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Postpartum Hemorrhage in Emergency Medicine Clinical Presentation

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Today What would you like to print? News Print this section (History) Reference [ CLOSE WINDOW ] Print the entire contents of Postpartum Hemorrhage in Emergency Medicine Clinical Presentation Education Log OutAbout My Account Medscape Reference Dr. A Rahmani Medscape's clinical reference is the most authoritative and accessible point-of-care medical reference for physicians and healthcare professionals, available online and via all major mobile devices. All content is free. The clinical information represents the expertise and practical knowledge of top physicians and pharmacists from leading academic medical centers in the United States and worldwide. The topics provided are comprehensive and span more than 30 medical specialties, covering: Diseases and Conditions Print than 6000 evidence-based and physician-reviewed disease and condition articles are More Share to rapidly and comprehensively answer clinical questions and to provide in-depth organized Email Twitter in Facebook information support of diagnosis, treatment, and other clinical decision-making. Topics are richly Feedback illustrated with more than 40,000 clinical photos, videos, diagrams, and radiographic images.

Postpartum Hemorrhage in Emergency Medicine Clinical Presentation

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Anatomy Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Pamela L Dyne, MD more... More than 100 anatomy articles feature clinical images and diagrams of the human body's major systems and organs. The articles assist in the understanding of the anatomy involved in treating specific conditions and performing procedures. They can also facilitate physician-patient discussions. Overview Drug Monographs Presentation More than 7100 monographs are provided for prescription and over-the-counter drugs, as well as DDx for corresponding brand-name drugs, herbals, and supplements. Drug images are also included. Workup Treatment Drug Interaction Checker Medication Our Drug Interaction Checker provides rapid access to tens of thousands of interactions between Follow-up brand and generic drugs, over-the-counter drugs, and supplements. Check mild interactions to serious contraindications for up to 30 drugs, herbals, and supplements at a time. Updated: May 2, 2012 Formulary Information Access health plan drug formulary information when looking up a particular drug, and save time and effort for you and your patient. Choose from our complete list of over 1800 insurance plans across History History all 50 US states. Customize your Medscape account with the health plans you accept, so that the Physical information you need is saved and readysurvey every time you of look a drug on our site include or in the The clinical history should be taken as a primary (ABCs) theup patient. This should collecting Causes Medscape app. Easily compare tier status for drugs in the same class when considering an an initial set of vital signs to guide the patients management, as the patient is positioned to begin the physical Show All drug for your patient. alternative examination. Keep in mind, that if the bleeding is very brisk, the patients mental status may wane. As a result, this first set of questions should include queries about signs and symptoms that are most crucial in managing Medical Calculators References Medscape Reference features 129 medical calculators covering formulas, scales, and classifications.

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potential circulatory collapse, identifying the cause of postpartum hemorrhage (PPH), and selecting appropriate therapies.[10] Severity of bleeding Is the placenta delivered? What has been the duration of the third stage of labor? How long has the bleeding been heavy? Was initial postdelivery bleeding light, medium, or heavy? Are symptoms of hypovolemia present such as dizziness/lightheadedness, changes in vision, palpitations, fatigue, orthostasis, syncope or presyncope? If evaluating a patient with delayed postpartum hemorrhage, what has been the bleeding pattern since delivery? Intervention guides Is there a history of transfusion? What was the reason for transfusion? Is there a history of a transfusion reaction? Past medical history (particularly cardiovascular, pulmonary, or hematologic conditions) Allergies Predisposing factors and potential etiology History of postpartum hemorrhage Gravity, parity, length of most recent pregnancy, history of multiple gestations Number of fetuses for the most recent pregnancy Pregnancy complications (polyhydramnios, infection, vaginal bleeding, placental abnormalities) If the placental was delivered, was it spontaneous, or was manual delivery required? Current and past history of vaginal delivery versus cesarean delivery If cesarean delivery, was it planned in advance, decided upon after a failed vaginal delivery attempt, or performed emergently? Other uterine surgeries such as myomectomy (transvaginal vs transabdominal), uterine septum removal Personal or family history of bleeding disorder Medications such as prescribed, over the counter, diet supplements, or vitamins (with particular attention to anticoagulants, platelet inhibitors, uterine relaxants, and antihypertensives) Vaginal penetration since delivery (tampons, finger, other foreign object, vaginal intercourse) Signs or symptoms of infection such as uterine pain or tenderness, fever, tachycardia, or foul vaginal discharge Information helpful for continued management When and where was the delivery? Who assisted the delivery? Where and with whom was prenatal care? Healthy infant(s) delivered (any complications or concerns before, during, or after delivery)? Past surgical history Next Section: Physical

Physical
As mentioned earlier, patients with postpartum hemorrhage (PPH) should be managed like all emergency department resuscitation situations, with the history and physical examination occurring simultaneously while following acute life support algorithms.
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The physical examination should focus on determining the cause of the bleeding. The patient may not have the typical hemodynamic changes of shock early in the course of the hemorrhage due to physiologic maternal hypervolemia. Important organ systems to assess include the pulmonary system (evidence of pulmonary edema), the cardiovascular (heart murmur, tachycardia, strength of peripheral pulses), and neurological systems (mental status changes from hypovolemia).The skin should also be checked for petechiae or oozing from skin puncture sites, which could indicate a coagulopathy, or a mottled appearance, which can be indicative of severe hypovolemia. Looking for occult postpartum hemorrhagein the form of a pelvic, vaginal, uterine, or abdominal wall hematoma, or intra-abdominal or perihepatic bleedingis always an important consideration when unstable hemodynamic findings are present without evidence of excessive vaginal blood loss. Having a gynecologic examination bed is helpful but not necessary. The patient's pelvis can always be elevated on an inverted bedpan (thick-side toward the patient's feet) cushioned with towels and a sheet for comfort. Ensure that good lighting and suction are available before beginning. Abdominal examination: Pain and tenderness (concerning for retained placenta tissue, rupture, or endometritis), distension, boggy or grossly palpable uterus (at or above the umbilicus) is suggestive of atony. Palpation of an overdistended bladder may indicate a barrier to adequate uterine contraction. Perineal examination: A brisk bleed should be visible at the introitus; identify any perineal lacerations. Speculum examination: Gently suction blood, clots, and tissue fragments as needed to maintain the view of the vagina and cervix. Careful inspection of the cervix and vagina under good light may reveal the presence and extent of lacerations. Bimanual examination: Bimanual palpation of the uterus may reveal bogginess, atony, uterine enlargement, or a large amount of accumulated blood. Palpation may also reveal hematomas in the vagina or pelvis. Assess if the cervical os is open or closed. Placental examination: Examine the placenta for missing portions, which suggest the possibility of retained placental tissue. Previous Next Section: Physical

Causes
The 4Ts of postpartum hemorrhage (PPH) +1: tone, trauma, tissue, thrombosis, and traction. More than one of these can cause postpartum hemorrhage in any given patient. Uterine atony - "Tone": Atony is by far the most common cause of postpartum hemorrhage. Uterine contraction is essential for appropriate hemostasis, and disruption of this process can lead to significant bleeding. Uterine atony is the typical cause of postpartum hemorrhage that occurs in the first 4 hours after delivery. Risk factors for atony include the following: Overdistended uterus (eg, multiple gestation, fetal macrosomia, polyhydramnios) Fatigued uterus (eg, augmented or prolonged labor, amnionitis, use of uterine tocolytics such as magnesium or calcium channel blockers) Obstructed uterus (eg, retained placenta or fetal parts, placenta accreta, or an overly distended bladder) Laceration or hematoma - "Trauma": Trauma to the uterus, cervix, and/or vagina is the second most frequent cause of postpartum hemorrhage. Injury to these tissues during or after delivery can cause
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significant bleeding because of their increased vascularity during pregnancy. Vaginal trauma is most common with surgical or assisted vaginal deliveries. It also occurs more frequently with deliveries that involve a large fetus, manual exploration, instrumentation, a fetal hand presenting with the head, or spontaneously from friction between mucosal tissue and the fetus during delivery. Cervical lacerations are rarer now that forceps-assisted deliveries are less common. They are more likely to occur when delivery assistance is provided before the cervix is fully dilated. Risk factors for trauma include the following: Delivery of a large infant Any instrumentation or intrauterine manipulation (eg, forceps, vacuum, manual removal of retained placental fragments) Vaginal birth after cesarean section (VBAC) Episiotomy Retained placenta - "Tissue": Retained placental tissue is most likely to occur with a placenta that has an accessory lobe, deliveries that are extremely preterm, or variants of placenta accreta. Retained or adherent placental tissue prevents adequate contraction of the uterus allowing for increased blood loss. Risk factors for retained products of conception include the following: Prior uterine surgery or procedures Premature delivery Difficult or prolonged placental delivery Multilobed placenta Signs of placental accreta by antepartum ultrasonography or MRI Clotting disorder - "Thrombosis": During the third stage of labor (after delivery of the fetus), hemostasis is most dependent on contraction and retraction of the myometrium. During this period, coagulation disorders are not often a contributing factor. However, hours to days after delivery, the deposition of fibrin (within the vessels in the area where the placenta adhered to the uterine wall and/or at cesarean delivery incision sites) plays a more prominent role. In this delayed period, coagulation abnormalities can cause postpartum hemorrhage alone or contribute to bleeding from other causes, most notably trauma. These abnormalities may be preexistent or acquired during pregnancy, delivery, or the postpartum period. Potential causes include the following: Platelet dysfunction: Thrombocytopenia may be related to preexisting disease, such as idiopathic thrombocytopenic purpura (ITP) or, less commonly, functional platelet abnormalities. Platelet dysfunction can also be acquired secondary to HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). Inherited coagulopathy: Preexisting abnormalities of the clotting system, as factor X deficiency or familial hypofibrinogenemia Use of anticoagulants: This is an iatrogenic coagulopathy from the use of heparin, enoxaparin, aspirin, or postpartum warfarin. Disseminated intravascular coagulation (DIC): This can occur, such as from sepsis, placental abruption, amniotic fluid embolism, HELLP syndrome, or intrauterine fetal demise. Dilutional coagulopathy: Large blood loss, or large volume resuscitation with crystalloid and/or packed red blood cells (PRBCs), can cause a dilutional coagulopathy and worsen hemorrhage from other causes. Physiologic factors: These factors may develop during the hemorrhage such as hypocalcemia, hypothermia, and acidemia. Uterine inversion - "Traction": The traditional teaching is that uterine inversion occurs with an atonic uterus that has not separated well from the placenta as it is being delivered, or from excessive traction on the umbilical cord while placental delivery is being assisted. Studies have yet to demonstrate the typical mechanism for uterine inversion. However, clinical vigilance for inversion, secondary to these
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potential causes, is generally practiced. Inversion prevents the myometrium from contracting and retracting, and it is associated with life-threatening blood losses as well as profound hypotension from vagal activation. Proceed Previous to Differential Diagnoses

Contributor Information and Disclosures Author Maame Yaa A B Yiadom, MD, MPH Staff Physician, Department of Emergency Medicine, Cooper University Hospital, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School Maame Yaa A B Yiadom, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, National Medical Association, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Coauthor(s) Daniela Carusi, MSc, MD Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director, Department of General Ambulatory Gynecology, Brigham and Women's Hospital Daniela Carusi, MSc, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, and Massachusetts Medical Society Disclosure: Nothing to disclose. Specialty Editor Board Assaad J Sayah, MD Chief, Department of Emergency Medicine, Cambridge Health Alliance Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
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Disclosure: Nothing to disclose. John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Chief Editor Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Additional Contributors Special thanks to Dr. Donnie Bell for his assistance with the "Imaging" section for this topic. The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Michael P Wainscott, MD, to the development and writing of this article.

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References 1. Minino AM, Heron MP, Murphy SL, Kochanek KD, et al. National Vital Statistic Reports: Deaths 2004. US Department of Health and Human Services and the Center for Disease Control and Prevention; August 21, 2007. 120. [Full Text]. 2. World Health Organization. World Health Report 2005: Make Every Mother and Child Count. Available at http://www.who.int/whr/2005/whr2005_en.pdf. Accessed September 10, 2008. 3. USAID (United States Agency for International Development). Postpartum Hemorrhage Prevention. USAID Postpartum Hemorrhage Prevention Initiative (POPPHI). Available at http://www.pphprevention.org/briefs_newsletters.php. Accessed September 9, 2008. 4. PATH. Saving Mother's Lives: Initiative promotes proven strategy for preventing postpartum hemorrhage. PATH: Preventing Postpartum Hemorrhage. Available at http://www.path.org/projects/preventing_postpartum_hemorrhage.php. Accessed September 9, 2008. 5. Miller S, Lester F, Hensleigh P. Prevention and treatment of postpartum hemorrhage: new advances for low-resource settings. J Midwifery Womens Health. Jul-Aug 2004;49(4):283-92. [Medline]. [Full Text]. 6. Menitove JE, McElligott MC, Aster RH. Febrile transfusion reaction: what blood component should be given next?. Vox Sang. 1982;42(6):318-21. [Medline]. 7. Shimada E, Tadokoro K, Watanabe Y, et al. Anaphylactic transfusion reactions in haptoglobindeficient patients with IgE and IgG haptoglobin antibodies. Transfusion. Jun 2002;42(6):766-73. [Medline]. 8. Popovsky MA. Transfusion and lung Injury. Transfusion Clin Biol. 2001;8:272-7. 9. Kicklighter EJ, Klein HG. Hemolytic transfusion reactions. In: Linden JV, Bianco C, eds. Blood Safety and Surveillance. New York: Marcel Dekker; 2001:47-70. View 10.Table Tintinalli List JE, Kelen GD, Stapczynski JS. Gynecology and Obstetrics: Post Partum Hemorrhage. In: Emergency Medicine: A Comprehensive Study Guide. 6th. New York: McGraw Hill; 2004:682. Read more about Postpartum Hemorrhage in Emergency Medicine on Medscape 11. Soriano D, Dulitzki M, Schiff E, Barkai G, Mashiach S, Seidman DS. A prospective cohort study Related Reference Topics Related News and Articles of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage. Br J Obstet Gynaecol . Nov 1996;103(11):1068-73. [Medline]. Hemolytic Uremic It Is Not the Ride: Inter-hospital Transport Is Not an Independent Risk in Factor for Intraventricular Hemorrhage Among Birth 12. Syndrome [Best Evidence] Winikoff B, Dabash R, Durocher J, Darwish E, Nguyen TN, Very LeonLow W, et al. Weight Emergency Medicine Infants with sublingual misoprostol versus oxytocin in women not Treatment of post-partum haemorrhage Vitreous Hemorrhage Advancing Maternal Survival in the Global Context exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial. Lancet . Jan in Emergency Twitter Introduces Alert System for Emergencies, Disasters 16 2010;375(9710):210-6. [Medline]. Medicine 13. Epidural SparrowHematoma AH, Schwemmer SS, Thompson KH. Radiosensitivity studies with woody plants. III. in Predictions Medicine of limits of probable acute and chronic LD50 values from lognormal distributions of Emergency interphase chromosome volumes in gymnosperms. Radiat Res. Feb 1976;65(2):315-26. [Medline]. Medscape Reference 2011 WebMD, LLC 14. [Guideline] American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage. Washington (DC): American College of Obstetricians and Gynecologists (ACOG);
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Postpartum Hemorrhage in Emergency Medicine Clinical Presentation

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