Postpartum Hemorrhage (PPH) 

 

 

Considerations

 

  • Emergency situation, little time to optimize

  • Physiological changes of pregnancy, Full stomach

  • Determine severity of hemorrhagic shock & resuscitate to goal end-points

  • Ddx for PPH:

    • Tone: Uterine atony (by far most common)

    • Tissue: Retained product, Placenta accreta

    • Trauma: Lower genital tract lacerations, Vascular injury

    • Thrombin: Coagulopathy

      • Aquired (ITP, PIH, DIC, TTP)

      • Prexisting (vWD, hemophilia)

    • Turn out: Uterine inversion

  • Avoid the lethal triad: hypothermia, acidosis, coagulopathy

  • Multidisciplinary management & need for extra help

  • Consider early intubation if patient deteriorating

 

 

Anesthetic Management

 

  • Simultaneous diagnosis & management

  • Get extra help, liaise with Obstetrics re: type of bleed

  • Resuscitate to goal end-points & declare massive transfusion if appropriate

  • Treat hypothermia, acidosis, coagulopathy

  • Send off frequent blood work including CBC, ABG, Lactate, INR/PTT/Fibrinogen, Ca

  • Uterotonics:

    • Oxytocin = 1st line: 5 IU IV push, then 20-40 IU in 250 mL of normal saline, infused IV at 500-1000 cc/hr

    • Hemabate: IM  0.25 mg, q15min PRN (max 8 doses).  Contraindications: asthma, pulmonary HTN, hypoxemia

    • Ergot: IM 0.2-0.25 mg, IV 0.125-0.25 mg.  Contraindications: HTN, pre-eclampsia, CAD

    • Misoprostol: PR 800-1000 mcg, Buccal/SL 400-600 mcg

  • Gather resources: rapid infusers, blood products/MTP, uterotonics/tocolytics, invasive monitoring, TXA, cell salvage, rFVIIa

  • Utilize blood conservation: Cell saver, Tranexamic acid (TXA), possible rFVIIa

  • Consider surgical control of bleeding: Bilateral uterine massage, B lynch suture, packing, aortic cross clamp, uterine artery ligation, embolization (IR), hysterectomy

  • If intubating:

    • Pre-induction arterial line if possible

    • Anti-acid prophylaxis

    • Titrated induction & accept aspiration risk

    • Ketamine as induction medication

 

PPH Management Guidelines

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