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34 OBG Management | January 2011 | Vol. 23 No. 1 obgmanagement.com Postpartum hemorrhage: 11 critical questions, answered by an expert

A playbook on postpartum hemorrhage, from prevention to essential management

Q&A with Haywood L. Brown, MD

1 e know the potentially tragic out- What is PPH? come of postpartum hemorrhage OBG Management: Dr. Brown, let’s start W (PPH): Worldwide, more than with a simple but important aspect of PPH— 140,000 women die every year as a result of how do you define it? PPH—one death every 4 minutes! Lest you Dr. Brown: Obstetric hemorrhage is exces- dismiss PPH as a concern largely for devel- sive bleeding that occurs during the intra- oping countries, where it accounts for 25% of partum or —specifically, maternal deaths, consider this: In our highly estimated loss of 500 mL or more after In this developed nation, it accounts for nearly 8% of vaginal delivery or 1,000 mL or more after ce- Article maternal deaths—a troubling statistic, to say sarean delivery. the least. PPH is characterized as early or late, 3 levels The significant rate asso- depending on whether the bleeding occurs of hemorrhage, ciated with PPH, and questions about how to within 24 hours of delivery (early, or prima- and how to manage reduce it, prompted the editors of OBG Man- ry) or between 24 hours and 6 to 12 weeks them agement to talk with Haywood L. Brown, postpartum (late, or secondary). Primary page 36 MD. Dr. Brown is Roy T. Parker Professor and PPH occurs in 4% to 6% of . chair of and gynecology at Duke Another way to define PPH: a decline of agents University Medical Center in Durham, NC. 10% or more in the baseline hematocrit level. page 39 He is also a nationally recognized specialist in OBG Management: How do you measure maternal-fetal medicine. In this interview, he blood loss? discusses the full spectrum of management Dr. Brown: The estimation of blood loss af- Is your patient obese? of PPH, from proactive assessment of a wom- ter delivery is an inexact science and typical- She requires extra an’s risk to determination of the cause to the ly yields an underestimation. Most clinicians attention tactic of last resort, emergent . rely on visual inspection to estimate the page 40 amount of blood collected in the drapes af-

Dr. Brown is Roy T. Parker ter vaginal delivery and in the suction bottles Dr. Brown Professor and Chair of the after cesarean delivery. Some facilities weigh describes blood Department of Obstetrics and lap pads or drapes to get a more accurate as- Gynecology at Duke University product replacement Medical Center in Durham, NC. sessment of blood loss. In a routine delivery, in severe PPH, at no specific calorimetric measuring devices obgmanagement.com are used to estimate blood loss. Dr. Brown serves as a speaker for Alere and Hologic At my institution, we make an attempt to and as an advisor for the Bayer Foundation and Ferring. estimate blood loss at every delivery—vagi- nal or cesarean—and record the estimate. By

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doing this routinely, the clinician improves 3 levels of hemorrhage—and how to in accuracy and becomes more adept at manage them identifying excessive bleeding. OBG Management: Is blood loss the only variable that arouses concern about possible Low: 500 to 1,000 mL hemorrhage? This level of hemorrhage should be anticipated and can usually be Dr. Brown: Because pregnant women ex- managed with uterine massage and administration of a uterotonic perience an increase in blood volume and agent, such as . Intravenous fluids and careful monitoring of physiologic cardiovascular changes, the usu- maternal vital signs are also warranted. al sign of significant bleeding can sometimes Active management of the third stage of labor has been shown be masked. Therefore, any changes in mater- to reduce the risk of significant postpartum hemorrhage (PPH). Ac- nal vital signs, such as a drop in blood pres- tive management includes: sure, tachycardia, or sensorial changes, may • administration of a uterotonic agent immediately after delivery of the infant suggest that more blood has been lost than • early cord clamping and cutting has been estimated. • gentle cord traction with uterine counter-traction when the Hypotension, dizziness, tachycardia or is well contracted palpitations, and decreasing urine output • uterine massage.2 will typically occur when more than 10% of If these methods are unsuccessful in correcting the atony, maternal blood volume has been lost. In this such as a (rectally administered misopro- situation, the patient should be given addi- stol [800 mg] or intramuscular tromethamine [Hemabate; 250 µg/mL]) will usually succeed. tional fluids, and a second intravenous line should be started using large-bore, 14-gauge Medium: 1,000 to 1,500 mL access. In addition, the patient’s hemoglobin and hematocrit levels should be measured. Blood loss of this volume is usually accompanied by cardiovascular All these actions constitute a first-line strate- signs, such as a fall in blood pressure, diaphoresis, and tachycardia. gy to prevent shock and potential irreversible Women with this level of hemorrhage exhibit mild signs of shock. renal failure and cardiovascular collapse. It is important to correct maternal hypotension with fluids, restabilize vital signs, and resolve the bleeding expeditiously. If uterotonics and massage fail to stanch the bleeding, consider 2 placing a balloon (e.g., Bakri balloon). Once the balloon is placed What causes PPH? and inflated, it can be left for as long as 24 hours or until the uterus OBG Management: Why does PPH occur? regains its tone. Dr. Brown: The leading cause is uterine Be sure to check hemoglobin and hematocrit levels and atony, a failure of the uterus to contract and transfuse the patient, if necessary, especially if vital signs have not undergo resolution following delivery of an stabilized. infant. Approximately 80% of cases of early PPH are related to uterine atony. High: 1,500 to 2,000 mL, or greater There are other causes of PPH: This is a medical emergency that must be managed aggressively • lacerations of the genital tract (perine- to prevent morbidity and death. Blood loss of this volume will um, vagina, , or uterus) usually bring significant cardiovascular changes, such as hypoten- • retained fragments of placental tissue sion, tachycardia, restlessness, pallor, oliguria, and cardiovascular • collapse from hemorrhagic shock. This degree of blood loss means • blood clotting abnormalities that the patient has lost 25% to 35% of her blood volume and will • . need blood-product replacement to prevent coagulation and the cascade of hemorrhage. If conservative measures are unsuccessful, timely surgical inter- 3 vention with B-Lynch suture, uterine vessel ligation, or hysterectomy Is it possible to prepare is lifesaving. for PPH? OBG Management: What is the starting —Haywood L. Brown, MD point for management of PPH? Dr. Brown: Prevention of, and preparation

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for, hemorrhage begin well before delivery. ­attention because it could signal uterine During the prenatal period, for example, it is rupture. Women who have a low transverse important to assess the woman’s level of risk uterine scar and who undergo VBAC have a for PPH. Among the variables that increase risk of uterine scar separation during labor of her risk: 0.5% to 1%. • any situation that leads to overstretching OBG Management: What about retained of the uterus, including multiple gesta- or a placenta that requires manual tion, whether delivery is vaginal or ce- removal? sarean Dr. Brown: These intrapartum variables are • a history of PPH. not as easy to anticipate. They may suggest It is important that women with these char- a condition such as placenta accreta, espe- acteristics maintain adequate hemoglobin cially if the patient is undergoing VBAC. and hematocrit levels by taking vitamin and Uterine inversion can also lead to hem- iron supplements in the antepartum period. orrhage and is a medical emergency. In addition, women who have abnor- OBG Management: What steps should be mal placental implantation, such as placenta taken at the time of labor to ensure a safe previa, are at risk for bleeding during the outcome? antepartum period and during cesarean de- Dr. Brown: A type and screen should be livery. They should maintain a hematocrit in available for all women on labor and deliv- the mid-30s because of expected blood loss ery, and the team should anticipate the need during delivery. to cross-match for blood if there is a high po- OBG Management: What preparatory steps tential for transfusion. For example, a wom- should be taken at the time of hospital ad- an known to have anemia (hematocrit <30%) mission if a woman has an elevated risk of should have a cross-match performed so bleeding? that blood can be prepared for transfusion. Dr. Brown: When the patient is hospitalized In addition, women who are undergoing Oxytocin in anticipation of delivery—whether vaginal planned delivery for placental implantation administration and or cesarean—the team should assess her disorders should have blood in the operating hemoglobin and hematocrit levels and type room ready for transfusion when cesarean is lessen the risk of and screen for possible transfusion. The pa- performed. These women are at great risk of uterine atony and tient should also be apprised of her risk and hemorrhage and peripartum hysterectomy. excessive bleeding the potential for transfusion. Last, the anesthesia team should be 5 alerted to her risk factors for postpartum What first-line strategies do bleeding. you recommend? OBG Management: Do you recommend oxytocin administration and fundal massage 4 What intrapartum variables for every patient after delivery of the infant? signal an increased risk Dr. Brown: Yes. These strategies lessen the of PPH? risk of uterine atony and excessive bleed- OBG Management: During labor and deliv- ing after vaginal delivery. At the time of ce- ery, what variables signal an elevated risk of sarean delivery, expression of the placenta bleeding? and uterine massage, along with oxytocin Dr. Brown: Risk factors for hemorrhage administration, reduce the risk of excessive become more apparent during this period. blood loss. They include prolonged or rapid labor, pro- If bleeding continues even after the uter- longed use of oxytocin, operative delivery, us begins to contract, look for other causes infections such as , and of the bleeding, such as uterine laceration or vaginal birth after cesarean delivery (VBAC). retained placental fragments. Bleeding with VBAC merits special OBG Management: What uterotonic agents

38 OBG Management | January 2011 | Vol. 23 No. 1 obgmanagement.com Uterotonic agents and how to administer them Drug Dosage and route Considerations FIRST-LINE Oxytocin 10–40 U/L of saline or lactated Ringer The preferred drug—often the only one needed solution, infused continuously, OR 10 U IM SECOND-LINE (Cytotec, Prostaglandin 800–1,000 µg can be given rectally Often, the second-line drug that is given just E1) after oxytocin because it is easy to administer Methylergonovine (Methergine) 0.2 mg IM every 2–4 hr Contraindicated in hypertension Carboprost tromethamine (Hemabate) 0.25 mg IM every 15–90 minutes Avoid in patients who have asthma. Contra­ (maximum of 8 doses) indicated in hepatic, renal, and cardiac disease Dinoprostone (Prostin E2) 20 mg suppository can be given vagi- Avoid in hypotension nally or rectally every 2 hours

do you use besides oxytocin, and when? more blood she loses.” What do you mean by Dr. Brown: Oxytocin is the first-line agent that? for control of hemorrhage. I give a dosage Dr. Brown: Excessive bleeding leads to a of 10 to 40 U/L of normal saline or lactated loss of critical clotting factors that are made Ringer solution, infused continuously. Alter- in the liver. Once the clotting factors are de- natively, 10 U can be given intramuscularly pleted, the woman is at risk of (IM). Second-line drugs and their dosages or disseminated intravascular coagulation. are listed in the TABLE. This depletion potentiates the cycle of hem- orrhage. When that occurs, the hemorrhage A delay in the can be controlled only with transfusion of red 6 response to post- How do you assess the blood cells (RBCs) and replacement of clot- partum hemorrhage patient once PPH is identified? ting factors with fresh frozen plasma, plate- raises the risk of OBG Management: How do you assess the lets, and cryoprecipitate, along with prompt maternal morbidity patient after hemorrhage begins? correction of the process that is causing the and death Dr. Brown: We recheck the hemoglobin and bleeding. hematocrit levels and monitor vital signs for OBG Management: What blood products hypotension and tachycardia. We also begin do you administer to a patient with hemor- fluid resuscitation and type and cross-match rhage, and when? blood and blood products. Dr. Brown: The first line of defense for blood A delayed response to hemorrhage raises loss requiring transfusion is packed RBCs. the risk of maternal morbidity and death. Each unit of packed cells increases the he- We notify the anesthesia team when it matocrit by 3% and hemoglobin by 1 g/dL, seems likely that a surgical approach to the assuming bleeding is under control. After hemorrhage will be needed. And we notify that, consider: interventional radiology if the bleeding may • Platelets. Depending on the severity of respond to uterine artery embolization. the hemorrhage and the level of platelets once the coagulation status is checked, platelets can be given. A 50-mL unit can 7 Why is it important to raise the platelet count 5,000–10,000/mm3. replace blood products? Platelets should be considered if the OBG Management: You’ve been known count is below 50,000/mm3. to say, “The more blood a patient loses, the • Fresh frozen plasma should be given

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when ­essential clotting ­factors have Is your patient obese? She requires been depleted. extra attention 8 A woman who is obese has additional risk factors for hemor- When do you use the rhage. Obesity itself is associated with prolonged labor and large- intrauterine balloon? for-gestational-age infants, which, in turn, lead to poor contractility OBG Management: When is the intrauter- of the uterus and the potential for early postpartum hemorrhage. ine balloon a management option? Begin by ensuring that the obese or morbidly obese woman Dr. Brown: The balloon offers a way to -ac has appropriate intravenous access at the time of labor and receives early regional anesthesia (epidural). Also alert anesthesia to the risk tively manage hemorrhage and has been and assess baseline hemoglobin and hematocrit levels, including a associated with decreasing morbidity and type and screen. a reduced need for surgical intervention, An obese woman undergoing cesarean delivery has a height- including hysterectomy. It works through a ened risk of uterine laceration, difficult extraction of the , and tamponade effect. Once the balloon is in- uterine atony, especially if prolonged labor preceded the cesarean. flated with 300 to 500 mL of saline, it com- Second-stage arrest and prolonged pushing before the cesarean presses the uterine cavity until the uterus may make extraction of the infant difficult and lead to poor uterine develops predelivery tone. It can be left in contractility once the placenta is removed. All obese women, as well as other women at risk of postpartum place as long as 24 hours, need be. uterine atony, should have oxytocin infused before the placenta is Several balloons are available for use, removed, especially at the time of cesarean delivery. Expressing the with the Bakri balloon being the prototype. placenta at the time of cesarean delivery—as opposed to manual The balloon may cut off uterine blood flow as removal—is associated with lower blood loss and allows the uterus a mechanism of action. to begin contracting before the placenta is removed. Before the advent of manufactured bal- —Haywood L. Brown, MD loons, uterine tamponade was attempted using packing with gauze and a large-bore Foley catheter. to replace clotting factors. Fresh frozen plasma contains fibrinogen, antithrom- 9 bin III, factor V, and factor VIII. Each unit How do you proceed when of fresh frozen plasma increases the fi- surgery is necessary? brinogen level by 10 mg/dL. OBG Management: What surgical tech- • Cryoprecipitate contains fibrinogen, niques—aside from hysterectomy—may be factors VIII and XIII, and von Willebrand useful in stanching hemorrhage? factor. Each unit of cryoprecipitate in- Dr. Brown: The first-line surgical approach creases fibrinogen by 10 mg/dL. after vaginal delivery is uterine exploration • Factor VII can be given if the hemor- to evacuate uterine clots and check for re- rhage is still active, but it should only be tained placental fragments. This act alone given after fresh frozen plasma and cryo- may impart improved uterine contractility. If precipitate have been given to replace retained placental fragments are suspected, clotting factors. Factor VII is ineffective a gentle curettage of the uterine cavity, using without clotting factor replacement pri- a large curette, is appropriate. or to its administration. This When it is obvious that atony is the is associated with a high risk of thrombo- cause of the hemorrhage, and medical man- embolism. It is also expensive. agement has failed, these surgical steps are • Synthetic fibrinogen (RiaSTAP) is appropriate: available for use in the United States, but • Uterine artery ligation, using the it has FDA approval only for the treat- “O’Leary” technique, can be performed ment of acute bleeding in patients who bilaterally. The utero-ovarian vessels can have congenital fibrinogen deficiency. It also be ligated (but not cut!) may have potential for use during PPH • B-Lynch suture as a technique to

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­compress the uterus. This strategy uses ­intervention. If uterine rupture or an inva- outside, draping, absorbable suture to sive placental abnormality is suspected, we collapse the uterine cavity. It can be assemble the surgical team, including any quite successful when combined with potential consultant surgeon. We also no- the use of uterotonics. One study report- tify the best available surgeons so that they ed more than 1,000 B-Lynch procedures, can be ready to perform the necessary tech- with only seven failures.1 Hemostatic niques. In addition, we notify the OR and multiple-square compression is a surgi- surgical intensive care unit, in case they are cal technique that works according to a needed. similar principle OBG Management: How can obstetricians • Hypogastric artery ligation can be per- and obstetric units practice the response to formed by an experienced surgeon but is OB hemorrhage so that, when a hemorrhage rarely employed in severe hemorrhage occurs, they are at the top of their game? owing to the risk of complications and Dr. Brown: Obstetric units prepare by per- lengthy procedure time. forming drills and simulations. These drills OBG Management: When does hysterec- are now considered part of most units’ qual- tomy become an option? ity and safety programs. Dr. Brown: Hysterectomy is the last defense Because obstetric hemorrhage can oc- against morbidity and maternal death from cur on any unit at any time, the team must hemorrhage due to atony. be prepared to respond around the clock Clearly, when hysterectomy is per- promptly and effectively to reduce the risk of formed, sooner is better than later, especially morbidity and death. if uterine artery ligation and B-Lynch suture After emergent surgical management of do not appear to be controlling the hemor- obstetric hemorrhage, the team should be rhage and the patient is hemodynamically assembled again to discuss what occurred unstable. and how they performed or could have per- Any obstetrician If the patient is a young woman with low formed more effectively as a team. who performs parity, the uterus should be preserved, if at OBG Management: Should all obstetricians cesarean delivery all possible, unless the hemorrhage cannot who perform repeat cesarean delivery be should be capable be controlled and the woman’s life is jeopar- able to perform a cesarean hysterectomy in of performing dized. the event that uncontrollable hemorrhage is a cesarean When a uterine rupture has occurred, encountered? usually after a VBAC attempt, it may be pru- Dr. Brown: It is an absolute must that any hysterectomy dent to proceed to hysterectomy, especially clinician who allows VBAC be capable of if the uterus appears to be difficult to repair. performing peripartum cesarean hysterec- tomy and know the indications for hyster- ectomy, as we have discussed. In fact, any 10 When do you call for help? obstetrician who performs cesarean deliv- OBG Management: When do you call in ex- ery should be capable of performing a ce- tra help? sarean hysterectomy. Dr. Brown: As soon as hemorrhage occurs, the team should be assembled. It is critical 11 that anesthesia be notified immediately, What do you recommend in the event that the patient requires surgi- for practice? cal management. The blood bank should be OBG Management: How would you sum- notified that blood and blood products are marize the main points of management of likely to be required. postpartum hemorrhage? We designate a nursing leader to moni- Dr. Brown: I would suggest that the first step tor the patient and another to keep the is organizing the team (obstetricians, nurses, staff and unit on alert for potential surgical anesthesiologist), followed by:

42 OBG Management | January 2011 | Vol. 23 No. 1 obgmanagement.com • resuscitation of the mother with oxy- • monitoring of vital signs and urine gen and fluids through large-bore intra- output throughout resuscitation and venous access sites medical and surgical intervention • notification of the blood bank (with • elimination of the cause of bleeding typing and cross-matching) of the pos- as soon as possible by whatever means sible need for 4 to 6 U of blood for trans- necessary to prevent maternal death, be- fusion ginning with conservative medical man- • liberal assessment of laboratory agement and, if necessary, followed by values, especially coagulation status surgical intervention. (International Normalized Ratio [INR], prothrombin time, and partial throm- References 1. Allam MS, B-Lynch C. The B-Lynch and other uterine boplastin time) and blood counts (he- compression techniques. Int J Gynaecol Obstet. moglobin and hematocrit). Values may 2005;89(3):236–241. 2. Prendiville WJ, Elbourne D, McDonald S. Active versus be lower if there has been significant expectant management in the third stage of labour. Cochrane blood loss and aggressive fluid resuscita- Database Syst Rev. 2000;(3):CD000007. tion. Blood products such as fresh frozen plasma and cryoprecipitate are indi- ››Tell us about a challenging cated, in addition to packed RBCs, if the case of postpartum hemorrhage patient has or is developing a coagulopa- and how you managed it thy. Also give platelets if the count is low. Go to obgmanagement.com Once it becomes apparent that surgical and click on “Send us your letters.” intervention will be necessary, begin We’ll publish a selection of transfusion and replace clotting factors “pearls” in an upcoming issue! before beginning the procedure

››Read more on postpartum hemorrhage Visit our archive at obgmanagement.com

A ctivated factor VII proves to be  Y ou should add the Bakri balloon a lifesaver in postpartum hemorrhage to your treatments for OB bleeds Robert L. Barbieri, MD (February 2007) Robert L. Barbieri, MD (February 2009)

 Postpartum hemorrhage: Solutions  Planning reduces the risk of maternal to 2 intractable cases death. This tool helps. Michael L. Stitely, MD, Robert L. Barbieri, MD (August 2009) and Robert B. Gherman, MD (April 2007)  What you can do to optimize blood  Give a uterotonic routinely during conservation in ObGyn practice the third stage of labor Eric J. Bieber, MD; Linda Scott, RN; Robert L. Barbieri, MD (May 2007) Corinna Muller, DO; Nancy Nuss, RN; and Edie L. Derian, MD (February 2010)  Consider retroperitoneal packing for postpartum hemorrhage Maj. William R. Fulton, DO (July 2008)

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