{"id":226,"date":"2020-08-13T16:33:54","date_gmt":"2020-08-13T16:33:54","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=226"},"modified":"2021-05-09T20:42:29","modified_gmt":"2021-05-09T20:42:29","slug":"27-postpartum-hemorrhage","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/overview\/27-postpartum-hemorrhage\/","title":{"rendered":"27.Postpartum Hemorrhage"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/rr3tsKb7Emw\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration = 7:09<\/p>\n<input type='hidden' bg_collapse_expand='69e9b580f1f941094339518' value='69e9b580f1f941094339518'><input type='hidden' id='bg-show-more-text-69e9b580f1f941094339518' value='Update to PP Hemorrhage Definition and Treatment'><input type='hidden' id='bg-show-less-text-69e9b580f1f941094339518' value='Close'><button id='bg-showmore-action-69e9b580f1f941094339518' class='bg-showmore-plg-button bg-red-button  '   style=\" color:#faf7f7;\">Update to PP Hemorrhage Definition and Treatment<\/button><div id='bg-showmore-hidden-69e9b580f1f941094339518' ><\/p>\n<p>Postpartum hemorrhage is currently defined as a cumulative blood loss of 1000 cc within 24 hours of delivery for all delivery types (as opposed to the prior definition of 500 cc for vaginal delivery and 1000 cc for Cesarean delivery). It can also be defined as blood loss accompanied by signs and symptoms of hypovolemia within 24 hours of delivery.<\/p>\n<p>Tranexamic acid (TXA) is now frequently used for treatment of postpartum hemorrhage. TXA is an antifibrinolytic agent that can be given intravenously or orally. It is used worldwide and its use has led to a significant reduction in maternal mortality from obstetric hemorrhage.<\/p>\n<p style=\"text-align: right\">&#8211; Dr. Smith<\/p>\n<p><\/div>\n<p>&nbsp;<\/p>\n<input type='hidden' bg_collapse_expand='69e9b580f22258018755817' value='69e9b580f22258018755817'><input type='hidden' id='bg-show-more-text-69e9b580f22258018755817' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b580f22258018755817' value='Hide Transcript'><button id='bg-showmore-action-69e9b580f22258018755817' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b580f22258018755817' ><\/p>\n<p>00:00<br \/>\nAPGO educational topic number 27<br \/>\n00:02<br \/>\npostpartum hemorrhage hello I am dr. PP<br \/>\n00:06<br \/>\nHemmings and I will be your guide for<br \/>\n00:07<br \/>\nour journey today into the land of<br \/>\n00:09<br \/>\npostpartum hemorrhage postpartum<br \/>\n00:11<br \/>\nhemorrhage is an obstetric emergency it<br \/>\n00:13<br \/>\nis a major often preventable cause of<br \/>\n00:16<br \/>\nmaternal morbidity and mortality it is<br \/>\n00:18<br \/>\none of the top three causes of maternal<br \/>\n00:20<br \/>\nmortality in both high and low income<br \/>\n00:22<br \/>\ncountries the absolute risk of death<br \/>\n00:25<br \/>\nfrom postpartum hemorrhage approach is<br \/>\n00:26<br \/>\none in a hundred in low-income countries<br \/>\n00:28<br \/>\nit is estimated that there is one<br \/>\n00:31<br \/>\nmaternal death every four minutes<br \/>\n00:32<br \/>\nsecondary to postpartum hemorrhage the<br \/>\n00:35<br \/>\nobjectives of this video are to list the<br \/>\n00:37<br \/>\nrisk factors for postpartum hemorrhage<br \/>\n00:38<br \/>\nconstruct a differential diagnosis for<br \/>\n00:41<br \/>\nimmediate and delayed postpartum<br \/>\n00:42<br \/>\nhemorrhage and finally develop an<br \/>\n00:45<br \/>\nevaluation and management plan for the<br \/>\n00:46<br \/>\npatient with postpartum hemorrhage<br \/>\n00:48<br \/>\nincluding consideration of various<br \/>\n00:49<br \/>\nresource settings let&#8217;s start with some<br \/>\n00:52<br \/>\nbasic definitions postpartum hemorrhage<br \/>\n00:54<br \/>\nis generally defined as blood loss<br \/>\n00:55<br \/>\ngreater than 500 CCS after a vaginal<br \/>\n00:58<br \/>\ndelivery are greater than 1,000 CCS<br \/>\n01:00<br \/>\nfollowing a cesarean delivery primary<br \/>\n01:03<br \/>\npostpartum hemorrhage occurs within the<br \/>\n01:04<br \/>\nfirst 24 hours after delivery and is<br \/>\n01:06<br \/>\ncaused by uterine atony<br \/>\n01:08<br \/>\n80% of cases other causes of primary<br \/>\n01:11<br \/>\npostpartum hemorrhage include retained<br \/>\n01:12<br \/>\nplacenta especially placenta accreta<br \/>\n01:15<br \/>\ndefects and coagulation uterine<br \/>\n01:17<br \/>\ninversion and lacerations secondary<br \/>\n01:19<br \/>\npostpartum hemorrhage occurs between 24<br \/>\n01:21<br \/>\nhours and 6 to 12 weeks postpartum<br \/>\n01:24<br \/>\ncauses include retain products of<br \/>\n01:26<br \/>\nconception infection inherited<br \/>\n01:28<br \/>\ncoagulation defects and sub involution<br \/>\n01:30<br \/>\nof the placental site let&#8217;s begin by<br \/>\n01:33<br \/>\ndiscussing risk factors for uterine<br \/>\n01:34<br \/>\natony<br \/>\n01:35<br \/>\nhere is our uterus and the baby has just<br \/>\n01:38<br \/>\ndelivered ideally the uterus will clamp<br \/>\n01:40<br \/>\ndown and you will feel good tone which<br \/>\n01:42<br \/>\nfeels like a rock of hard muscle when<br \/>\n01:44<br \/>\nthe uterus does not clamp down we call<br \/>\n01:45<br \/>\nthis uterine atony<br \/>\n01:46<br \/>\nwhat can cause acne anything that over<br \/>\n01:49<br \/>\ndescends the uterus so polyhydramnios<br \/>\n01:51<br \/>\nare multiple to stations if a patient<br \/>\n01:56<br \/>\ndevelops chorioamnionitis during labor<br \/>\n01:58<br \/>\nthen the muscle will not work as well<br \/>\n02:00<br \/>\nsymbolized here by the little green<br \/>\n02:01<br \/>\nbacteria if she had a prolonged labor<br \/>\n02:04<br \/>\nand\/or an augmented labor with oxytocin<br \/>\n02:06<br \/>\nso here is her arm with the IV that has<br \/>\n02:09<br \/>\n\u00e9xito sand running into it for a long<br \/>\n02:11<br \/>\ntime on the opposite extreme of<br \/>\n02:13<br \/>\nat a fast labor than the uterus can<br \/>\n02:14<br \/>\nsometimes react by acting surprised as<br \/>\n02:16<br \/>\nalready all done and does not clamp down<br \/>\n02:18<br \/>\nlastly a history of a postpartum<br \/>\n02:20<br \/>\nhemorrhage or Asian or Hispanic<br \/>\n02:22<br \/>\nethnicity are also risk factors are<br \/>\n02:24<br \/>\nthere actions that we can take to try to<br \/>\n02:26<br \/>\nprevent uterine atony active management<br \/>\n02:29<br \/>\nof the third stage of labor which is the<br \/>\n02:31<br \/>\ntime between the delivery of the fetus<br \/>\n02:32<br \/>\nand the placenta can reduce the<br \/>\n02:34<br \/>\nincidence of postpartum hemorrhage<br \/>\n02:36<br \/>\nactive management includes fundal<br \/>\n02:38<br \/>\nmassage gentle cord traction and IV or<br \/>\n02:41<br \/>\nIM oxytocin let&#8217;s move now to evaluation<br \/>\n02:45<br \/>\nand management we&#8217;ve discussed risk<br \/>\n02:46<br \/>\nfactors in preparation but it&#8217;s<br \/>\n02:48<br \/>\nimportant to note that postpartum<br \/>\n02:49<br \/>\nhemorrhage can often occur without any<br \/>\n02:51<br \/>\nwarning as well general measures upon<br \/>\n02:53<br \/>\nrecognizing excessive blood loss include<br \/>\n02:55<br \/>\nassessing the patient&#8217;s overall status<br \/>\n02:57<br \/>\nincluding vital signs make sure that you<br \/>\n03:00<br \/>\nhave adequate nursing and physician<br \/>\n03:01<br \/>\nsupport and think right away about<br \/>\n03:03<br \/>\nadequacy of IV access and blood<br \/>\n03:05<br \/>\navailability start the evaluation with a<br \/>\n03:07<br \/>\nbimanual examination if there is uterine<br \/>\n03:09<br \/>\natony the uterus will feel boggy and<br \/>\n03:11<br \/>\nsoft at the time of bimanual exam you<br \/>\n03:13<br \/>\ncan assess for retained placental<br \/>\n03:15<br \/>\nfragments and you can assess the uterine<br \/>\n03:17<br \/>\nwall for rupture a careful inspection<br \/>\n03:19<br \/>\nshould also be performed of the perineum<br \/>\n03:21<br \/>\nvulva vagina and cervix the next step<br \/>\n03:24<br \/>\nwill be the targeted intervention<br \/>\n03:26<br \/>\ndepending on the etiology we will start<br \/>\n03:29<br \/>\nby discussing the management of uterine<br \/>\n03:30<br \/>\natony in more detail here is the big<br \/>\n03:33<br \/>\nboggy atonic uterus we will start by<br \/>\n03:36<br \/>\ndraining the bladder it&#8217;s difficult for<br \/>\n03:38<br \/>\na uterus to clamp down if there&#8217;s a full<br \/>\n03:39<br \/>\nbladder next we&#8217;ll move on to medical<br \/>\n03:41<br \/>\nmanagement there are multiple uterotonic<br \/>\n03:44<br \/>\nmedications that can be used<br \/>\n03:45<br \/>\nindividually or combined to contract the<br \/>\n03:47<br \/>\nuterus methyl gerg\u00f5 novan maleate<br \/>\n03:50<br \/>\ntradename methergine is a potent<br \/>\n03:52<br \/>\nuterotonic and is given intramuscularly<br \/>\n03:54<br \/>\nthis should not be given to women with<br \/>\n03:57<br \/>\nhypertension 15 methyl prostaglandin F 2<br \/>\n04:00<br \/>\nalpha tradename Hema bate also<br \/>\n04:02<br \/>\nstimulates the myometrium muscles to<br \/>\n04:04<br \/>\ncontract and is given intramuscularly<br \/>\n04:06<br \/>\nit should not be given to women with<br \/>\n04:08<br \/>\nasthma for it can theoretically<br \/>\n04:09<br \/>\nconstrict the bronchioles oxytocin<br \/>\n04:12<br \/>\nshould also be given intravenously and<br \/>\n04:14<br \/>\nmisoprostol can be administered buccal E<br \/>\n04:16<br \/>\nor rectally in cases where medical<br \/>\n04:19<br \/>\nmanagement is not sufficient for<br \/>\n04:20<br \/>\nhemostasis the next step is uterine<br \/>\n04:22<br \/>\ntamponade this is achieved by uterine<br \/>\n04:25<br \/>\npacking or by inflating<br \/>\n04:27<br \/>\nBakri balloon within the uterine cavity<br \/>\n04:29<br \/>\nboth of these methods work by applying<br \/>\n04:31<br \/>\npressure internally to staunch the flow<br \/>\n04:33<br \/>\nof blood if these measures do not<br \/>\n04:36<br \/>\nimprove the bleeding then the next step<br \/>\n04:37<br \/>\nwill be surgical management one of the<br \/>\n04:40<br \/>\nfirst steps can be a b-lynch suture a<br \/>\n04:42<br \/>\nstitch is placed on the anterior surface<br \/>\n04:44<br \/>\nof the uterus and then travels<br \/>\n04:46<br \/>\nposteriorly on the posterior aspect of<br \/>\n04:49<br \/>\nthe uterus a stitch is placed and in the<br \/>\n04:51<br \/>\nsuture travels anteriorly and the suture<br \/>\n04:54<br \/>\nis tied this manually compresses the<br \/>\n04:57<br \/>\nuterus in addition a uterine artery<br \/>\n05:00<br \/>\nligation can be performed for the<br \/>\n05:02<br \/>\nuterine arteries insert here on the<br \/>\n05:05<br \/>\nuterus at the level of the internal loss<br \/>\n05:08<br \/>\nin interventional radiology can also be<br \/>\n05:11<br \/>\nused to assist with uterine artery<br \/>\n05:13<br \/>\nembolization the patient has to be<br \/>\n05:15<br \/>\nstable however in order to be able to<br \/>\n05:16<br \/>\ntransport her to the interventional<br \/>\n05:18<br \/>\nradiology location if all of these<br \/>\n05:20<br \/>\nmeasures fail hysterectomy is the<br \/>\n05:22<br \/>\ndefinitive step in managing postpartum<br \/>\n05:24<br \/>\nhemorrhage it is important to note some<br \/>\n05:27<br \/>\nkey concepts here about blood<br \/>\n05:28<br \/>\nreplacement therapy when a patient is<br \/>\n05:30<br \/>\nexperiencing a severe postpartum<br \/>\n05:31<br \/>\nhemorrhage the idea now is to intervene<br \/>\n05:33<br \/>\nearlier to prevent coagulopathy such as<br \/>\n05:36<br \/>\ndi C from developing packed red blood<br \/>\n05:38<br \/>\ncells are the mainstay of blood<br \/>\n05:40<br \/>\nreplacement therapy when there is a<br \/>\n05:42<br \/>\nsevere ongoing hemorrhage of four or<br \/>\n05:45<br \/>\nmore units of packed red blood cells<br \/>\n05:46<br \/>\nneeded over one hour or ten or more<br \/>\n05:48<br \/>\nunits over 12 to 24 hours the current<br \/>\n05:51<br \/>\nrecommendation is to transfuse in a 1 to<br \/>\n05:53<br \/>\n1 to 1 ratio which is one unit of packed<br \/>\n05:55<br \/>\nred blood cells to one unit of fresh<br \/>\n05:57<br \/>\nfrozen plasma to one unit of platelets<br \/>\n05:59<br \/>\nthese interventions thus far have<br \/>\n06:02<br \/>\ndescribed options in high resource<br \/>\n06:03<br \/>\nsettings what are the options for low<br \/>\n06:05<br \/>\nresource settings<br \/>\n06:06<br \/>\nremember that 99% of maternal deaths<br \/>\n06:09<br \/>\noccur in developing countries and<br \/>\n06:11<br \/>\npostpartum hemorrhage accounts for one<br \/>\n06:13<br \/>\nhalf of all postpartum maternal deaths<br \/>\n06:15<br \/>\nactive management of the third stage of<br \/>\n06:17<br \/>\nlabor is the gold standard<br \/>\n06:18<br \/>\nrecommendation at this time the same<br \/>\n06:20<br \/>\nthree measures that we discussed earlier<br \/>\n06:22<br \/>\nin this video<br \/>\n06:23<br \/>\nIV or I am oxytocin gentle cord traction<br \/>\n06:26<br \/>\nand fundal massage oxytocin is the<br \/>\n06:29<br \/>\nrecommended uterotonic however it is not<br \/>\n06:31<br \/>\nreadily available in some settings with<br \/>\n06:33<br \/>\nthe highest risk for mortality and<br \/>\n06:34<br \/>\nmorbidity from postpartum hemorrhage<br \/>\n06:36<br \/>\ncurrent investigations are looking into<br \/>\n06:38<br \/>\nwhether misoprostol could prove to be a<br \/>\n06:40<br \/>\nviable substitute<br \/>\n06:41<br \/>\nsettings where oxytocin is not available<br \/>\n06:43<br \/>\nthis concludes the aapko video on<br \/>\n06:46<br \/>\npostpartum hemorrhage<br \/>\n06:47<br \/>\nwe reviewed key concepts about<br \/>\n06:48<br \/>\nideologies risk factors and management<br \/>\n06:50<br \/>\nfor postpartum hemorrhage in low and<br \/>\n06:52<br \/>\nhigh resource settings<\/p>\n<p><\/div>\n<hr>\n","protected":false},"excerpt":{"rendered":"<p>Duration = 7:09 &nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":46,"menu_order":27,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-226","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/226","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=226"}],"version-history":[{"count":1,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/226\/revisions"}],"predecessor-version":[{"id":2833,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/226\/revisions\/2833"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/46"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=226"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}