34 OBG Management | January 2011 | Vol. 23 No. 1 ligation is one surgical option. ligation isonesurgical to stanchthebleeding,bilateraluterine artery hemorrhage. Whenmedicalmanagement fails Uterine atonyistheleadingcause ofpostpartum obgmanagement.com joe gorMaN fOr obg MaNaGeMeNt 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 postpartum period—specifically, maternal deaths, consider this: In our highly estimated blood 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 maternal death 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 pregnancies. chair of obstetrics and gynecology at Duke Another way to define PPH: a decline of Uterotonic 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 hysterectomy. 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 obgmanagement.com Vol. 23 No. 1 | January 2011 | OBG Management 35 Postpartum hemorrhage 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 oxytocin. 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 uterus 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 uterotonics such as a prostaglandin (rectally administered misopro- situation, the patient should be given addi- stol [800 mg] or intramuscular carboprost 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, cervix, or uterus) usually bring significant cardiovascular changes, such as hypoten- • retained fragments of placental tissue sion, tachycardia, restlessness, pallor, oliguria, and cardiovascular • uterine rupture 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 • uterine inversion. 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 36 OBG Management | January 2011 | Vol. 23 No. 1 obgmanagement.com Postpartum hemorrhage 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- placenta 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 fundal massage 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.