Virtual Rounds Session 10: Postpartum Hemorrhage (Premed Shadowing)

Throughout each premed virtual shadowing session, you will actively participate by answering and asking questions about the week’s proposed case. Like an in-person shadowing experience, we strive to stimulate students intellectually and ultimately reaffirm their interest in medicine.

Introduction – Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a life-threatening disorder that can lead to shock and death if not treated rapidly. We define PPH as >500mL blood loss in a vaginal delivery or >1000mL in a cesarean section.

Case Highlights 

A 27 y/o G3P2 F at 39 weeks gestation presents to L&D with new onset contractions. The patient received regular, routine prenatal care throughout her pregnancy. This pregnancy was complicated by polyhydramnios and gestational diabetes, diagnosed in the 25th week and controlled with insulin. The labor was augmented with oxytocin delivery proceeded rapidly which resulted in a healthy 4600g (10lb, 2oz) baby boy. The placenta was delivered in its entirety with normal vascularity. The estimated blood loss was approximately 900mL. Following delivery, the patient appeared lethargic and difficult to arouse and experienced one isolated syncopal episode.

Pathology 

When considering PPH, we want to consider the 4 T’s:

• Tone
  
  • Uterine Atony – a soft, “boggy” uterus of which has not contracted down after child birth, leading to hemorrhage from dilated spiral arteries.
• Trauma
  • Lacerations – often the result of vacuum or forceps delivery as well as episiotomy.

• Tissue
  • placenta – Evident when part of the placenta is missing once the placenta itself is delivered. This leads to bleeding from that part of the placenta.
• Thrombin 
  • Hypercoagulability – disorders such as Factor V Leiden, DIC,  and other clotting disorders.

The diagnosis of PPH is often made clinically on examination. As stated before, considerable blood losses (>500mL for vaginal delivery and >1000mL for C-section) prompt us to consider PPH. On examination, the patient may appear lethargic with altered mental status (AMS), hypotension, and tachycardia. The following physical exam findings are indicative of specific causes of PPH:

• Soft, “boggy” uterus = uterine atony 
• Laceration = genital trauma 
• Missing placenta = retained placental tissue 
• DIC = blood oozing from access sites, petechiae

To assist in the diagnosis of PPH, consider getting the following labs:

• H&H (CBC) – anemia (acute hemorrhage may not reflect for several hours due to loss of whole blood)
• CMP – electrolyte disturbances
• Coagulation – coagulopathy 
• Lactate – tissue ischemia 
• BUN / Cr – renal failure
• Type and Cross – for transfusion 

Complications of PPH and severe blood loss include:

• Severe hemorrhage resulting in hypovolemia, anemia, dilutional coagulopathy, or Sheehan’s syndrome (infarction of the pituitary gland leading to hypopituitarism, see image below)
• Shock, death

Treatment of PPH ultimately depends on the underlying cause:

• Uterine Atony
  • Uterine massage 
  • Medications
    • Methylergonovine 
    • Oxytocin 
    • PGF-2a
  • Surgery (Uterine artery embolization/Uterine artery ligation, hysterectomy) 
• Trauma (laceration)
  • Correct the laceration 
• Retained placenta 
  • Dilation and curettage (1st), then Total abdominal hysterectomy (if D&C unsuccessful) 
• Hypercoagulability (DIC) 
  • Replace PLT, fibrinogen (cryoprecipitate), Factors (FFP)
• Uterine inversion
  • Manual replacement of the uterus 
  • Oxytocin to contact uterus

 Take home points

1. 1. Postpartum hemorrhage (PPH) can be fatal if not treated rapidly
   2. By definition, PPH is defined as >500mL for a vaginal delivery and >1000mL for a c-section. This can be determined by estimated blood loss during delivery.
   3. In terms of causes of PPH, remember the 4 T’s: Tone, Trauma, Tissue, and Thrombin (clotting).
   4. Complications of PPH include shock, hypovolemia, anemia, dilutional coagulopathy, Sheehan’s syndrome, or death.
   5. Determining the cause of PPH is important since the treatment of PPH varies depending on the cause.