Managing Obstetric Hemorrhage: Interventions and Guidelines

• Obstetric Hemorrhage as a Leading Cause of Maternal Mortality:
  • Obstetric hemorrhage remains a leading cause of maternal mortality and morbidity worldwide, with most deaths occurring in the postpartum period.
  • Interventions at patient, provider, and system level are imperative to provide optimal patient care and reduce maternal morbidity and mortality.
• Definition of Postpartum Hemorrhage (PPH):
  • PPH is excessive and life-threatening bleeding after 20 weeks of gestation, occurring at the time of delivery of the fetus or placenta.
  • Primary PPH is excessive blood loss within 24 hours of delivery, while secondary PPH occurs between 24 hours and 12 weeks after delivery.
• Challenges in Recognizing Blood Loss:
  • Recognition of blood loss in obstetric hemorrhage can be challenging due to difficulty in determining the exact amount of blood loss.
  • Clinicians tend to underestimate blood loss, making it problematic to define excessive bleeding.
• Incidence and Mortality:
  • Maternal mortality has decreased in developed countries, but racial and ethnic gaps exist in the United States.
  • Worldwide, obstetric hemorrhage is the leading cause of maternal mortality, causing an estimated 127,000 maternal deaths annually.
• Pathophysiology:
  • The uterus contracts to provide hemostasis after delivery, but uterine atony can result in excessive bleeding.
  • Increased blood flow to the uterus and placenta contributes to excessive bleeding in PPH.
• Presentation of PPH:
  • PPH often manifests as brisk and excessive flow of blood from the uterus.
  • Maternal hemodynamics may be unaltered initially, but signs of hypovolemic shock can appear if left untreated.
• Causes and Risk Factors:
  • A detailed antenatal history is important in determining possible causes of PPH.
  • Risk factors for PPH include previous episodes of PPH, multiparity, multiple fetuses, and other predisposing factors.
• Risk Assessment and Management:
  • Protocols for managing and treating obstetric hemorrhage should be in place at all institutions.
  • Risk factors may change during the labor process, so constant assessment is essential to identify patients at risk.
• Uterine Atony:
  • Uterine atony is a major cause of postpartum hemorrhage (PPH), occurring approximately in 1 in 20 deliveries.
  • Factors leading to uterine atony include overdistention of the uterus, retained placenta, chorioamnionitis, uterine structural abnormalities, and muscle fatigue.
• Lacerations:
  • Lacerations of the lower genital tract, resulting from prolonged or tumultuous labor, instrumentation, or manipulations of the fetus, can lead to PPH.
  • Careful examination is necessary to detect lacerations, which can cause excessive vaginal bleeding.
• Retained Placenta:
  • Retained placenta can lead to severe and life-threatening hemorrhage, immediate or delayed.
  • Retained placenta is more likely to occur with a preterm gestation of less than 24 weeks.
• Placental Abnormalities:
  • Placental abnormalities are associated with retained placenta and failure of complete separation of the placenta from the uterus.
  • Examination of the placenta for missing fragments is crucial to identify retained placental tissue.
• Uterine Rupture and Hemostasis:
  • Uterine rupture, more common in patients with prior cesarean incisions, can cause acute abdominal pain and hemodynamic instability.
  • Disseminated intravascular coagulation (DIC) should be considered if there are coagulopathy-related issues.
• Diagnostic Studies:
  • Bedside ultrasonography and angiography can help in diagnosis and evaluation of PPH.
  • Laboratory studies including complete blood count, coagulation studies, and hemoglobin concentration are essential for evaluation.
• Prevention:
  • Controversy exists concerning active versus expectant management of the third stage of labor to decrease bleeding complications.
  • Vigorous manual external massage, administration of oxytocin, and gentle traction on the umbilical cord are part of active management of the third stage of labor.
• Management Protocols and Guidelines:
  • Rapid and aggressive resuscitation with fluids and blood products is crucial in managing PPH.
  • Quantification of blood loss, simulation, and detailed physical examination are recommended for prompt diagnosis and management.
• Initial Management of Postpartum Hemorrhage:
  • Administer oxygen as a routine measure and establish large-caliber IV lines for immediate access.
  • Institute aggressive volume resuscitation with normal saline or lactated Ringer’s solution.
• Therapeutic Response to Initial Fluid Resuscitation:
  • Initiate transfusion therapy in the setting of ongoing blood loss, considering the use of tranexamic acid.
  • Prepare for transfusion in cases of ongoing blood loss of 1500 mL or more; use packed red blood cells and fresh frozen plasma in a 1:1 ratio.
• Blood Product Replacement:
  • Give tranexamic acid when there is a need for massive transfusion and consider using rFVIIa in cases of refractory PPH.
  • Administer specific blood products based on the extent of bleeding and coagulation abnormalities.