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The OB/GYN Resident Survival Guide
#12: Manage Postpartum Hemorrhage Like a Pro (Part 2): Meds, Devices, and Surgical Management
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Hello and welcome back to another episode. Today is Part two of Postpartum Hemorrhage Basics. If you haven't already, make sure you go back and listen to part one where I reviewed the definition of postpartum hemorrhage, risk factors and causes of hemorrhage, and the initial interventions that should be performed.
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Now, for the last couple of weeks.
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You'Ve heard me talk about the OB Residency starter pack that I created for incoming interns, but this week I wanted to invite you to attend a free live training I've put together for those incoming interns. Although anyone is welcome to join, you.
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Don'T have to be an intern. It is designed for those of you.
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That did just match. It's called the Intern's Guide to Managing.
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Labor Induction and Augmentation and in just about an hour I'm going to review how to counsel patients before starting an induction, how to calculate the Bishop score, and then apply it so you can develop a plan for managing their labor. And I'm also going to do a deeper dive on the various medical and mechanical methods we use to induce labor. If you show up live, you'll get a little screenshot cheat sheet of all the meds with their doses, routes and frequency of administration. And I'll also be doing a Q and A at the end as well. I'll be hosting the training on three different dates, so hopefully you'll be able.
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To make it to one of them.
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And if you're interested, the link to register is in the show notes.
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Okay, let's jump in and pick up where we left off at the end of last week's episode. You you have identified a postpartum hemorrhage in a patient that just delivered vaginally. You performed a bimanual exam and massage, drained the bladder, assessed for and repaired any obstetric lacerations, and you did a manual sweep to confirm that there are no products of conception still remaining within the uterine cavity. At this point, you're still appreciating ongoing brisk bleeding and are starting to wonder what your remaining options are. So so let's talk first about pharmacologic interventions. The majority of medications available to treat postpartum hemorrhage are uterotonic medications, meaning they help the uterus to contract. If uterine atomy is not the problem, the following medications are not going to be helpful. There are three mainstay uterotonic medications methyl ergonivine or brand name methargine in the US 15 methyl prostaglandin F2 Alpha no one calls it that. The brand name here is Hemobate and Mesoprostol. Brand name Cytotec. Based off of the data we have, none of these have been shown to be superior to one another, so you can really start with any of them. However, it's worth considering how long it takes for each of them to work. I'll usually start with methergine because it takes about two to five minutes to work, whereas Hemabate takes anywhere from 15 minutes to an hour to reach peak concentration and Cytotec takes about 30 minutes. If I start with Methergine and the bleeding is still ongoing, I'll usually then place Cytotec rectally because I'm going to want to give it time to actually start working. And in the interim, if the bleeding is ongoing, then you can consider hemovate. Table 3. In the previously mentioned practice bulletin, 183 reviews dosing, route frequency contraindications and adverse effects of these medications and you should save that table for review. One other medication that is not a uterotonic that can be used for postpartum hemorrhage is tranexamic acid. This is an anti fibrinolytic medication with an onset of action of 5 to 10 minutes when administered IV. There was a large randomized control trial published in 2017 called the Woman Trial and and outcomes showed that when compared with placebo, the administration of 1 gram of TXA within 3 hours of birth reduced mortality in those patients with obstetric hemorrhage. The ACOG suggests that TXA should be considered in the setting of obstetric hemorrhage when initial medical therapy fails. And really the sooner the better, given that the efficacy seemed to be reduced the farther away from delivery that it was administered. Now we can move on to our mechanical interventions or tamponade techniques. Generally these are used when all the previously mentioned interventions fail to sustain uterine contractions and the bleeding remains uncontrolled. We have the intrauterine balloon. A common brand name is the Bakri balloon and this is inserted transcervically into the uterus and the balloon can be inflated up to 500cc with saline. We usually leave it in place for several hours. Um, you can technically leave it in for 24 hours, but not any longer than that. Then we have the intrauterine vacuum or brand name the data device. And this works extremely well. We actually pretty much stopped using the Bakri balloon where I work altogether in favor of the Jada device. And similar to the Bakri balloon. This is inserted through the cervix into the uterus, but instead of inflating a balloon within the uterus, you actually place the device on a low level suction and this sort of forces the uterus to contract. It's usually left in place for one to three hours, but that varies. However, it shouldn't be left in longer than 24 hours. The less preferred tamponade techniques include the placement of a uterine Foley balloon. However, those typically have a maximum capacity of about 60cc's and so placing a tiny golf ball sized balloon in a giant floppy uterus is not likely going to be helpful. You could also consider uterine packing on its own or soaked with thrombin. However, again, this is suboptimal. Now we move on to our last resort options. If the patient has failed all of the above and has persistent slow bleeding but is hemodynamically stable, you can consult interventional radiology to perform a uterine artery embolization. And the purpose of this is to embolize the large vessels perfusing the uterus that are feeding those spiral arteries. If that fails, or if the patient is not a candidate because they're too unstable or they're bleeding too briskly, you have no choice but to take them back to the operating room to perform an exploratory laparotomy. As this is happening, be sure to activate a mass transfusion protocol and consider notifying the gynecologic oncology and or trauma surgery teams in case their assistance is needed in the operating room. Now, when the patient is open and you have visualization of the uterus, you can attempt to ligate the bilateral uterine arteries through an oleary stitch. You can also ligate the vessels within the utero ovarian ligament. Less commonly, you do have the option to ligate the internal iliac artery. However, that requires retroperitoneal dissection, which you may not have time for or the experience to do. And in such cases, gynecologic oncology or trauma surgery should be consulted. You can apply uterine compression sutures like the B. Lynch, Cho or Haman sutures, and those essentially squish the uterus onto itself, tamponading those vessels. Then, after all of the above has failed, as a very last but definitive resort, you can perform a hysterectomy. Again, if you are at this point in the hemorrhage, gynonc or trauma surgery should be notified and the mass transfusion protocol activated if not already done. All right, we made it through. Let's review what you've learned from start to finish. Postpartum hemorrhage is defined as a cumulative blood loss of 1 liter or any blood loss accompanied by signs or symptoms of hypovolemia within 24 hours of birth. Hemorrhage that occurs within 24 hours of birth is a primary or early postpartum hemorrhage, whereas a hemorrhage that occurs after the 24 hours from birth is defined as a secondary or late postpartum hemorrhage. The number one cause of a primary postpartum hemorrhage is uterine atomy, but other causes include lacerations, retained placental products, an abnormally adherent placenta, coagulation defects and or uterine inversion. Postpartum hemorrhage can be prevented through active management of the third stage of labor, and this includes administering pitocin, applying fungal massage and cord traction to help deliver the placenta. If a patient hemorrhages, your first steps involve a bimanual exam and massage, draining of the bladder and assessing for any obstetric lacerations. For uterine atony, you can administer methregin hemabate and or Cytotec, and you can also consider placing a Bakri balloon or a data device. Tranexamic acid has been shown to reduce mortality from postpartum hemorrhage when administered within three hours of birth, and last resort interventions for hemorrhage include uterine artery embolization, intraoperative vascular ligation and compression sutures, and finally, hysterectomy. There you have it. I hope this helps. All the references I mentioned are linked in the show notes for this episode as well as the free OB GYN Residency starter pack. Have a great week and I will see you next Saturday.