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November 15 2001 • Volume 36 • Number 22

Obstetrics

Postpartum blood loss
Hemorrhage Management: Be Practical, Prepared

Sharon Worcester
Tallahassee Bureau


ASHEVILLE, N.C. — The risk of death from postpartum hemorrhage can be minimized by taking a practical approach to management and being prepared for every eventuality, including hysterectomy, Dr. James E. Ferguson II said at the annual Southern Obstetric and Gynecologic Seminar.

“Remember, surgery can be your friend,” he said, noting that several steps can be taken first to determine if a nonsurgical approach will suffice.

Many of these steps need to be taken simultaneously, said Dr. Ferguson, professor and director of the division of maternal-fetal medicine at the University of Virginia, Charlottesville.

There are numerous causes of postpartum hemorrhage. With uterine bleeding, atony is responsible for at least 70% of cases.

Other risk factors for uterine bleeding include infection, use of uterine relaxing agents, prolonged use of oxytocin, multiparity, and history of prior postpartum hemorrhage.

Uterine rupture, another cause of uterine hemorrhage, is responsible for fewer than 1% of cases. That number is expected to rise due to the increasing number of women with uterine scarring from prior cesarean sections. Rupture is more likely following breech extraction, obstructed labor, abnormal fetal presentation, and midforceps delivery.

Extrauterine causes of bleeding include placental implantation problems, lower genital tract lacerations, and vulvar or vaginal hematomas.

Retroperitoneal hematomas can also cause bleeding. These are rare, but they are important to keep in mind because patients often show no symptoms before experiencing hypotension and shock, Dr. Ferguson noted.

Retained placental tissue, abnormal implantation, and coagulopathies are other causes of hemorrhage.

The initial steps should be to determine the cause of bleeding and initiate medical stabilization. The physician should evaluate for the most common and likely causes, such as atony and lacerations, and work through to the least common, including uterine rupture or inversion.

Slow, unrelenting bleeding is usually associated with lacerations or retained placental fragments. A large gush of blood and clots often signifies uterine atony, he said.

Inspect the cervix and the vaginal wall, and use bimanual compression to determine if the uterus is firm.

If the fundus is round and softball sized, atony is probably not the cause. If it is soft, above the umbilicus, and easily indented, atony probably is the cause.

If the fundus cannot be felt, the uterus may have inverted, in which case the placenta should not be removed.

If uterine inversion is recognized early, use the Johnson maneuver, which involves placing the fingers in the center of the inverted uterus and elevating it, along with the placenta, to lift it back into place.

If uterine inversion is recognized later, a uterine-relaxing agent such as nitroglycerine may be required. Once the uterus is replaced, administer oxytocic agents and check the patient frequently for the next 4-6 hours because of the increased risk for another uterine inversion, he advised.

Begin with medical stabilization, which entails intravenous access, a couple large-bore IVs, 3 mL of crystalloid for every estimated mL of blood loss, and uterotonic agents such as oxytocin or misoprostol if atony is suspected.

If there is concern about coagulation status and hematocrit, baseline studies will be useful.

Also, if the hemorrhage appears to be anything more than transient, a Foley catheter should be placed, oxygen administered, and appropriate blood products obtained.

Getting plenty of extra help and preparing for the possibility of surgery are other important steps.

If there is persistent uterine atony or if the source of hemorrhage cannot be determined, opt for surgery. General anesthesia is required, but avoid agents that relax the uterus, Dr. Ferguson advised at the meeting.

Reinspect the birth canal for lacerations, uterine rupture, and retained placental fragments. If none are found, there are several possible surgical procedures that may be helpful.

Uterine artery ligation is simple and straightforward, but it works in only about 50% of patients with uterine atony. The B-Lynch suture, a uterus-sparing technique that can stop bleeding by compressing the uterus, can be tremendously beneficial and may prevent the need for hysterectomy (Obstet. Gynecol. 95[6 Pt. 2]:1020-22, 2000).

As a last resort, particularly in younger women having their first child, perform a hysterectomy. Hysterectomy may be considered earlier for those women who don't desire fertility, he said.

Most importantly, remain calm.

“This is a problem we can deal with,” he said.



Copyright © 2001 by International Medical News Group. Click for restrictions.