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  VOL. 108, NO. 4, OCTOBER 2006 OBSTETRICS & GYNECOLOGY 1039  ACOG PRACTICE BULLETIN   C LINICAL  M  ANAGEMENT  G UIDELINES FOR O BSTETRICIAN –G  YNECOLOGISTS N UMBER  76, O CTOBER  2006 (Replaces Committee Opinion Number 266, January 2002) This Practice Bulletin wasdeveloped by the ACOG Com-mittee on Practice Bulletins—Obstetrics with the assistanceof William N. P. Herbert,MD,and Carolyn M. Zelop,MD.The information is designed toaid practitioners in makingdecisions about appropriateobstetric and gynecologic care.These guidelines shouldnot beconstrued as dictating an exclu-sive course of treatment or pro-cedure. Variations in practicemay be warranted based on theneeds of the individual patient,resources,and limitationsunique to the institution or typeof practice. Postpartum Hemorrhage Severe bleeding is the single most significant cause of maternal death world-wide. More than half of all maternal deaths occur within 24 hours of delivery,most commonly from excessive bleeding. It is estimated that,worldwide,140,000 women die of postpartum hemorrhage each year—one every 4 minutes(1). In addition to death,serious morbidity may follow postpartum hemorrhage.Sequelae include adult respiratory distress syndrome,coagulopathy,shock,lossof fertility,and pituitary necrosis (Sheehan syndrome). Although many risk factors have been associated with postpartum hemor-rhage,it often occurs without warning. All obstetric units and practitionersmust have the facilities,personnel,and equipment in place to manage thisemergency properly. Clinical drills to enhance the management of maternalhemorrhage have been recommended by the Joint Commission on Accreditationof Healthcare Organizations (2). The purpose of this bulletin is to review theetiology,evaluation,and management of postpartum hemorrhage. Background The physiologic changes over the course of pregnancy,including a plasma vol-ume increase of approximately 40% and a red cell mass increase of approxi-mately 25%,occur in anticipation of the blood loss that will occur at delivery(3). There is no single,satisfactory definition of postpartum hemorrhage. Anestimated blood loss in excess of 500 mL following a vaginal birth or a loss of greater than 1,000 mL following cesarean birth often has been used for thediagnosis,but the average volume of blood lost at delivery can approach theseamounts (4,5). Estimates of blood loss at delivery are notoriously inaccurate,with significant underreporting being the rule. Limited instruction on estimat-ing blood loss has been shown to improve the accuracy of such estimates (6).Also,a decline in hematocrit levels of 10% has been used to define postpartumhemorrhage,but determinations of hemoglobin or hematocrit concentrationsmay not reflect the current hematologic status (7). Hypotension,dizziness,pal-  1040  ACOG Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY  lor,and oliguria do not occur until blood loss is substan-tial—10% or more of total blood volume (8).Postpartum hemorrhage generally is classified asprimary or secondary,with primary hemorrhage occur-ring within the first 24 hours of delivery and secondaryhemorrhage occurring between 24 hours and 6–12 weekspostpartum. Primary postpartum hemorrhage,whichoccurs in 4–6% of pregnancies,is caused by uterineatony in 80% or more of cases (7). Other etiologies areshown in the box “Etiology of Postpartum Hemorrhage,”with risk factors for excessive bleeding listed in the box“Risk Factors for Postpartum Hemorrhage.”If excessive blood loss is ongoing,concurrent evalu-ation and management are necessary. A number of gen-eral medical supportive measures may be instituted,including provision of ample intravenous access; crystal-loid infusion; blood bank notification that blood productsmay be necessary; prompt communication with anesthe-siology,nursing,and obstetrician–gynecologists; andblood collection for baseline laboratory determinations.When treating postpartum hemorrhage,it is neces-sary to balance the use of conservative management tech-niques with the need to control the bleeding and achievehemostasis. A multidisciplinary approach often isrequired. In the decision-making process,less-invasivemethods should be tried initially if possible,but if unsuc-cessful,preservation of life may require hysterectomy.Management of postpartum hemorrhage may vary great-ly among patients,depending on etiology of the bleeding,available treatment options,and a patient’s desire forfuture fertility. At times,immediate surgery is requiredbecause time spent using other treatment methods wouldbe dangerous for the patient. There are few randomizedcontrolled studies relevant to the management of post-partum hemorrhage,so management decisions usuallyare made based on clinical judgment. Evaluation and ManagementConsiderations In an effort to prevent uterine atony and associated bleed-ing,it is routine to administer oxytocin soon after deliv-ery. This may be given at the time of delivery of theanterior shoulder of the fetus,or more commonly in theUnited States,following delivery of the placenta. It may be helpful to post protocols for hemorrhagemanagement in delivery rooms or operating suites. A sam-ple poster from the New York City Department of Healthand Mental Hygiene is available at html/doh/downloads/pdf/ms/ms-hemorr-poster.pdf. Clinical Considerations andRecommendations What should be considered in the initial eval-uation of a patient with excessive bleeding in the immediate puerperium? Because the single most common cause of hemorrhage isuterine atony,the bladder should be emptied and abimanual pelvic examination should be performed. Thefinding of the characteristic soft,poorly contracted(“boggy”) uterus suggests atony as a causative factor.Compression or massage of the uterine corpus can dimin-ish bleeding,expel blood and clots,and allow time forother measures to be implemented. If bleeding persists,other etiologies besides atonymust be considered. Even if atony is present,there maybe other contributing factors. Lacerations should be ruledout by careful visual assessment of the lower genitaltract. Proper patient positioning,adequate operativeassistance,good lighting,appropriate instrumentation(eg,Simpson or Heaney retractors),and adequate anes-thesia are necessary for the identification and properrepair of lacerations. Satisfactory repair may requiretransfer to a well-equipped operating room. Genital tract hematomas also can lead to significantblood loss. Progressive enlargement of the mass indicatesa need for incision and drainage. Often a single bleedingsource is not identified when a hematoma is incised.Draining the blood within the hematoma (sometimes Etiology of Postpartum Hemorrhage Primary Uterine atony Retained placenta—especially placenta accretaDefects in coagulationUterine inversionSecondary Subinvolution of placental siteRetained products of conceptionInfection Inherited coagulation defects Adapted from Cunningham FG, Leveno KJ, Bloom SL, Hauth JC,Gilstrap L 3rd, Wenstrom KD. Obstetric hemorrhage. In: Williamsobstetrics. 22nd ed. New York (NY): McGraw-Hill; 2005. p. 809–54and Alexander J, Thomas P, Sanghera J. Treatments for secondary postpartum haemorrhage. The Cochrane Database of SystematicReviews 2002, Issue 1. Art. No.: CD002867. DOI: 10.1002/14651858.CD002867. ▲       VOL. 108, NO. 4, OCTOBER 2006  ACOG Practice Bulletin Postpartum Hemorrhage  1041 placing a drain in situ),suturing the incision,and if appropriate,packing the vagina are measures usuallysuccessful in achieving hemostasis. Interventional radi-ology is another option for management of a hematoma.Genital tract hematomas may not be recognized untilhours after the delivery,and they sometimes occur in theabsence of vaginal or perineal lacerations. The mainsymptoms are pelvic or rectal pressure and pain. The possibility that additional products of concep-tion remain within the uterine cavity should be consid-ered. Ultrasonography can help diagnose a retainedplacenta. Retained placental tissue is unlikely whenultrasonography reveals a normal endometrial stripe.Although ultrasonographic images of retained placentaltissue are inconsistent,detection of an echogenic mass inthe uterus is more conclusive. Ultrasound evaluation forretained tissue should be performed before uterineinstrumentation is undertaken (9). Spontaneous expul-sion of the placenta,apparent structural integrity oninspection,and the lack of a history of previous uterinesurgery (suggesting an increased risk of abnormal pla-centation) make a diagnosis of retained products of theplacenta less likely,but a curettage may identify a suc-centuriate lobe of the placenta or additional placental tis-sue. When a retained placenta is identified,a large,bluntinstrument,such as a banjo curette or ring forceps,guid-ed by ultrasonography,makes removal of the retainedtissue easier and reduces the risk of perforation. Less commonly,postpartum hemorrhage may becaused by coagulopathy. Clotting abnormalities shouldbe suspected on the basis of patient or family history Risk Factors for Postpartum Hemorrhage Prolonged laborAugmented laborRapid laborHistory of postpartum hemorrhageEpisiotomy, especially mediolateralPreeclampsiaOverdistended uterus (macrosomia, twins, hydramnios)Operative delivery Asian or Hispanic ethnicity Chorioamnionitis Data from Stones RW, Paterson CM, Saunders NJ. Risk factors formajor obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol1993;48:15–8 and Combs CA, Murphy EL, Laros RK. Factors associ-ated with hemorrhage in cesarean deliveries. Obstet Gynecol1991;77:77–82. or clinical circumstances. Hemolysis,elevated liverenzymes,and low platelet count (HELLP) syndrome,abruptio placentae,prolonged intrauterine fetal demise,sepsis,and amniotic fluid embolism are associated withclotting abnormalities. Significant hemorrhage from anycause can lead to consumption of clotting factors.Observation of the clotting status of blood recently lostcan provide important information. When a coagulopa-thy is suspected,appropriate testing should be ordered,with blood products infused as indicated. In some situa-tions,the coagulopathy may be caused or perpetuated bythe hemorrhage. In such cases,simultaneous surgery andblood product replacement may be necessary.Baseline studies should be ordered when excessiveblood loss is suspected and should be repeated periodi-cally as clinical circumstances warrant. Cliniciansshould remember that the results of some studies may bemisleading because equilibration may not have occurred.In addition,response to hemorrhage may be requiredbefore laboratory results are known. Baseline studiesinclude a complete blood count with platelets,a pro-thrombin time,an activated partial thromboplastin time,fibrinogen,and a type and cross order. The blood bank should be notified that transfusion may be necessary.The clot observation test provides a simple measureof fibrinogen (10). A volume of 5 mL of the patient’sblood is placed into a clean,red-topped tube andobserved frequently. Normally,blood will clot within8–10 minutes and will remain intact. If the fibrinogenconcentration is low,generally less than 150 mg/dL,theblood in the tube will not clot,or if it does,it will under-go partial or complete dissolution in 30–60 minutes. What is the appropriate medical management approach for excessive postpartum bleeding? Ongoing blood loss in the setting of decreased uterinetone requires the administration of additional uterotonicsas the first-line treatment for hemorrhage (Table 1).Some practitioners prefer direct injection of methyler-gonovine maleate and 15-methyl prostaglandin (PG) F 2 α into the uterine corpus. Human recombinant factor VIIais a new treatment modality shown to be effective in controlling severe,life-threatening hemorrhage by actingon the extrinsic clotting pathway. Intravenous dosagesvary by case and generally range from 50 to 100 mcg/kgevery 2 hours until hemostasis is achieved. Cessation of bleeding ranges from 10 minutes to 40 minutes afteradministration(11–14). Concern has been raised be-cause of apparent risk of subsequent thromboembolicevents following factor VIIa use (15). Compared withother agents,factor VIIa is extremely expensive.Additional clinical experience in all specialties will help ▲       1042  ACOG Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY  available to control bleeding (Table 3). Hypogastricartery ligation is performed much less frequently than inyears past. Its purpose is to diminish the pulse pressure of blood flowing to the uterus via the internal iliac(hypogastric) vessels. Practitioners are less familiar withthis technique,and the procedure has been found to beconsiderably less successful than previously thought(17). Bilateral uterine artery ligation (O’Leary sutures)accomplishes the same goal,and this procedure is quick-er and easier to perform (18,19). To further diminishblood flow to the uterus,similar sutures can be placedacross the vessels within the uteroovarian ligaments.The B-Lynch technique is a newer procedure forstopping excessive bleeding caused by uterine atony (20).The suture provides even pressure to compress the uterinecorpus and decrease bleeding. One study reported moredetermine factor VIIa’s role in the treatment of patientswith postpartum hemorrhage. When is packing or tamponade of the uterine cavity advisable? When uterotonics fail to cause sustained uterine contrac-tions and satisfactory control of hemorrhage after vaginaldelivery,tamponade of the uterus can be effective indecreasing hemorrhage secondary to uterine atony (Table2). Such approaches can be particularly useful as a tem-porizing measure,but if a prompt response is not seen,preparations should be made for exploratory laparotomy.Packing with gauze requires careful layering of thematerial back and forth from one cornu to the other usinga sponge stick,packing back and forth,and ending withextension of the gauze through the cervical os. The sameeffect often can be derived more easily using a Foleycatheter,Sengstaken-Blakemore tube,or,more recently,the SOS Bakri tamponade balloon (16),specifically tai-lored for tamponade within the uterine cavity in cases of postpartum hemorrhage secondary to uterine atony. When are surgical techniques used to control uterine bleeding? When uterotonic agents with or without tamponademeasures fail to control bleeding in a patient who hasgiven birth vaginally,exploratory laparotomy is indicat-ed. A midline vertical abdominal incision usually is pre-ferred to optimize exposure. Several techniques are ▲     ▲      Table 1. Medical Management of Postpartum Hemorrhage Drug*Dose/RouteFrequencyComment Oxytocin (Pitocin)IV: 10–40 units in 1 literContinuousAvoid undiluted rapid IV infusion,normal saline or lactatedwhich causes hypotension.Ringer’s solution IM: 10 unitsMethylergonovine IM: 0.2 mgEvery 2–4 hAvoid if patient is hypertensive.(Methergine)15-methyl PGF 2 α IM: 0.25 mgEvery 15–90 min,Avoid in asthmatic patients;(Carboprost) 8 doses maximumrelative contraindication if (Hemabate)hepatic, renal, and cardiac disease. Diarrhea, fever, tachycardia can occur.Dinoprostone Suppository: vaginal Every 2 hAvoid if patient is hypotensive.(Prostin E 2 )or rectalFever is common. Stored frozen, 20 mgit must be thawed to room temperature.Misoprostol 800–1,000 mcg rectally(Cytotec, PGE 1 )  Abbreviations: IV, intravenously; IM, intramuscularly; PG, prostaglandin.*All agents can cause nausea and vomiting.Modified from Dildy GA, Clark SL. Postpartum hemorrhage. Contemp Ob/Gyn 1993;38(8):21–9. Table 2. Tamponade Techniques for Postpartum Hemorrhage TechniqueComment Uterine tamponade—Packing—4-inch gauze; can soak with 5,000 units of thrombin in 5 mL of sterile saline—Foley catheter—Insert one or more bulbs; instill 60–80 mL of saline—Sengstaken–Blakemore tube —SOS Bakri tamponade balloon—Insert balloon; instill 300–500 mL of saline
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