareandelivery,andwillbediscussedseparately:
(See"Managementofpostpartumhemorrhageatvaginaldelivery".)
(See"Managementofpostpartumhemorrhageatcesareandelivery".)
DEFINITIONSPPHisdescribedasprimaryorsecondary:PrimaryPPHoccursinthefirst24hoursafter
delivery(alsocalledearlyPPH)andsecondaryPPHoccurs24hoursto12weeksafterdelivery(alsocalled
lateordelayedPPH).
PPHisclassicallydefinedbythevolumeofbloodloss.Themostcommondefinitionisestimatedbloodloss
500mLaftervaginalbirthor1000mLaftercesareandelivery.Theinadequacyofthisdefinitionwas
illustratedinstudiesthatassessedbloodlossusingvariousobjectivemethods:Themeanbloodlossreported
aftervaginalandcesareandeliverieswasapproximately400to600mLand1000mL,respectively,and
clinicianswerelikelytounderestimatethevolumeofbloodlost[13].Anotherproblemisthatbleedingmaynot
bevisible.
Anotherclassicdefinitionisa10pointdeclineinpostpartumhematocritconcentrationfromantepartumlevels.
However,thisisnotaclinicallyusefuldefinitionforseveralreasons:Rapidbloodlossmaytriggeramedical
emergencypriortoobservationofafallinhematocritconcentrationlaboratorychangesnotcorrelatedwith
eventsthatendangerthepatientshouldnotbeusedtodefineamedicalemergencycrystalloidandblood
productinfusionsbeforeandduringthedeliverymayobfuscatethefindingsandantepartum
hemoconcentration(eg,frompreeclampsiaordehydration)maycausealargefallinhematocritconcentration
followingdeliveryintheabsenceofexcessiveintrapartumbloodloss.
TheRoyalCollegeofObstetriciansandGynaecologistsdefinesPPHasminor(500to1000mLs)ormajor
(>1000mLs),withfurthersubdivisionsofmajorhemorrhageasmoderate(1000to2000mLs)orsevere(>2000
mLs)[4].AninternationalexpertpaneldefinedPPHas"activebleeding>1000mLwithinthe24hoursfollowing
birththatcontinuesdespitetheuseofinitialmeasures,includingfirstlineuterotonicagentsanduterine
massage"[5].
INCIDENCETheincidenceofPPHvarieswidely,dependinguponcriteriausedtodefinethedisorder.A
reasonableestimateis1to5percentofdeliveries[6].InananalysisofpopulationbaseddatafromtheUnited
StatesNationalInpatientSample,theincidencewasbetween2and3percentduringtheyears1994to2006
[7].Theincidenceincreasedacrosstheintervalduetoanincreaseintheproportionofwomendiagnosedwith
uterineatony,themostcommoncauseofPPHinthisseries.
PATHOGENESISThepotentialformassivehemorrhageafterdeliveryishighbecauseinlatepregnancy
uterinearterybloodflowis500to700mL/minandaccountsforabout15percentofcardiacoutput.Normally,
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hemostasisoccursuponplacentalseparationbecauseuterinebleedingiscontrolledbyacombinationoftwo
mechanisms:
Contractionofthemyometrium,whichcompressesthebloodvesselssupplyingtheplacentalbedand
causesmechanicalhemostasis.
Localdecidualhemostaticfactors(tissuefactor[8,9],type1plasminogenactivatorinhibitor[10,11],
systemiccoagulationfactors[eg,platelets,circulatingclottingfactors]),whichcauseclotting.
PPHoccurswhenthereisadisturbanceinoneorbothofthesemechanisms.Thesedisturbancesinclude
incompleteplacentalseparation,defectivemyometrialcontraction,andbleedingdiatheses.
DeliveryrelatedtraumaisanotherpathwaytoPPH.
CAUSES
AtonyThemostcommoncauseofPPHisuterineatony(ie,lackofeffectivecontractionoftheuterusafter
delivery),whichcomplicates1in20birthsandisresponsibleforatleast80percentofcasesofPPH[12,13].
Bloodlosscanbemuchgreaterthanobservedbecauseaboggyanddilateduterusmaycontainasignificant
amountofblood.Thediagnosisismadeiftheuterusdoesnotbecomefirmafteruterinemassageand
administrationofuterotonicagents.
Atonymaybediffuseorlocalizedtoanareaofuterinemuscle.Inthelatter,thefundalregionmaybewell
contractedwhiletheloweruterinesegmentisdilatedandatonic,whichisdifficulttoappreciateonphysical
examination.Womenwithpersistentbleedingdespiteafirmfundusshouldundergoavaginalexaminationto
identifyballooningoftheloweruterus,aswellascervicalandvaginallacerations.
AlthoughdiffuseuterineatonyisthemostcommoncauseofPPH,itisoftenresponsivetouterotonictherapy,
thusitisnotthemostcommonreasonformassivetransfusionatdelivery[14].
TraumaTraumarelatedbleedingcanbeduetolacerations,surgicalincisions,oruterinerupture.
Cervicalandvaginallacerationsmaydevelopspontaneouslyormayberelatedtoproviderinterventions.They
maynotbenoteduntilexcessivepostpartumvaginalbleedingpromptslowergenitaltractexamination,
includingexaminationforhematomas.
Corpuslacerationsmaybecompleterupturesorincompletelacerationsoftheinnermyometrium[15].(See
"Ruptureoftheunscarreduterus"and"Uterinedehiscenceandruptureafterpreviouscesareandelivery".)
Atcesareandelivery,hemorrhagefromtheuterineincisionisgenerallycausedbylateralextensionofthe
incision,whichcanresultfromspontaneoustearingofanedematouslowersegmentduringanotherwise
uneventfulcesareandeliveryafterprolongedlabor,fromanincisionmadetoolowornotsufficientlycurvedon
thelowersegment,orfromdeliveryofthefetusthroughanincisionthatistoosmall.Bleedingfromlateral
extensionoftheuterineincisionisreadilyascertainedbyinspectionoftheincision,lateralpelvicsidewalls,and
broadligament.Retroperitonealenlargementorbulgingofthebroadligamentatcesareandeliverycanbesigns
ofretroperitonealhemorrhage.
CoagulopathyCoagulopathyisbothacauseandresultofPPHsincepersistentheavybleeding,
irrespectiveofthecause,leadstoconsumptionofclottingfactorsandhemodilutionofremainingclotting
factors.
RISKFACTORSManyriskfactorsforPPHhavebeenreportedandtheyareofteninterdependent.
Astudyincluding154,311deliveriescompared666casesofPPHtocontrolswithouthemorrhage[16].
Factorssignificantlyassociatedwithhemorrhage,indecreasingorderoffrequency,were:

Retainedplacenta/membranes(oddsratio[OR]3.5,95%CI2.15.8)
Failuretoprogressduringthesecondstageoflabor(OR3.4,95%CI2.44.7)
Morbidlyadherentplacenta(OR3.3,95%CI1.76.4)
Lacerations(OR2.4,95%CI2.02.8)
Instrumentaldelivery(OR2.3,95%CI1.63.4)

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Largeforgestationalagenewborn(eg,>4000g)(OR1.9,95%CI1.62.4)
Hypertensivedisorders(preeclampsia,eclampsia,HELLP[Hemolysis,ElevatedLiverenzymes,
LowPlatelets])(OR1.7,95%CI1.22.1)
Inductionoflabor(OR1.4,95%CI1.11.7)
Prolongedfirstorsecondstageoflabor(OR1.4,95%CI1.21.7)
Inanotherlargeseries,themostcommonriskfactorsassociatedwithneedformassivetransfusion
duringhospitalizationfordeliverywereabnormalplacentation(1.6/10,000deliveries,adjustedOR[aOR]
18.5,95%CI14.723.3),placentalabruption(1.0/10,000,aOR14.6,95%CI11.219.0),severe
preeclampsia(0.8/10,000,aOR10.4,95%CI7.714.2),andintrauterinefetaldemise(0.7/10,000,aOR
5.5,95%CI3.97.8)[17].
OtherriskfactorsincludepersonalorfamilyhistoryofpreviousPPH,obesity,highparity,Asianor
Hispanicrace,precipitouslabor,uterineoverdistention(eg,multiplegestation,polyhydramnios,
macrosomia),uterineinfection,uterineinversion,inheritedbleedingdiathesis,acquiredbleedingdiathesis
(eg,amnioticfluidembolism,abruptioplacenta,sepsis,fetaldemise),anduseofsomedrugs,suchas
uterinerelaxantsanddrugsthataffectcoagulation(possiblyincludingantidepressants)[14,1826].
DIAGNOSISWemakethediagnosisofPPHinpostpartumwomenwithbleedingthatisgreaterthan
expectedandcausessymptoms(eg,pallor,lightheadedness,weakness,palpitations,diaphoresis,
restlessness,confusion,airhunger,syncope)and/orresultsinsignsofhypovolemia(eg,hypotension,
tachycardia,oliguria,oxygensaturation<95percent)(table1).
Diagnosismaybedelayedinsymptomaticwomenwithoutheavyvaginalbleedingwhoarebleedinginternally,
suchasintraabdominalbleedingrelatedtoacesareandeliveryorabroadligamentorvaginalhematomadueto
asulcuslaceration.
DifferentialdiagnosisAlthoughvasodilatationduetoneuraxialanesthesiaandvasovagalreactionsmay
resultinlightheadedness/syncope,tachycardia,andhypotension,theseentitiesarelesslikelypostpartumthan
PPH,andtheyarereadilyreversibleandgenerallynotdangerous.Lightheadedness,tachycardia,or
hypotensionisunlikelytobeduetoneuraxialanesthesiaifthewomanwashemodynamicallystablepriorto
delivery,theleveloftheblockdidnotbecomesignificantlyhigherimmediatelyfollowingdelivery,and
symptomsdidnotabruptlyfollowsystemicadministrationofadrugknowntocausehypotension.(See
"Adverseeffectsofneuraxialanalgesiaandanesthesiaforobstetrics",sectionon'Hypotension'.)
PLANNING
ManagementofriskWomenwithriskfactorsforPPHshouldbeidentifiedandcounseledasappropriatefor
theirlevelofriskandgestationalage.Planningforthesepatientsinvolvesensuringavailabilityofresources
thatmightbeneeded,includingpersonnel,medication,equipment,andbloodproducts.Routineprophylactic
useofuterotonicdrugs,suchasoxytocin,reducestheriskofPPHby50percentintheoverallobstetric
population[27](see"Pharmacologicmanagementofthethirdstageoflabor").However,knowledgeofrisk
factorsforPPHisnotusefulclinicallyinmostpatientsbecauseonlyasmallproportionofwomenwithrisk
factorsforPPHotherthanabnormalplacentationdevelophemorrhageandmanywomenwithoutriskfactors
experiencehemorrhageafterdelivery[26].
Specificinterventionsareavailableformanagingriskinwomenwithantenatallyidentifiedabnormal
placentation(see"Managementofthemorbidlyadherentplacenta(placentaaccreta,increta,andpercreta)"and
"Managementofplacentaprevia")andbleedingdiatheses.(See"TreatmentofvonWillebranddisease",section
on'Pregnancyanddelivery'and"Clinicalmanifestationsanddiagnosisofhemophilia",sectionon'Obstetrical
issues'and"Useofanticoagulantsduringpregnancyandpostpartum",sectionon'Laboranddelivery'.)
PPHprotocolsIdeally,eachhospitallaboranddeliveryunitshouldhaveaPPHprotocolforpatientswith
estimatedbloodlossexceedingapredefinedthreshold(often1000mL).Theprotocolshouldprovidea
standardizedapproachtoevaluatingandmonitoringthepatientwithPPH,notifyingamultidisciplinaryteam,
andtreatment.DevelopmentandconsistentapplicationofacomprehensiveprotocolformanagementofPPH
appearstoresultinimprovedoutcomesforthesewomen[28,29].Examplesofsuchprotocolsaredescribed
below(see'Management'below).Inanobservationalstudy,theinitiationofaPPHprotocolwasassociated
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withresolutionofmaternalbleedingatanearlierstage,useoffewerbloodproducts,anda64percentreduction
intherateofdisseminatedintravascularcoagulation[30].Intheauthor'sopinion,clinicaltrainingprogramsthat
encourageateamapproachforearlyrecognitionofPPHcanimproveoutcomesbyengagingthenecessary
providersbeforehypovolemiaanduncompensatedshockoccur.
PPHkitsInadditiontoaprotocol,itisusefulforlaboranddeliveryunitstoassemblekitsincluding
medicationsandinstrumentsthatmaybeneededtomanagePPHsothatthisequipmentisreadilyavailable
whenneeded(similartoa"codecart").
TrainingandsimulationTheJointCommissionrecommendsthatobstetricalstaffundergoteamtrainingto
teachstafftoworktogetherandcommunicatemoreeffectivelywhenPPHoccurs,conductclinicaldrillstohelp
staffprepareforPPH,andconductdebriefingsafterPPHtoevaluateteamperformanceandidentifyareasfor
improvement[31].Simulationteamtrainingcanhelptoidentifyareasthatneedpractice,andregular
unannouncedsimulatedPPHscenariosinareallifesetting,suchasthelaboranddeliveryfloororpost
anesthesiacareunit,mayalsoincreasecomfortwiththeprotocolsandteamworkrequiredinsuch
emergencies.
MANAGEMENTTimely,accuratediagnosisisimportantinordertoinitiateappropriateinterventions(eg,
drugs,surgery,referral,consultation)andimproveoutcome[32].Earlyinterventionmaypreventshock
(inadequateperfusionandoxygenationoftissues)andthedevelopmentofthepotentiallylethaltriadof
hypothermia,acidosis,andcoagulopathy.Manypotentiallyeffectiveinterventionsareavailableformanagement
ofPPH(table2).
ThemanagementofPPHismultifacetedandrequirescarebyseveralteamswithinthehospital(obstetricians,
midwives,nurses,anesthesiologists,hematologists/bloodbankpersonnel,laboratorymedicine,surgical
subspecialists[eg,vascular,urology],interventionalradiology)[33].Theseteamsareoftensummonedand
requiredtoworktogetherunderconditionsofgreatstressandtimepressures.Coordinationisessentialand
canbefacilitatedbyprotocolsandflowdiagramsthatanticipatehowtheseteamswillcommunicateand
functiontogetherthefollowingtable(table3)andalgorithmsarerepresentativeexamples(algorithm1and
algorithm2).Inaddition,numerousprofessionalorganizationshaveprovidedguidanceforteammanagementof
PPH(eg,CaliforniaMaternalQualityCareCollaborative).(See'Guidelinesfromprofessionalorganizations'
below.)
GeneralprinciplesTherateandvolumeofbleeding,vitalsigns,andlaboratoryresultsshouldbeclosely
monitoredtoassessthebestapproachtoandaggressivenessofintervention.Itisimportanttonotallowthe
patienttobecomemoribundbeforeinitiatinglifesavingmeasures.(See"Managementofpostpartum
hemorrhageatvaginaldelivery",sectionon'Initialinterventions'and"Managementofpostpartumhemorrhage
atcesareandelivery",sectionon'Initialmanagement'.)
Theobstetricalprovidershouldinitiateasequenceofnonoperativeandoperativeinterventions(table4)for
controlofPPHandpromptlyassessthesuccessorfailureofeachmeasure.Thegoalisto:

Restoreormaintainadequatecirculatoryvolumetopreventhypoperfusionofvitalorgans
Restoreormaintainadequatetissueoxygenation
Reverseorpreventcoagulopathy
EliminatetheobstetriccauseofPPH

Ifaninterventiondoesnotsucceed,thenexttreatmentinthesequencemustbeswiftlyinstituted.
Indecisivenessdelaystherapyandresultsinexcessivehemorrhage,whicheventuallycausesdilutional
coagulopathyandseverehypovolemia,tissuehypoxia,hypothermia,andacidosis.Thiswillmakecontrolof
hemorrhagemuchmoredifficultandwillincreasethelikelihoodofhysterectomy,majormorbidityfrom
hemorrhagicshock,anddeath.
AlthoughtherearenodatafromclinicaltrialstohelpguidemanagementoftransfusionspecificallyinPPH,
managementofbloodcomponenttherapyissimilartothatinothermassivehemorrhage[34].Developmentofa
standardizedinstitutionalapproachimprovesoutcome(algorithm2).
TheapproachtotreatmentofPPHdifferssomewhatdependingonthecauseandwhetherhemorrhageoccurs
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afteravaginalbirthorafteracesareandelivery.Traumatic,hemorrhaginglesionsneedtobecontrolled
surgically,eithertransvaginallyortransabdominally.Coagulationdefectscanoftenbetreatedmedically,with
transfusionofbloodandbloodproducts.Thetreatmentofatony,themostcommoncauseofPPH,dependson
therouteofdelivery.Afteravaginalbirth,treatmentbeginswithlessinvasiveinterventionsandprogressesto
moreinvasiveproceduresuntilhemorrhageiscontrolled.Itisusuallypossibletoavoidlaparotomyandits
associatedmorbidity.
Bycomparison,afteracesareandeliverywheretheabdomenisalreadyopenandadequateanesthesiahas
alreadybeenadministered,thereismuchlessconcernaboutopenoperativeinterventions.Thefrequencyof
thedifferentcausesofhemorrhagealsodiffersbyrouteofbirthretainedproductsofconceptionaremorelikely
afteravaginalbirththanafteracesareandeliverysincetheuterinecavityisreadilyaccessedandvisualized
duringsurgery.
IfPPHdoesnotoccurwhilethepatientishospitalized,useofanantishockgarmentmaybehelpfulfor
reversinghypovolemicshockanddecreasingobstetrichemorrhagewhilethepatientisbeingtransportedto
emergencyobstetricalcarefacilitiesandabletoreceivedefinitivetherapies[3537].
KeycomponentsofevaluationandtreatmentAggressiveactiveevaluationandmanagementofpersistent
vaginalbleedingafterdeliveryinvolves:
Cumulativemeasurementofbloodlossateverydelivery.Thisisanimportantfactorforearlyrecognition
ofexcessivebloodlossandtimelyinitiationoflifesavinginterventions[3840]:
Collectbloodingraduatedmeasurementcontainers,includingdrapeswithcalibratedpockets.
Usevisualaids(eg,posters)thatcorrelatethesizeandappearanceofbloodonspecificsurfaces
(eg,maternitypad,bedsheet,lapsponge)withthevolumeofbloodabsorbedbythatsurface
(picture1).Regularlyschedulingstandardizedtrainingintheuseofthesechartscanbehelpfulfor
thisassessment.
Measurethetotalweightofbloodymaterialsandsubtracttheknownweightofthesamematerials
whendry.Thedifferenceinweightbetweenwetanddryingramsapproximatesthevolumeofblood
inmilliliters.
Forallofthesemethods,theclinicianshouldattempttoaccountforfluidsotherthanblood(eg,amniotic
fluid,irrigationfluid,urine)thatarecollectedorabsorbed.
Bedsideevaluationbytheprovider.
Activemanagementofthethirdstagewithoxytocinandsecondaryuterotonicdrugs,asneeded(eg
carboprost,methylergonovine,misoprostol).(See"Managementofpostpartumhemorrhageatvaginal
delivery",sectionon'Uterotonicdrugs'.)
Early,adequateintravenousaccess(16gauge)formassivetransfusion.
Frequentassessmentofvitalsigns.
Laboratoryevaluation(completebloodcount,coagulationstudies,potassiumandionizedcalciumlevels).
Bloodcrossmatchoractivationofamassivetransfusionprotocol.
TheAdvancedTraumaLifeSupportmanualdescribesfourclassesofhemorrhagetoemphasizetheearlysigns
oftheshockstate[41].Cliniciansshouldnotethatsignificantdropsinbloodpressurearegenerallynot
manifesteduntilclassIIIhemorrhagedevelops,andupto30percentofapatient'sbloodvolumecanbelost
beforethisoccurs.Hemoglobinandhematocritvaluesarepoorindicatorsofacutebloodlosssincetheymay
notdeclineimmediatelyafteranacutebleed.
ClassIhemorrhageinvolvesabloodvolumelossofupto15percent.Theheartrateisminimallyelevated
ornormal,andthereisnochangeinbloodpressure,pulsepressure,orrespiratoryrate.
ClassIIhemorrhageoccurswhenthereisa15to30percentbloodvolumelossandismanifested
clinicallyastachycardia(heartrateof100to120),tachypnea(respiratoryrateof20to24),anda
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decreasedpulsepressure,althoughsystolicbloodpressurechangesminimallyifatall.Theskinmaybe
coolandclammy,andcapillaryrefillmaybedelayed.Anincreasingmaternalheartrateandtachypnea
withstablesystolicbloodpressureshouldberegardedasevidenceofcompensatedshockandshould
promptinvestigationandinstitutionofaPPHprotocol,evenifonlylightvaginalbleedingisobserved.
ClassIIIhemorrhageinvolvesa30to40percentbloodvolumeloss,resultinginasignificantdropin
bloodpressureandchangesinmentalstatus.Anyhypotension(systolicbloodpressurelessthan90
mmHg)ordropinbloodpressuregreaterthan20to30percentofthemeasurementatpresentationis
causeforconcern.Whilediminishedanxietyorpainmaycontributetosuchadrop,theclinicianmust
assumeitisduetohemorrhageuntilprovenotherwise.Heartrate(120andthready)andrespiratoryrate
aremarkedlyelevated,whileurineoutputisdiminished.Capillaryrefillisdelayed.
ClassIVhemorrhageinvolvesmorethan40percentbloodvolumelossleadingtosignificantdepression
inbloodpressureandmentalstatus.MostpatientsinclassIVshockarehypotensive(systolicblood
pressurelessthan90mmHg).Pulsepressureisnarrowed(25mmHg),andtachycardiaismarked
(>120).Urineoutputisminimalorabsent.Theskiniscoldandpale,andcapillaryrefillisdelayed.
Hypovolemichemorrhagicshockistreatedbyaggressivevolumeresuscitationwithpackedredbloodcellsand
otherappropriatebloodproducts.(See"Managementofpostpartumhemorrhageatvaginaldelivery",sectionon
'Fluidresuscitationandtransfusion'.)
Inaddition,theauthorbelievesearlyrecoursetointrauterineballoontamponadecanbeusefultodecrease
ongoingbloodlossandallowtimeforstabilizationandinstitutionofresuscitativeprocedures.(See
"Managementofpostpartumhemorrhageatvaginaldelivery",sectionon'Uterinetamponade'.)
Ifthepatientiscoagulopathicwithanextremelylowfibrinogenlevel,cryoprecipitateandotherhigh
concentrationfibrinogenproducts(eg,fibrinogenconcentrate)areindicatedsincefreshfrozenplasmaalonewill
notincreasethefibrinogenleveltothenormalrangewithoutrequiringexcessivevolumeinfusion.(See
"Managementofpostpartumhemorrhageatvaginaldelivery",sectionon'Repletionofclottingfactors'.)
Arterialembolizationisanappropriatetreatmentforpersistentbleedinginahemodynamicallystablepatientin
whomthecapacityforbloodreplacementexceedsthatoftheongoinghemorrhage.Generally,itshouldnotbe
attemptedinunstablepatientswhohavetobetransferredtoaradiologysuitefortheprocedureanditshould
notbeconsideredanemergencyprocedureformanaginguncontrolledPPHofindeterminatecause.(See
"Managementofpostpartumhemorrhageatvaginaldelivery",sectionon'Arterialembolization'.)
Undermostcircumstances,anacutelyunstableand/orcoagulopathicpatientshouldreceivetemporizing
measuressuchasbimanualuterinecompression,balloontamponade,aorticcompression,transfusionofblood
products,andpossiblyahighcoagulationfactorconcentrate(eg,fibrinogenconcentrate,prothrombincomplex
concentrate)toallowresuscitationtoapointwheregeneralanesthesiaandsurgeryarebettertolerated.Unless
absolutelynecessary,emergencyhysterectomyshouldbeavoidedinacoagulopathicpatientwithinadequate
intravenousaccessformassivetransfusion/correctionofelectrolyteimbalances,asmajorsurgeryinthis
settingmaycausefurtherdeteriorationinmaternalstatusasaresultofuncontrolledretroperitonealhemorrhage
andmyocardialdepression.(See"Managementofpostpartumhemorrhageatcesareandelivery",sectionon
'Temporizingmeasures'and"Managementofpostpartumhemorrhageatcesareandelivery",sectionon
'Conservativesurgicalinterventions'.)
Earlyresorttohysterectomyisappropriateinwomenwithseverebleedingduetodiffuseplacenta
accreta/increta/percretaoralargeuterinerupture.Incontrast,hysterectomyisgenerallyalastresortinpatients
withatony,asthesepatientscanoftenbemanagedsuccessfullywithmedicaltherapyandlessaggressive
surgicalinterventions.However,hysterectomyshouldnotbedelayedinthosewhohavedepletedtheirclotting
factorsandrequirepromptcontrolofuterinehemorrhagetopreventdeath.(See"Managementofpostpartum
hemorrhageatcesareandelivery",sectionon'Hysterectomy'.)
HemorrhageassociatedwithvaginalversuscesareandeliveryAvarietyofmedicationsandtechniques
areavailableforcontrolofPPH.Thechoiceoftechniquedepends,inpart,onthesetting:postvaginaldelivery
oratcesareandeliverywheretheabdomenisalreadyopen.TheapproachtomanagementofPPHaftervaginal
birthandcesareandeliveryaredescribedindetailseparately:
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(See"Managementofpostpartumhemorrhageatvaginaldelivery".)
(See"Managementofpostpartumhemorrhageatcesareandelivery".)
Detaileddiscussionsofspecifictechniquesandpatientsupportarealsoavailable:

(See"Intrauterineballoontamponadeforcontrolofpostpartumhemorrhage".)
(See"Massivebloodtransfusion".)
(See"Clinicaluseofplasmacomponents".)
(See"Intraoperativefluidmanagement".)
(See"Overviewoftopicalhemostaticagentsandtissuesadhesivesusedintheoperatingroom".)
(See"Managementofhemorrhageingynecologicsurgery".)

GuidelinesfromprofessionalorganizationsGuidelinesfordiagnosis,management,andpreventionof
postpartumhemorrhagehavebeendevelopedbyseveralorganizationsandaregenerallyconsistentwiththe
approachdescribedintheUpToDatetopics.
CaliforniaMaternalQualityCareCollaborativebestpracticesformanagementofobstetricalhemorrhage
RoyalCollegeofObstetriciansandGynaecologistsguidelineforpreventionandmanagementof
postpartumhemorrhage
WorldHealthOrganizationguidelineforpreventionandtreatmentofpostpartumhaemorrhage
SocietyofObstetriciansandGynaecologistsofCanadaguidelineforpreventionandmanagementof
postpartumhemorrhage
AmericanCollegeofObstetriciansandGynecologistspracticebulletinforpostpartumhemorrhage[42]
NewYorkhealthadvisoryrecommendationsforreducingtheriskofmaternaldeathfromhemorrhage
InternationalExpertPanelconsensusstatement[5]
NationalPartnershipforMaternalSafety:ConsensusBundleonObstetricHemorrhage[43]
FrenchCollegeofGynaecologistsandObstetricians[44]
COMPLICATIONSPPHisamajorcauseofmaternalmorbidity,includingcatastrophicsequelae:
Death
Hypovolemicshockandorganfailure:renalfailure,stroke,myocardialinfarction,postpartum
hypopituitarism(Sheehansyndrome)
Fluidoverload(pulmonaryedema,dilutionalcoagulopathy)
Abdominalcompartmentsyndrome
Anemia
Transfusionrelatedcomplications,includingsevereelectrolyteabnormalities(predominantlyhyperkalemia
andhypocalcemia)(see"Useofbloodproductsinthecriticallyill",sectionon'Complications')
Acuterespiratorydistresssyndrome
Anesthesiarelatedcomplications
Sepsis,woundinfection,pneumonia
Venousthrombosisandembolism
Unplannedsterilizationduetoneedforhysterectomy
Ashermansyndrome(relatedtocurettageifperformedforretainedproductsofconception)
SheehansyndromeSheehansyndrome(ie,postpartumhypopituitarism)isararebutpotentiallylife
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threateningcomplication.Thepituitaryglandisenlargedinpregnancyandpronetoinfarctionfromhypovolemic
shock.Damagetothepituitarycanbemildorsevere,andcanaffectthesecretionofone,several,orallofits
hormones.Acommonpresentationisacombinationoffailuretolactatepostdeliveryandamenorrheaor
oligomenorrhea,butanyofthemanifestationsofhypopituitarism(eg,hypotension,hyponatremia,
hypothyroidism)canoccuranytimefromtheimmediatepostpartumperiodtoyearsafterdelivery.Ifthepatient
remainshypotensiveaftercontrolofhemorrhageandvolumereplacement,sheshouldbeevaluatedandtreated
foradrenalinsufficiencyimmediatelyevaluationofotherhormonaldeficienciescanbedeferreduntilfourtosix
weekspostpartum.Thisevaluationisdescribedindetailseparately.(See"Clinicalmanifestationsof
hypopituitarism"and"Diagnosisofhypopituitarism".)
AbdominalcompartmentsyndromeAnotherrarebutlifethreateningcomplicationisabdominal
compartmentsyndrome(organdysfunctioncausedbyintraabdominalhypertension).Thediagnosisshouldbe
consideredinpatientswithatenselydistendedabdomenandprogressiveoliguriawhoaredeveloping
multiorganfailure(see"Abdominalcompartmentsyndrome").Ofnote,thenormalpostpartumpatientafter
cesareandeliveryhasbeenreportedtohaveanintraabdominalpressurethatapproachesthatseenin
abdominalcompartmentsyndromeinnonpregnantindividuals[45].
ThromboembolismIntraumapatients,transfusionisanindependentriskfactorfordevelopmentof
thromboembolism[46].Forthisreason,allwomenwhohavebeentransfusedforPPHshouldreceive
mechanicalthromboprophylaxis(graduatedcompressionstockingsorpneumaticcompressiondevice)assoon
asfeasibleandcontinuethromboprophylaxisuntildischarge[47].Twelveto24hoursafterbleedinghasbeen
controlled,pharmacologicthromboprophylaxisshouldbeadded,providingcoagulationtestsarenormalorclose
tonormal.
SeverepostpartumanemiaPostpartumanemiaistreatedwithoralironsupplementation.Asingle325mg
ferroussulfatetablettakenorallythreetimesdailybetweenmealsprovides195mgofelementalironperday.
Thisregimenshouldleadtoamodestreticulocytosisbeginninginapproximatelysevendaysandariseinthe
hemoglobinconcentrationofapproximately2g/dLovertheensuingthreeweeks.Ifthepatientcannottolerate
thisdose,sheshouldtakealowertolerabledose.
Hemoglobinlevelsrisefasterwithparenteralirontherapythanwithoraltherapyhowever,mostwomenresolve
theiranemiasufficientlyrapidlywithoraliron[4850].Administrationofparenteralironisrarelyindicated,given
itsrisks(eg,anaphylaxis)andcosts.Ifparenteraltherapyisadministered,ferricgluconateinsucrosecomplex
andironsucrosearesaferthanirondextran.
Althougherythropoietincanincreasetherateofrecoverytonormalhemoglobinlevels,itdoesnothavean
immediateeffectandhasnotbeenproventoreducetransfusionrequirementsafterPPH[51].Itisnomore
effectivethanirontherapyinthissetting[52],andisexpensive.Inafewwomenwithsevereanemiawhodo
notrespondtoironalonebecauseofbluntederythropoiesisduetoinfectionand/orinflammation,some
hematologistsconsiderrecombinanthumanerythropoietinasanalternativetotransfusion[53].
Theindicationsforredbloodcelltransfusionandparenteralirontherapyarediscussedseparately.These
interventionsmaybeneededinsteadoforalirontherapyinwomenwhoareunabletocareforthemselvesor
theirnewbornsbecauseofsevereanemia.(See"Indicationsandhemoglobinthresholdsforredbloodcell
transfusionintheadult"and"Treatmentofirondeficiencyanemiainadults".)
RECURRENCEWomenwithapriorPPHhaveasmuchasa15percentriskofrecurrenceinasubsequent
pregnancy[54,55].Theriskofrecurrencedepends,inpart,ontheunderlyingcause(eg,theriskofrecurrent
abruptionis5to15percent).
PPHaloneisnotastrongindicationforscreeningforinheritedbleedingdiatheses,giventhatundiagnosed
bleedingdisordersarerarelythecauseofPPH.Asanexample,onestudyof50womenwithPPHwho
underwentpostpartumscreeningidentifiedableedingdiathesisinonlyonewoman[56].However,unexplained
PPHthatdoesnotrespondtogeneralmeasuresshouldalertclinicianstothepossibilityofableedingdisorder
asacausativefactor[57],especiallyinwomenwithahistoryofmenorrhagia,excessivebleedingafterminor
trauma,orafamilyhistoryofableedingdisorder.(See"Approachtotheadultpatientwithableeding
diathesis".)
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SECONDARYPOSTPARTUMHEMORRHAGESecondaryPPHreferstoexcessiveuterinebleeding
occurringbetween24hoursand12weekspostpartum.Moststudiesreportpeakincidenceatonetotwo
weekspostpartum[58].Itaffects0.2to2percentofwomeninhighincomecountries[5860].
Themostcommoncauseisdiffuseuterineatonyorsubinvolutionoftheplacentalsitesecondarytoretained
productsofconceptionand/orinfection.Ableedingdiathesismayalsoberesponsible.Pseudoaneurysmofthe
uterinearteryandarteriovenousmalformationsarerarecausesofsecondaryPPHdescribedincasereports
[6168].Choriocarcinomaisrare,butmaypresentasprolonged,new,orincreasedbleedingpostpartum.Some
caseshavebeenattributedtoexcessivelystrongresumptionofmenses[58].Sometimesthecausecannotbe
determined.
AhistoryofprimaryPPHisariskfactorforseveresecondaryPPH[60,69,70].UnlikeprimaryPPH,bleeding
isnotcatastrophicinmostpatients.AprevioushistoryofsecondaryPPHappearstopredisposetoa
recurrence,aswithprimaryPPH[7072].
OurapproachOurapproachtodiagnosisandmanagementofsecondaryPPHisillustratedbythealgorithm
(algorithm3).
DiagnosticevaluationAthoroughhistoryandphysicalexaminationshouldbeperformed.Evaluationfor
ableedingdiathesis,suchasvonWillebranddisease,shouldbeconsidered,especiallyinwomenwitha
historyofmenorrhagiaorotherpersonalorfamilyhistoryofexcessiveorunusualbleeding.Basiclaboratory
screeningforableedingdiathesisincludesplateletcount,prothrombintime,andactivatedpartial
thromboplastintimehowever,thesetestsmaybenormalinwomenwithvonWillebranddisease.(See
"Approachtotheadultpatientwithableedingdiathesis",sectionon'Laboratorytesting'and"Approachtothe
adultpatientwithableedingdiathesis",sectionon'Diagnosticapproach'.)
Ultrasoundexamination(includingcolorandspectralflowDoppler)oftheuterusmaydetectthecauseof
bleeding,andwillhelpexcludesomepotentialbleedingsourcesinthedifferentialdiagnosis(see'Ultrasound
images'below).However,thepostpartumuterushasavariableappearanceonultrasoundexaminationand
thereisconsiderableoverlapbetweennormalpostpartumfindingsandfindingsassociatedwithsecondary
bleeding[73,74].Inbothcases,theuterusmaybeemptyorcontaingas,fluid,orechogenicmaterial.
VascularityofechogenicintracavitarymaterialisakeyfindingasvascularityoncolorDopplersuggests
retainedproductswhereaslackofvascularityisconsistentwithbloodclot,butdoesnotexcludethepresence
ofretainednecrotic(avascular)placentaltissue.Ifnointracavitarymass,endometrialfluid,orvascularityis
seenandtheendometrialthicknessisthin,retainedproductsarenotlikely.(See"Overviewofpostpartum
care",sectionon'Ultrasoundoftheinvolutinguterus'.)
Inwomenwithbleedingmanyweeksafterdelivery,aquantitativepregnancytestisusefulforevaluatingfor
choriocarcinoma,retainedproductsofconception,orevenanewpregnancy.Ultrasoundexaminationandserial
determinationsofhumanchorionicgonadotropinmaybeneededtodistinguishamongtheseentitieswhenthe
testispositive.(See"Gestationaltrophoblasticneoplasia:Epidemiology,clinicalfeatures,diagnosis,staging,
andriskstratification".)
Ultrasoundimages

Normalpostpartumuterus(image1)
Retainedproductsofconception(image2)
Vascularizedretainedproductsofconception(image3)
Bloodclotinpostpartumuterus(image4)
Endometritis(image5)
Choriocarcinoma(image6andimage7)

ManagementTherearenodatafromrandomizedcontrolledtrialstoguidemanagement[59].Because
sonographicevidenceofaccumulationoffluidanddebrisintheuterinecavityisacommonfindinginthe
involutinguterus,ultrasoundmaynotdistinguishpatientsrequiringsurgicalversusmedicaltherapy[60,75,76].
Iftheuterusisatonic,uterotonicagentsaregiven.Optionsincludeoxytocininfusion,methylergonovine(0.2mg
intramuscularly,repeatedeverytwotofourhoursuptothreedoses),orintramuscularcarboprosttromethamine
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(Hemabate,250mcgintramuscularlyuptoeightdosesatintervalsofnolessthan15minutes).Theseagents
willnotbeusefuliftheuterusisfirm.
Ifbleedingisnotmassiveandfever,uterinetenderness,and/oramalodorousdischargearepresent,then
endometritisshouldbesuspected.Underthesecircumstances,weprescribebroadspectrumantibiotictherapy
(table5).However,somecliniciansadministerantibioticstoallpatientswithsecondaryPPH,includingthose
withoutobvioussignsofinfection.Rare,butpotentiallylethalcausesofendometritisincludeClostridium
sordellii[7780],Clostridiumperfringens[81],andstreptococcalorstaphylococcaltoxicshocksyndrome[82
84].(See"Postpartumendometritis",sectionon'Endometritiswithtoxicshocksyndrome'.)
Womendiagnosedwithableedingdiathesisshouldbetreatedasappropriatefortheunderlyingdisorder.
Consultationwithahematologistisadvised.
Surgicalprocedures(dilationandcurettage,suctioncurettage)aredirectedatevacuationofretainedproducts
ofconception,whicharemorecommonaftervaginalthancesareandeliveryandwhenavascularized
endometrialmassisnotedoncolorDoppler.However,theseproceduresareofteneffectivewhenmedical
managementfails,evenifretainedplacentalormembranefragmentscannotbeidentifiedsonographically
[60,85].Asanexample,astudyof132consecutivewomenwithsecondaryPPHreported75(57percent)were
initiallytreatedwithsurgicalevacuation,whichwassuccessfulin67(90percent)[60].Ofthe57women
initiallymanagedmedically,treatmentwassuccessfulin41(72percent)16womenhadcontinuingsymptoms,
ofwhom12subsequentlyunderwentsurgicalevacuation.Tissuespecimenswereobtainedatsurgeryinonly
38womenandjustonethirdofthesehadhistologicalconfirmationofplacentaltissue.
Ideally,curettageisperformedunderultrasoundguidance.Thisislikelytoreducetherateofperforation,will
allowidentificationofplacentaltissue,andconfirmthatthistissuehasbeenevacuated[73].Suctioncurettage
shouldbeemployedwhenbleedingisover500mLandisnotcontrolledbymedicalmeasures.Thesizeofthe
suctioncannulaisdeterminedbythesizeoftheuterus.Thediameterofthecannulaisusuallychosen
accordingtotheuterinesizebygestationalage(eg,a12mmcannulaforauterusof12weekssize)witha
minimumdiameterof10mmandamaximumdiameterof16mm.
Uterineperforationandformationofintrauterineadhesionsarethemajorcomplicationsofsurgery.Intheseries
describedabove,perforationoccurredin3percentofcases[60].(See"Intrauterineadhesions".)
Selectivearterialembolizationisagoodoptionforwomenwithvascularlesionsasthesourceofbleeding,but
hasalsobeeneffectiveforcontrollingseverebleedingrefractorytouterotonicdrugsoruterinecurettage
[58,86].
Managementofpatientswithgestationaltrophoblasticdiseaseisreviewedseparately.(See"Gestational
trophoblasticneoplasia:Epidemiology,clinicalfeatures,diagnosis,staging,andriskstratification".)
UseofuterotonicdrugsinbreastfeedingwomenOxytocincanbeadministeredtobreastfeedingmothers.
Limitedinformationindicatesthatmaternaldosesofmethylergonovineupto0.75mgdailyproducelowlevels
inmilkandwouldnotbeexpectedtocauseanyadverseeffectsinbreastfedinfants.Althoughresultsof
severalstudiesaremixed,itappearsthatmethylergonovinecandecreaseserumprolactinandpossiblythe
amountofmilkproductionanddurationoflactation,especiallywhenusedintheimmediatepostpartumperiod.
Theeffectseemstoberelatedtothedosageandrouteofadministration,withinjecteddoseshavingagreater
impactthanoral.Afeworaldosesmaynotseverelyaffectlactationhowever,methylergonovineshould
probablynotbethefirstlineuterotonicinmotherswhowishtonurse.TheUSFoodandDrugAdministration
recommendswomenavoidbreastfeedingforatleast12hoursafterreceivingtheirlastdoseof
methylergonovineanddiscardbreastmilkproducedduringthisperiod.Thisrecommendationwasmadeinthe
absenceofanyavailableevidenceofrisktobreastfedinfants,andhasnotbeenendorsedbyotherexperts
[87].
Ergotamineinbreastmilkmaycausevomitinganddiarrheainexposedinfants.Thedrugmayalsoinhibit
prolactinsecretionandlowermilkproduction.Itisgenerallynotrecommendedforbreastfeedingwomen.
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"
and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
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gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoread
materials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.
Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepth
informationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
"patientinfo"andthekeyword(s)ofinterest.)
Basicstopic(see"Patientinformation:Postpartumhemorrhage(TheBasics)")
SUMMARYANDRECOMMENDATIONS
Wemakethediagnosisofpostpartumhemorrhage(PPH)inwomenwithexcessivebleedingthatcauses
symptoms(eg,lightheaded,palpitations,diaphoresis,confusion)and/orresultsinsignsofhypovolemia
(eg,hypotension,tachycardia,oliguria,decreasedoxygensaturation).(See'Diagnosis'above.)
PrimaryPPHoccursinthefirst24hoursafterdelivery(alsocalledearlyPPH)andsecondaryPPH
occurs24hoursto12weeksafterdelivery(alsocalledlateordelayedPPH).(See'Definitions'above.)
ThemostcommoncausesofPPHareatony,trauma,andacquiredorcongenitalcoagulationdefects.
(See'Pathogenesis'above.)
AlthoughtherearemanyknownriskfactorsforPPH,knowledgeoftheseriskfactorsisnotalways
clinicallyusefulinpreventionofhemorrhage.(See'Pathogenesis'above.)
TheapproachtomanagementofPPHvariesdependingonthecauseandwhetherthepatienthashada
vaginalbirthorcesareandelivery.Traumatic,hemorrhaginglesionsaremanagedsurgicallyand
coagulopathyismanagedmedically,withreplacementofbloodproducts.Thetreatmentofatonydepends
ontherouteofdelivery,asthereislessconcernaboutthemorbidityofopenoperativeinterventionswhen
thepatient'sabdomenisalreadyopen.(See'Management'above.)
Massivetransfusionrequiresclosemonitoringofvolumestatus,hemodynamiceffects,coagulation
parameters,andelectrolytelevels.Resuscitativeeffortscanbecompromisedbycardiacdysfunction
frompotassiumandcalciumimbalancesthatresultfromrapidtransfusionofstoredblood.(See'Key
componentsofevaluationandtreatment'above.)
Coordinationisessentialandcanbefacilitatedbyprotocolsandflowdiagramsthefollowingtable(table
3)andalgorithmsarerepresentativeexamples(algorithm1andalgorithm2).Inaddition,numerous
professionalorganizationshaveprovidedguidanceforteammanagementofPPH(eg,CaliforniaMaternal
QualityCareCollaborative).(See'Guidelinesfromprofessionalorganizations'above.)
Ourapproachtoevaluationandmanagementofwomenwithsecondarypostpartumhemorrhageis
describedinthealgorithm(algorithm3).(See'Secondarypostpartumhemorrhage'above.)
Becauseofeaseoftreatmentandalesserincidenceofseveresideeffects,werecommendthatpatients
withanemiabetreatedwithanoral,ratherthanaparenteral,ironpreparation(Grade1B).(See'Severe
postpartumanemia'above.)
WomenwithapriorPPHhaveasmuchasa10percentriskofrecurrenceinasubsequentpregnancy.
(See'Recurrence'above.)
ACKNOWLEDGMENTTheauthorandUpToDatewouldliketoacknowledgeDr.AllanJJacobs,who
contributedtoearlierversionsofthistopicreview.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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57.KadirRA,AledortLM.Obstetricalandgynaecologicalbleeding:acommonpresentingsymptom.ClinLab
Haematol200022Suppl1:12.
58.DossouM,DebostLegrandA,DchelotteP,etal.Severesecondarypostpartumhemorrhage:a
historicalcohort.Birth201542:149.
59.AlexanderJ,ThomasP,SangheraJ.Treatmentsforsecondarypostpartumhaemorrhage.Cochrane
DatabaseSystRev2002:CD002867.
60.HoveydaF,MacKenzieIZ.Secondarypostpartumhaemorrhage:incidence,morbidityandcurrent
management.BJOG2001108:927.
61.NanjundanP,RohillaM,RaveendranA,etal.Pseudoaneurysmofuterineartery:ararecauseof
secondarypostpartumhemorrhage,managedwithuterinearteryembolisation.JClinImagingSci2011
1:14.
62.YunSY,LeeDH,ChoKH,etal.Delayedpostpartumhemorrhageresultingfromuterineartery
pseudoaneurysmrupture.JEmergMed201242:e11.
63.HayataE,MatsudaH,FuruyaK.Rarecaseofpostpartumhemorrhagecausedbyruptureofauterine
arterypseudoaneurysm3monthsafterCesareandelivery.UltrasoundObstetGynecol201035:621.
64.MarnelaK,SaarelainenS,PalomkiO,KirkinenP.Sonographicdiagnosisofpostpartum
pseudoaneurysmsoftheuterineartery:areportof2cases.JClinUltrasound201038:205.
65.LausmanAY,EllisCA,BeecroftJR,etal.Arareetiologyofdelayedpostpartumhemorrhage.JObstet
GynaecolCan200830:239.
66.AzizN,LenziTA,JeffreyRBJr,LyellDJ.Postpartumuterinearteriovenousfistula.ObstetGynecol
2004103:1076.
67.YiSW,AhnJH.Secondarypostpartumhemorrhageduetoapseudoaneurysmruptureatthefundalarea
oftheuterus:acasetreatedwithselectiveuterinearterialembolization.FertilSteril201093:2048.
68.GrsesC,YilmazS,BiyikliS,etal.Uterinearterypseudoaneurysm:unusualcauseofdelayed
postpartumhemorrhage.JClinUltrasound200836:189.
69.DebostLegrandA,RivireO,DossouM,VendittelliF.RiskFactorsforSevereSecondaryPostpartum
Hemorrhages:AHistoricalCohortStudy.Birth201542:235.
70.MarchantS,AlexanderJ,ThomasP,etal.Riskfactorsforhospitaladmissionrelatedtoexcessive
and/orprolongedpostpartumvaginalbloodlossafterthefirst24hfollowingchildbirth.PaediatrPerinat
Epidemiol200620:392.
71.DewhurstCJ.Secondarypostpartumhaemorrhage.JObstetGynaecolBrCommonw196673:53.
72.ThorsteinssonVT,KempersRD.Delayedpostpartumbleeding.AmJObstetGynecol1970107:565.
73.MulicLutvicaA,AxelssonO.Ultrasoundfindingofanechogenicmassinwomenwithsecondary
postpartumhemorrhageisassociatedwithretainedplacentaltissue.UltrasoundObstetGynecol2006
28:312.
74.MulicLutvicaA,EureniusK,AxelssonO.UterinearteryDopplerultrasoundinpostpartumwomenwith
retainedplacentaltissue.ActaObstetGynecolScand200988:724.
75.MulicLutvicaA,BekuretsionM,BakosO,AxelssonO.Ultrasonicevaluationoftheuterusanduterine
cavityafternormal,vaginaldelivery.UltrasoundObstetGynecol200118:491.
76.EdwardsA,EllwoodDA.Ultrasonographicevaluationofthepostpartumuterus.UltrasoundObstet
Gynecol200016:640.
77.HollierLM,ScottLL,MurphreeSS,WendelGDJr.Postpartumendometritiscausedbyherpessimplex
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virus.ObstetGynecol199789:836.
78.RrbyeC,PetersenIS,NilasL.PostpartumClostridiumsordelliiinfectionassociatedwithfataltoxic
shocksyndrome.ActaObstetGynecolScand200079:1134.
79.BittiA,MastrantonioP,SpigagliaP,etal.AfatalpostpartumClostridiumsordelliiassociatedtoxicshock
syndrome.JClinPathol199750:259.
80.AldapeMJ,BryantAE,StevensDL.Clostridiumsordelliiinfection:epidemiology,clinicalfindings,and
currentperspectivesondiagnosisandtreatment.ClinInfectDis200643:1436.
81.CohenAL,BhatnagarJ,ReaganS,etal.ToxicshockassociatedwithClostridiumsordelliiand
Clostridiumperfringensaftermedicalandspontaneousabortion.ObstetGynecol2007110:1027.
82.JorupRnstrmC,HoflingM,LundbergC,HolmS.Streptococcaltoxicshocksyndromeina
postpartumwoman.Casereportandreviewoftheliterature.Infection199624:164.
83.GibneyRT,MooreA,MuldowneyFP.Toxicshocksyndromeassociatedwithpostpartumstaphylococcal
endometritis.IrMedJ198376:90.
84.GibbsRS,BlancoJD.Streptococcalinfectionsinpregnancy.Astudyof48bacteremias.AmJObstet
Gynecol1981140:405.
85.KingPA,DuthieSJ,DongZG,MaHK.Secondarypostpartumhaemorrhage.AustNZJObstet
Gynaecol198929:394.
86.PelageJP,SoyerP,RepiquetD,etal.Secondarypostpartumhemorrhage:treatmentwithselective
arterialembolization.Radiology1999212:385.
87.HaleTW,BakerTE.Useofmethylergonovineinbreastfeedingmothers.
http://www.infantrisk.com/content/usemethylergonovinebreastfeedingmothers0(AccessedonAugust
16,2012).
Topic6710Version66.0

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GRAPHICS
Symptomsrelatedtobloodlosswithpostpartumhemorrhage
Blood
pressure,mm
Hg

Bloodloss,
percent(mL)

Signsandsymptoms

10to15(500to
1000)

Normal

Palpitations,lightheadedness,mildincreasein
heartrate

15to25(1000to
1500)

Slightlylow

Weakness,sweating,tachycardia(100to120
beats/minute)

25to35(1500to
2000)

70to80

Restlessness,confusion,pallor,oliguria,
tachycardia(120to140beats/minute)

35to45(2000to
3000)

50to70

Lethargy,airhunger,anuria,collapse,tachycardia
(>140beats/minute)

Adaptedfrom:BonnarJ.BaillieresBestPractResClinObstetGynaecol200014:1.
Graphic56885Version3.0

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Potentialinterventionsfortreatmentofpostpartumhemorrhage
Pharmacologicinterventions
Drug

Dosing

Oxytocin

10to40unitsin500to1000mLsalineinfusedataratesufficientto
controlatonyor10unitsIM

Ergots

Methylergonovine0.2mgIMeverytwotofourhoursorergometrine
0.5mgIVorIMorergonovine0.25mgIMorIVeverytwohours

Carboprost

0.25mgIMevery15to90minutesuptoeightdosesor500mcgIM
incrementallyupto3mgor0.5mgintramyometrial

Misoprostol

800to1000mcgrectally

Dinoprostone

20mgvaginallyorrectallyeverytwohours

Recombinant
humanFactor
VIIa

50to100mcg/kgeverytwohours

Surgicalinterventions
Repairlacerations
Curettage
Uterinecompressionsuture(eg,BLynchsuture)
Uterinearteryligation
Uteroovarianarteryligationorcrossclamp
Pelvicpacking
Uterinetourniquet
Focalmyometrialexcision
Useoffibringluesandpatchestocoverareasofoozingandpromoteclotting
Placementoffigure8suturesorotherhemostaticsuturesdirectlyintotheplacentalbed
Internaliliacartery(hypogastricartery)ligation
Aorticcompression
Hysterectomy,supracervical
Hysterectomy,total

Interventionalradiology
Selectivearterialembolization
Intermittentaorticballoonocclusion
Commoniliacarteryballoonocclusion

Bloodbank
Packedredbloodcells
Platelets
Freshfrozenplasma
Cryoprecipitate
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Nonsurgicalinterventions
Uterinemassage
Intravenousfluids
Tamponade
Intrauterinetamponadewithanintrauterineballoonoralternativedevice(eg,bladdercatheter
bulb,SengstakenBlakemoretube)
Uterinepacking(eg,4inchgaugepacking)

Consultations
Generalsurgery
Traumasurgery
Anesthesiateam
Interventionalradiology
Gynecologiconcology
Urology
IV:intravenousIM:intramuscularmcg:microgramskg:kilogram.
Datafrom:DahlkeJD,MendozFigueroaH,MaggioL,etal.Preventionandmanagement
ofpostpartumhemorrhage:acomparisonof4nationalguidelines.AmJObstetGynecol2015
213.e1.
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Overviewofmanagementofpostpartumhemorrhagebasedon
estimatedbloodlossandhemodynamicstability
Step1:Beforedelivery
ScreenallwomenadmittedtoLaborandDeliveryforriskfactorsforobstetric
hemorrhage.
Drawbloodandholdclot,typeandscreen,ortypeandcrossmatch,dependingonlevelof
hemorrhagerisk.
Ensureintravenousaccesswithintravenouscatheter(s)orheparinlock,asappropriatefor
levelofhemorrhagerisk.

Step2:Atdelivery
Giveoxytocinforactivemanagementofthethirdstage.

Step3:Afterdelivery
Quantifybloodloss.
Initiateadditionalmeasurestocontrolbleedingbasedonseverityofobstetric
hemorrhage.
Bloodloss>500mLand<1000mLatvaginaldeliveryor>1000mLand<1500mL
atcesareandeliverywithongoingexcessivebleedingand/ormildtachycardiaand/or
hypotension.
Gethelpandnotifyobstetrichemorrhageteam.
Continuetomonitorvitalsignsandquantifybloodloss.
Ensureintravenousaccesswithalargegaugecatheter(s).
Beginbimanualuterinemassage.
Increaseoxytocinflowrate(avoiddirectintravenousinjectionofundiluted
oxytocin).
Volumeresuscitation,preferablywithbloodandbloodproductsifbleedingisheavy
andcoagulopathyisimminent.
Giveaseconduterotonic(eg,methylergonovine,carboprosttromethamine).
Examineforlacerations,retainedproductsofconception,uterineinversion,and
othercausesofbleeding.Considerbedsideultrasoundofuterus.Treatas
appropriate(eg,repairlacerations,curettage,repositionuterus,etc).
Ifcesareandelivery:Applyconservativesurgicalinterventionstocontrolbleeding
(eg,uterineartery/ovarianarteryligation,uterinecompressionsutures).
Bloodloss>1000mLand<1500mLatvaginaldeliveryor>1500mLatcesarean
deliverywithongoingexcessivebleedingand/orhemodynamicinstability.
Doalloftheabove.
Drawbloodforbaselinelabs(completebloodcount,coagulationstudies)andclot
observationtest.
Insertintrauterineballoonfortamponade.
Transfusetwounitspackedredcellsandonetotwounitsfreshfrozenplasma.
Activateamassivetransfusionprotocolifbleedingisheavyandtransfusionoffour
ormoreunitsofbloodislikely.
Ifvaginaldelivery:Movethepatienttoanoperatingroomtoperformconservative
surgicalinterventionstocontrolbleeding.
Considerselectivearterialembolizationonlyifpatientishemodynamicallystable.
Thisshouldpreferablybeperformedinanoperatingroomorhybridsuiteif
available.Bleedingpatientsshouldonlybemovedtoaradiologysuitefor
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embolizationiftheyarehemodynamicallystableandbloodproductsarebeing
replacedataratethatcanexceedthatofthebleeding.Arterialembolization
outsideofanoperatingroomisnotanoptioninsituationswherethereis
catastrophicbleedinginadecompensatingpatient.
Ifcesareandelivery:Continuetoapplyconservativesurgicalinterventionsto
controlbleeding(eg,uterineartery/ovarianarteryligation,uterinecompression
sutures).
Bloodloss>1500mL,ongoingexcessivebleeding,andhemodynamicinstability
despiteinitialtherapy.
Initiatemassivetransfusionprotocol(transfuseappropriateratioofredcells,fresh
frozenplasma/cryoprecipitate,andplatelets).
Ifconservativesurgicalinterventionsarenotsuccessful,performhysterectomy.
Hysterectomyshouldnotbedelayedinwomenwhorequirepromptcontrolof
uterinehemorrhagetopreventdeath.
Keeppatientwarm.
Treatacidosis.
Checkionizedcalciumandpotassiumlevelsevery15minutesonceamassive
transfusionprotocolhasbeeninitiatedandtreathypocalcemiaandhyperkalemia
aggressively.Continueuntiltheemergencyhasbeencontainedandtheprotocol
formassivetransfusionhasbeenstopped.
Maintainoxygensaturation>95%.
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SamplealgorithmofapproachtoPPHduetoatony

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TexasChildren'sHospitalEvidenceBasedOutcomesCenterclinicalalgorithmforprimarypostpartumh
uterineatony.

EBOC:EvidenceBasedOutcomesCenterPPH:primarypostpartumhemorrhageUA:uterineatonyLR:lactated
rebreathermaskRN:registerednurseEBL:estimatedbloodlossEPIC:electronichealthrecordOR:operatingr
SBP:systolicbloodpressureHR:heartrateIM:intramuscularIMM:intramyometriallyRRT:rapidresponseteam

INR:internationalnormalizedratioPTT:partialthromboplastintimeCVP:centralvenouspressureICU:intensiv
bloodgasIR:interventionalradiology.

Reproducedwithpermission.AccessedonJanuary8,2014.CopyrightEvidenceBasedOutcomesCenter,2013
Center,TexasChildren'sHospital.ThisguidelinewaspreparedbytheEvidenceBasedOutcomesCenter(EBOC)te
contentexpertsatTexasChildren'sHospitalPavilionforWomen.DevelopmentofthisguidelinesupportstheTCH
Programinitiativetopromoteclinicalguidelinesandoutcomesthatbuildacultureofqualityandsafetywithinthe
recommendationsaremadefromthebestevidence,clinicalexpertiseandconsensus,inadditiontothoughtfulcon
patientsandfamiliescaredforwithintheIntegratedDeliverySystem.Whenevidencewaslackingorinconclusive,
consensusrecommendations.Expertconsensusisimpliedwhenareferenceisnototherwiseindicated.Theguidel
imposestandardsofcarepreventingselectivevariationinpracticethatisnecessarytomeettheuniqueneedsofi
physicianmustconsidereachpatientandfamily'scircumstancetomaketheultimatejudgmentregardingbestca
Graphic91258Version1.0

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Samplemassivetransfusionalgorithm

TexasChildren'sPavilionforWomenmassivetransfusionprotocol.
MTP:massivetransfusionprotocolPRBC:packedredbloodcellsPCA:patientcontrolled
analgesiaRRT:rapidresponseteamBB:bloodbankHg:hemoglobinHct:hematocritDIC:
disseminatedintravascularcoagulationPT:prothrombintimeINR:internationalnormalized
ratioPTT:partialthromboplastintimeABG:arterialbloodgasRBC:redbloodcellsFFP:fresh
frozenplasmaOB:ObstetricsAnes:AnesthesiaOR:operatingroomCRNA:certifiedregistered
nurseanesthetistChrg:chargeRN:registerednurseLab:laboratoryTech:technicianMD:
medicaldoctorL&D:laboranddeliveryiCa:ionizedcalciumK:potassiumGlu:glucosePCA:
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patientcareassistant.
*Everytwopackagesorbasedonlabresults.
Reproducedwithpermission.AccessedonFebruary19,2013.CopyrightEvidenceBased
OutcomesCenter,2013.QualityandOutcomesCenter,TexasChildren'sHospital.Thisguideline
waspreparedbytheEvidenceBasedOutcomesCenter(EBOC)teamincollaborationwithcontent
expertsatTexasChildren'sHospitalPavilionforWomen.Developmentofthisguidelinesupports
theTCHQualityandPatientSafetyPrograminitiativetopromoteclinicalguidelinesandoutcomes
thatbuildacultureofqualityandsafetywithintheorganization.Guidelinerecommendationsare
madefromthebestevidence,clinicalexpertiseandconsensus,inadditiontothoughtful
considerationforthepatientsandfamiliescaredforwithintheIntegratedDeliverySystem.When
evidencewaslackingorinconclusive,contentexpertsmadeconsensusrecommendations.Expert
consensusisimpliedwhenareferenceisnototherwiseindicated.Theguidelineisnotintendedto
imposestandardsofcarepreventingselectivevariationinpracticethatisnecessarytomeetthe
uniqueneedsofindividualpatients.Thephysicianmustconsidereachpatientandfamily's
circumstancetomaketheultimatejudgmentregardingbestcare.
Graphic91236Version4.0

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Stepsinmanagementofpostpartumhemorrhage
Assembleteamandnotifyappropriatedepartments(obstetrics,nursing,
anesthesiology,bloodbank,laboratory).
Initiateuterinemassageand/ormanualcompressionandestablishlargebore(two
16or18gauge,ideally14gauge)intravenousaccess.
Tamponadebleedingfromtheuterinecavity.Balloontamponadeshouldbeinitiatedearly
ifbleedingisbrisk,particularlyifthepatientisnothemodynamicallystable,andbloodproducts
arenotreadilyavailable.Bothballoontamponadeorpackingcanbeperformedpriorto,orin
conjunctionwith,preparationsforlaparotomyortransarterialembolization.Balloontamponade
mayreducebloodlosswhileinitiatingcarboprostorergotdrugs,ifusedafteroxytocinhasfailed.
Earlyuseofaballoontamponadewithorafteruseoftheseagentsmayreducetheincidenceof
heavybloodlossandtheneedforbloodproducts.
Administeroxygen(10to15liters/minute)byfacemask.Anesthesiateamshould
evaluateairwayandbreathingintubateifindicated.
Fluidresuscitation:Infuseisotoniccrystalloidtopreventhypotension(targetsystolicpressure
90mmHg)andmaintainurineoutputat>30mL/hour.
Transfusion:Ifhemodynamicsdonotimprovewith2to3litersofcrystalloidadministration
andbleedingcontinues,administerbloodproducts,initiallytwounitspackedredbloodcells.
Aggressiveuseofplasmareplacementisalsoimportanttoreversedilutionalcoagulopathy.
Coagulationfactorconcentratesmayalsobeneeded.Forpatientswithmassivehemorrhage,
redbloodcells,freshfrozenplasma,andapheresisplateletsarebestadministeredaccordingto
anestablishedmassivetransfusionprotocol.
Administeruterotonicdrugs*toreverseatony:Itshouldbepossibletodeterminewithin
30minuteswhetheruterotonictreatmentwillreverseatony.Ifitdoesnot,promptinvasive
interventionisusuallywarranted.
Initiateoxytocin:
Beginwithoxytocin40unitsin1literofnormalsalineorRinger'slactate.Usinganintravenous
infusionpump,startat10to40milliunitsperminute.Adjustratetoachieveandmaintain
uterinecontraction [1]15unitsin250mLnormalsalineorRinger'slactatemaybegivenifa
highconcentrationmustbeadministeredrapidly.Expectrapidresponse.
Avoidrapidintravenousbolusinjectionofoxytocin.
Ifnointravenousaccess,give10unitsintramuscularlyexpectresponsewithinthreetofive
minutes.
TherearenoabsolutecontraindicationstooxytocinforPPHoxytocinistheuterotonicof
choice,evenifitwasalreadygivenasprophylaxis.
Carbetocin(whereavailable )100microgramsslowintravenousinjectionassingledose.A
longactinganalogueofoxytocin,carbetocinisapotentialalternativeiftitrableoxytocin
intravenousinfusionisnotfeasible.
IfoxytocinisnotimmediatelyavailableordoesnotcontrolPPH:
Addergot:
Methylergonovine(methylergometrine)200microgramsintramuscularly(including
intramyometrial)everytwotofourhoursuptoamaximumof1mg(fivedoses).Expect
responsewithintwotofiveminutes.
Donotgiveintravenously.
Avoidinwomenwithhypertension,Raynaud'sphenomenon,orscleroderma.
Iffirstdoseineffective,quicklyaddadifferentuterotonicagent(eg,carboprost
tromethamine).
Ergonovine(ergometrine),whereavailable ,isanalternativetomethylergonovineits
actionsandcontraindicationsaresimilartomethylergonovine(seeabove). [2]
Ergonovine(ergometrine)200microgramsintramuscularlymayberepeatedoncein15
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minutes.
Ifrequired,additionaldosesof200microgramsintramuscularlymaybegivenevery
fourhoursuptoamaximumof1mg(fivedoses). [2]
Addcarboprost:
Carboprosttromethamine(PGF 2 alpha,Hemabate)250microgramsintramuscularlyevery
15to90minutes,asneeded,toamaximumof2mg(eightdoses).Peakplasmalevelis
approximately30minutesafterinjection.
Donotgiveintravenously.
Avoidinwomenwithasthma/bronchospasmorhypertension.
Relativelycontraindicatedinrenalorhepaticinsufficiencyorreducedcardiacoutput.
Cancausetachycardia,pyrexia,diarrhea.
Ifnoresponseafteroneortwodoses,quicklymovetoadifferentuterotonicagent.

Inspectthevaginaandcervixforlacerationsrepairasnecessary.Evacuateany
retainedproductsofconception.Replaceuterusifinverted.
Performtransarterialembolizationifthewomanisstableandthereistimefor
personnelandfacilitiestomobilize.
Performlaparotomyiftheabovemeasuresfail.Surgicalapproachesthatarequick,
relativelyeasy,andeffectiveshouldbetriedfirst.Inutilizingthesemeasures,thesurgeon
shouldbecognizantoftheamountofbloodlossandthestabilityofthepatient,andshould
performhysterectomyratherthanresorttotemporizingmeasuresifhercardiovascularstatus
isunstableorifitappearsthattheanesthesiologistwillnotbeabletokeepupwithherfluid
needs.Optionsinclude:
Ligatebleedingsites.
Performuterinearteryligation,includingtheuteroovarianarcade.
PlaceaBLynchstitchorotheruterinecompressionsuture.
PerformhysterectomyHysterectomyisthelastresortforatony,butshouldnotbedelayedin
womenwhohavedisseminatedintravascularcoagulationandrequirepromptcontrolofuterine
hemorrhagetopreventdeath.Plannedhysterectomyisoftentheappropriatefirstlineapproachfor
placentacreta.
Suturedeeppelvicbleeders.
Tamponadepelvicbleedingwithpelvicpacking.

Simultaneoususeofmisoprostolwithoxytocinisunlikelytohaveaddedbenefit,butwhere
otheruterotonicdrugsareunavailable,misoprostol(PGE1)canbeuseful.Givemisoprostol
400microgramssublinguallyorrectallyasasingledose.Maximumdose800micrograms.
Themeantimetopeakconcentrationisapproximately30minutesaftersublingual
administrationversus40to60minutesafterrectaladministration.Misoprostolcanbe
giventowomenwithhypertensionorasthma/bronchospasm.Monitorforpyrexia.
Acetaminophen(paracetamol)isusefulforreducingfever.
Dinoprostone(PGE2)20mgvaginalorrectalsuppositoryisanalternativetomisoprostol.
Itsactionsandcontraindicationsaresimilartomisoprostolitcanberepeatedattwo
hours.
PG:prostglandinPPH:postpartumhemorrhage.
*Alluterotonicagentscancausenauseaandvomiting.
NotavailableinUS.AvailableinCanada,UK,EU,andelsewhere.
Oraltabletsmaybegivenperrectumorasamicroenemapreparedfromoralmisoprostoltablets
dissolvedin5mLsaline [3] .
References:
1.AmericanCollegeofObstetriciansandGynecologistsCommitteeonPracticeBulletins
ObstetricsPostpartumhemorrhage(ACOGPracticeBulletin,number76,issuedOctober2006).
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ObstetGynecol2006108:1039.
2.WHOguidelinesforthemanagementofpostpartumhaemorrhageandretainedplacenta
(issued2009).
3.BugalhoA,DanielA,FaundesA,etal.Misoprostolforpreventionofpostpartumhemorrhage.
IntJGynecolObstet200173:1.
Withadditionaldatafrom:
RamanathanG,ArulkumaranS.Postpartumhemorrhage.JObstetGynaecolCan2006
28:967.
TunalpO,SouzaJP,GlmezogluM.NewWHOrecommendationsonpreventionandtreatment
ofpostpartumhemorrhage.IntJGynaecolObstet2013123:254.
HofmeyrGJ,GlmezogluM,NovikovaN,LawrieTA.Postpartummisoprostolforpreventing
maternalmortalityandmorbidity.CochraneDatabaseSystRev2013:7:CD008982.
InternationalFederationofGynecologyandObstetrics.Treatmentofpostpartumhemorrhage
withmisoprostol.IntJGynaecolObstet2012119:215.
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Visualaidforestimatingintrapartumbloodloss

Visualaid.Pocketcardwithimagesofmeasuredvolumesofartificialblood.

From:ZuckerwiseLC,PettkerCM,IlluzziJ,etal.Useofanovelvisualaidtoimproveestimationofobstetricblood
2014123:982.DOI:10.1097/AOG.0000000000000233.ReproducedwithpermissionfromLippincottWilliams&
2014AmericanCollegeofObstetriciansandGynecologists.Unauthorizedreproductionofthismaterialisprohibited
Graphic103418Version1.0

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Diagnosisandmanagementofsecondarypostpartumhemorrhage

Ultrasoundexaminationinpatientswithsecondarypostpartumhemorrhageisoftennotdefinitiveasth
ultrasoundfindingsandfindingsassociatedwithsecondarybleeding.
1.Ultrasoundfindingsareoftennonspecificinendometritis.Theuterusmayhaveathickened,het
postpartumfindings,suchasintracavitarydebris,fluid,orgas.Infectedretainedplacentaltissu
2.Retainedproductsofconceptionhaveavariableandsometimesnonspecificappearanceonultr
intracavitarymassthatextendstotheendometrium.However,necroticdeciduaandbloodclots
spectralDopplershowinghighvelocity,lowresistancearterialflowinthemassdifferentiatespl
intheretainedtissue.Intheabsenceofamass,increasedvascularityinathickenedpostpartu
tissue.Rarely,afocalmorbidlyadherentplacentapresentsassecondarypostpartumhemorrhag
orbeyondthemyometrium.
3.Bleedingdiathesisandsubinvolutionhaveasimilarultrasoundappearance.Ultrasoundmaysho
debris,fluid,orgas.Anintracavitaryhematomamaybepresentandappearsasanechogenicm
retainedproductsofconception.However,hematomasarenotvascularized,whereasretainedp
withsubinvolutionandanintracavitaryhematoma,lowresistancearterialflowwithinthemyom
confusedwithlowresistancearterialflowinretainedplacentaltissue.Theuterusmaybeenlarg
4.AVMandpseudoaneurysmhavecharacteristicfeaturesonultrasound.Ultrasoundfindingsofan
spaceswithinthemyometrium,withturbulentflowoncolorDopplerandhighvelocityandlowr
heterogeneity,amyometrialorendometrialmass,orprominentparametrialvesselsmaybeobs
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pseudoaneurysmmayincludeahypoechoicintrauterinelesion,vascularityoncolorDoppler,and
spectralDoppler.
CBC:completebloodcounthCG:humanchorionicgonadotropinAVM:arteriovenousmalformation.
*Inwomenwithbleedingmanyweeksafterdelivery,aquantitativepregnancytestisusefulforevaluatingforch
pregnancy.

Datafrom:
KamayaA,RoK,BenedettiNJ,etal.Imaginganddiagnosisofpostpartumcomplications:sonographyando
BrownDL.Pelvicultrasoundinthepostabortionandpostpartumpatient.UltrasoundQ200521:27.
DiSalvoDN.Sonographicimagingofmaternalcomplicationsofpregnancy.JUltrasoundMed200322:69.
LaiferNarinSL,KwakE,KimH,etal.Multimodalityimagingofthepostpartumorpostterminationuterus:e
magneticresonanceimaging.CurrProblDiagnRadiol201443:374.
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Fluidanddebrisinpostpartumuterus

(A)Transabdominalsagittalgreyscaleimageand(B)transvaginal
colorDopplerimagefroma35yearoldwomantwoweekspostpartum
withvaginalbleeding.Notethefluidanddebrisintheuterus.The
colorDopplerimageshowsnoflowwithinthedebris.
CourtesyofDeborahLevine,MD.
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RetainedproductsofconceptioncausingsecondaryPPH

(A)TransvaginalcolorDopplershowsanechogenicareawithbloodflow,consistentwithretainedprod
(over120cm/sec).
(B)Angiogramshowsearlyfillingvein(arrow).Thepatientwastreatedwithembolizationpriortocure
products.
CourtesyofDeborahLevine,MD.
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Vascularizedretainedproductsofconceptionwithsecondarypostpartum
hemorrhage

(A)Transvaginalimageshowsaheterogeneousmass(betweencalipermarkers)intheendometriumo
withsecondarypostpartumhemorrhage.
(B)Transabdominalimageshowsalargeamountofbloodflowtothisendometrialregion.Thiscombin
findingsisconsistentwithvascularizedretainedproductsofconception.
CourtesyofDeborahLevine,MD.
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Bloodclotinpostpartumuterus

Patientwithsecondarypostpartumbleeding.
(A)Transvaginalsonogramshowsfluidintheendometrialcavitywithsomeechogenicareasbothante
posterior.
(B)PowerDopplerimageshowsnormalbloodflowinthemyometrium,nobloodflowtotheseareasin
endometrium,whichisconsistentwitheithernonvascularizedretainedproductsofconceptionorblood
theappearanceinthiscaseismostsuggestiveofbloodclot.
CourtesyofDeborahLevine,MD.
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Postpartumendometritisassociatedwithbleeding

Postpartumpatientwithpain,bleeding,andfever.
(A)Transabdominalsagittalimageoftheuterusshowsfluidwithintheendometrialcavityandashagg
irregularappearanceoftheendometriumanteriorly.
(B)PowerDopplerimageshowsnobloodflowtothisareaoftheendometrium,whichrulesoutretaine
vascularizedproductsofconceptioninthisarea.Thepatientwastreatedforendometritisandimprove
clinically.
CourtesyofDeborahLevine,MD.
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Ultrasoundchoriocarcinoma

Choriocarcinoma:Patientwithstage3choriocarcinomaaftertermpregnancy.
Theendometrialcavityisfilledwithahyperechoicmassmeasuring3.0x2.9
x2.8cm.
CourtesyofDepartmentofRadiology,SantaClaraValleyMedicalCenter.
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Dopplerultrasoundchoriocarcinoma

Choriocarcinoma:Ultrasoundrevealsahyperechoicmassshowing
hypervascularityoncolorDoppler.
CourtesyofDepartmentofRadiology,SantaClaraValleyMedicalCenter.
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Sampleantibioticregimensforendometritisalternativestothe
"GoldStandard"gentamicinandclindamycin
Ampicillinsulbactam3gramsIVQ6hours
Ticarcillinclavulanate3.1gramsIVQ4hours
Cefoxitin2gramsIVQ6hours
Ceftriaxone2gramsIVQ24hoursplusmetronidazole500mgPOorIVQ8hours*
Levofloxacin500mgIVQ24hoursplusmetronidazole500mgPOorIVQ8hours*

Ifchlamydiainfectionissuspected,azithromycin1gramPOforonedoseshouldbeadded
totheregimen.
*Shouldnotbegiventobreastfeedingmothers.
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Disclosures
Disclosures:MichaelABelfort,MBBCH,MD,PhD,FRCSC,FRCOGPatentHolder:ClinicalInnovations[Balloontamponade
systemforcontrolofpostpartumhemorrhage].CharlesJLockwood,MD,MHCMConsultant/AdvisoryBoards:Celula[Aneuploidy
screening(PrenatalandcancerDNAscreeningtestsindevelopment)].DeborahLevine,MDNothingtodisclose.VanessaABarss,
MD,FACOGNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvetting
throughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriately
referencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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