Postpartum Hemorrhage (PPH)
Considerations
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Emergency situation, little time to optimize
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Physiological changes of pregnancy, Full stomach
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Determine severity of hemorrhagic shock & resuscitate to goal end-points
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Ddx for PPH:
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Tone: Uterine atony (by far most common)
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Tissue: Retained product, Placenta accreta
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Trauma: Lower genital tract lacerations, Vascular injury
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Thrombin: Coagulopathy
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Aquired (ITP, PIH, DIC, TTP)
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Prexisting (vWD, hemophilia)
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Turn out: Uterine inversion
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Avoid the lethal triad: hypothermia, acidosis, coagulopathy
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Multidisciplinary management & need for extra help
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Consider early intubation if patient deteriorating
Anesthetic Management
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Simultaneous diagnosis & management
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Get extra help, liaise with Obstetrics re: type of bleed
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Resuscitate to goal end-points & declare massive transfusion if appropriate
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Treat hypothermia, acidosis, coagulopathy
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Send off frequent blood work including CBC, ABG, Lactate, INR/PTT/Fibrinogen, Ca
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Uterotonics:
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Oxytocin = 1st line: 5 IU IV push, then 20-40 IU in 250 mL of normal saline, infused IV at 500-1000 cc/hr
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Hemabate: IM 0.25 mg, q15min PRN (max 8 doses). Contraindications: asthma, pulmonary HTN, hypoxemia
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Ergot: IM 0.2-0.25 mg, IV 0.125-0.25 mg. Contraindications: HTN, pre-eclampsia, CAD
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Misoprostol: PR 800-1000 mcg, Buccal/SL 400-600 mcg
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Gather resources: rapid infusers, blood products/MTP, uterotonics/tocolytics, invasive monitoring, TXA, cell salvage, rFVIIa
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Utilize blood conservation: Cell saver, Tranexamic acid (TXA), possible rFVIIa
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Consider surgical control of bleeding: Bilateral uterine massage, B lynch suture, packing, aortic cross clamp, uterine artery ligation, embolization (IR), hysterectomy
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If intubating:
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Pre-induction arterial line if possible
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Anti-acid prophylaxis
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Titrated induction & accept aspiration risk
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Ketamine as induction medication
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PPH Management Guidelines