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Subsections
Post-Partum Complications: Hemorrhage Conditions

Obstetrics

Uterine Atony (Hypotonic Myometrium)

Background

  1. Definition
    • Corpus uteri myometrial cells have inadequate contraction in response to endogenous oxytocin release
  2. Synopsis
    • Uterine atony is a cause of
      • Post-partum hemorrhage
      • Delivery complications due to absence of uterine contractions

Pathophysiology

  1. Mechanism
    • Inability of the uterine musculature to stop arterial bleeding at the placental implantation site
  2. Etiology/Risk Factors
    • Overdistension of the uterus
    • Use of halogenated anesthetic agents
    • Labor augmented with oxytocin
    • High parity
    • Prolonged labor
    • Precipitous labor
    • Chorioamnionitis
    • Retained placental tissue
    • Placental disorders
    • Coagulopathy
    • Uterine inversion
    • BMI > 40
  3. Epidemiology
    • Incidence/Prevalence
      • 1/40 pregnancies (USA)
        • Have absence of effective uterine contractions
    • Morbidity/Mortality
      • 75% of cases of postpartum hemorrhage are
        • Attributed to uterine atony

Diagnostics

  1. Physical Exam/Signs
    • When obstetric vaginal/cesarean delivery concludes
      • Palpate directly after cesarean
        • Closure of the uterine incision
      • Indirect exam at bimanual exam post-vaginal delivery
        • Boggy, soft, and unusually enlarged uterus
        • Seen with co-existent bleeding from the cervical os usually
    • Greater than normal blood loss during exam
      • Showing flaccid and enlarged uterus
    • Vaginal examination
      • Fundal region
        • Contracted
      • Lower uterine region
        • Dilated and atonic
  2. Imaging
    • Bedside obstetric ultrasound
      • Echogenic endometrial stripe
      • Used to exclude obstetric laceration

Treatment

  1. Initial/Prep/Goals
    • ABCs, IV access, monitor
      • Monitor fetal HR, contractions
      • Aggressive fluid management with replacements of
        • Crystalloids
        • Blood
    • Symptomatic treatment
      • Fungal massage
  2. Medical/Pharmaceutical
    • Oxytocin
      • 10 U IM or 10-30 U IV per 1000 mL
      • Rapid undiluted infusion may cause hypotension
    • Methylergonovine
      • 0.2 mg IM q2-4H
      • Avoid if hypertensive
    • 15-methyl prostaglandin F2-alpha
      • 0.25 mg IM q15-90 for maximum 8 doses
      • Avoid in asthmatics
      • Sides
        • Diarrhea
        • Fever
        • Tachycardia
    • Misoprostol
      • 800-1000 mg suppository
      • Delayed action
      • Sides
        • Low-grade fever
    • Dinoprostone
      • 20 mg vaginal/rectal suppository q2H
    • Consider Tranexamic Acid as soon as possible after bleeding onset
  3. Surgical/Procedural
    • Uterovaginal packing with gauze
      • Foley catheter insertion to allow bladder drainage
      • Rolled gauze ribbons
    • Bakri balloon
      • Foley catheter insertion to facilitate bladder drainage
    • Uterine curettage for retained products
    • Uterine artery ligation
      • Extending arterial ligation to tubo-ovarian vessels
    • Compression sutures (B-Lynch)
      • Used when scenarios such as bimanual compression of the
        • Uterus causes arrest in bleeding
    • Hypogastric artery ligation
    • Hysterectomy
  4. Complications
    • Postpartum anemia
    • Death

Disposition

  1. Admission criteria
    • Close observation for recurrence of hemorrhage
  2. Consult(s)
    • OB/GYN
  3. Discharge/Follow-up Instructions
    • If stable, discharge home with methylergonovine 0.2 mg orally q 8 hours x 2 days (avoid if hypertensive)
    • Follow-up per care team orders

Placenta Accreta

Background

  1. Definition
    • Abnormal invasion of placental trophoblasts
      • Into the uterine myometrium
  2. Synopsis
    • Invasion of chorionic villi into maternal myometrium
    • Placenta accreta spectrum disorders include
      • Placenta accreta
      • Placenta increta
      • Placenta percreta

Pathophysiology

  1. Mechanism
    • Unknown, theories:
    • Imperfect development of the fibrinoid layer (Nitabuch layer) cause placental villi to attach to the myometrium
    • Spongiosus layer of the decidualized endometrium may not be present
      • Stop signal is absent
      • Trophoblast invasion expands beyond spongiosus layer of decidua
      • Seen in patients with prior uterine surgeries
    • Cytotrophoblasts must reach spiral arterioles prior to differentiation into
      • Placenta tissue may occur, but uterine scars have relative lack of vasculature
  2. Etiology/Risk Factors
    • Previous cesarean section
      • Loss of decidua in the cesarean section scar
    • Advanced maternal age
    • Multiparity
    • Uterine surgery
      • Myomectomy
      • Uterine curettage
      • Hysteroscopic surgery
      • Prior endometrial ablation
      • Uterine embolization
      • Pelvic irradiation
  3. Epidemiology
    • Incidence/Prevalence
      • 1/1000 deliveries
      • Increasing trend from 0.04-0.9%

Diagnostics

  1. History/Symptoms
    • Prior uterine surgery history
  2. Labs
    • CBC +Diff, CMP
      • WBC count
    • ESR, CRP
    • PT, aPTT, INR
  3. Imaging
    • Transabdominal US
      • Presence of placental lacuna
        • Irregular spaces resembling "Swiss cheese"
        • Loss of normal hypoechoic retroplacental zone
    • 3D Doppler US
      • Disorganized/high velocity myometrium blood flow
    • MRI
      • Complementary to ultrasound
      • Abnormal uterine bulging
      • Heterogeneity of signal intensity within body of placenta
      • Dark intraplacental bands on T2 weighted images
  4. Differential Diagnosis
    • Placenta increta
    • Placenta percreta
    • Placenta previa

Treatment

  1. Initial/Prep/Goals
    • ABCs, IV access, monitor
      • Be prepared to treat
        • Anemia
        • Shock
    • Preventative measures
      • Optimize patients Hb prior to delivery, if possible
      • Coordinate with blood bank to ensure supplies
        • If transfusion needed
  2. Medical/Pharmaceutical
    • Tranexamic acid
      • 1 g IV
      • Consider use within < 3 hours of delivery
      • Can reduce maternal death due to hemorrhage
      • Does not increase adverse effects
  3. Surgical/Procedural
    • If possible, prior to delivery patient should be considered to transfer to
      • Placenta Accreta Center of Excellence (PACE)
        • Level 3 or 4 center for delivery
    • Delivery recommended between 34 to < 36 weeks gestation via
      • Cesarean hysterectomy to optimize neonatal maturity and
        • Reduce maternal risks for bleeding
    • Cesarean section
      • Dorsal lithotomy positioning and vertical skin incision
        • Uterine incision should be made to avoid placenta
      • After delivery of neonate, if the placenta does not deliver voluntarily, then
        • Leave the placenta
        • Close the hysterotomy
        • Perform a hysterectomy
          • Supracervical hysterectomy may not be possible
            • Due to bleeding
          • Consider cystotomy to separate placental tissue
    • Conservative management to preserve future fertility
      • Small defects can be surgically removed/over-sewn
      • Bakri balloons have been reported to be successful
    • Conservative management with extensive accreta
      • Leave placenta in situ with/without use of methotrexate
        • 78% in one study were able to avoid hysterectomy
        • Some placentas were removed through hysteroscopic resection
  4. Complications
    • Postpartum hemorrhage
    • Surgical damage to nearby structures
    • Neonatal morbidity/mortality from preterm birth
    • Maternal hemorrhage can lead to decreased fetal oxygenation

Disposition

  1. Admission criteria
    • Cesarean delivery planned
    • Hemorrhage
    • NICU need
  2. Consult(s)
    • OB/GYN, perinatologist, surgery, urology and neonatology as needed
  3. Discharge/Follow-up Instructions
    • Follow-up per care team orders
    • Assure correction of patient Hb prior to discharge
    • Ensure patient's needs met
    • Refer patient to counseling if distressed

Delayed Post-partum Hemorrhage

Background

  1. Definition
    • Hemorrhage commencing > 24 hours post-delivery up
      • Until 6 weeks postpartum
  2. Synopsis
    • Rare obstetrical emergency
    • May be fatal
    • Hypovolemic shock without
      • Significant external bleeding
      • Palpable mass
      • Peritoneal signs
      • Abdominal pain
    • Bleeding may be hard to identify

Pathophysiology

  1. Mechanism
    • Depends on etiology
  2. Etiology/Risk Factors
    • Remaining products of conception
    • Cervical/vaginal tear
    • Uterine infection
      • Endometritis
    • Trophoblastic disease
  3. Epidemiology
    • Incidence/Prevalence
      • Post-partum hemorrhage
        • 1-5% of deliveries
    • Morbidity/Mortality
      • 140,000 deaths worldwide
        • All cases of post-partum hemorrhage

Diagnostics

  1. History/Symptoms
    • First menses: usually abnormal, may be longer, heavier, with clots
    • Non-nursing mothers: menses start at 1-3 months postpartum
    • Nursing mother: may spot lightly for 1-2 months, menses usually return at 5-6 months, but can be much delayed
  2. Physical Exam/Signs
    • General
      • Ill-appearing
      • Fever
      • Pale
    • Abdomen
      • Lower abdominal pain
    • Female Reproductive
      • Excessive vaginal bleeding
  3. Labs/Tests
    • CBC +Diff, CMP
      • WBC count
    • ESR, CRP
    • PT, aPTT, INR
    • Blood cultures
  4. Imaging
    • Pelvic US
      • Retained placental tissue

Treatment

  1. Initial/Prep/Goals
    • ABCs, IV access, monitor
      • Be prepared to treat shock
      • Fluid rehydration
      • Transfuse blood if needed
  2. Medical/Pharmaceutical
    • Antibiotics
      • Ampicillin + metronidazole
        • Gentamicin added if endomyometritis/overt sepsis cases
    • Uterotonics
      • Oxytocin (syntocinon)
      • Oxytocin + ergometrine (syntometrine)
      • Prostaglandin F2 (carboprost)
      • Prostaglandin E1 (misoprostol)
  3. Surgical/Procedural
    • Balloon tamponade
    • Manual removal of placenta
    • Manual removal of clots
    • Uterine artery embolization
    • Laceration repair
      • Genital tract trauma
    • Curettage
    • Uterine/pelvic artery ligation
    • Uterine compression sutures
    • Hysterectomy
  4. Complications
    • Anemia
    • Death

Disposition

  1. Admission criteria
    • Any signs of unusual bleeding per vagina
  2. Consult(s)
    • OB/GYN and radiology
  3. Discharge/Follow-up Instructions
    • Follow-up per care team orders
    • Readmit if any signs of bleeding recur

Subinvolution of the Uterus

Background

  1. Definition
    • Delayed/inadequate physiologic closure and sloughing of the superficial modified spiral artery at placental site
      • Normal involution failure
  2. Synopsis
    • Abnormal persistence of large, dilated, superficially modified spiral arteries
      • In absence of retained products of conception
    • Major cause of postpartum hemorrhage (secondary)
      • Seen most commonly in 2nd week post partum
    • Remains a histological diagnosis
      • No imaging or other markers are available in definite diagnosis

Pathophysiology

  1. Mechanism
    • Exact pathogenesis unknown, theories:
    • Immunological factors are essential for normal involution to occur
    • Increased expression of bcl-2
    • Human trophoblast invasion involving
      • STATs
      • PPAR-gamma
      • Homeobox genes
      • Wingless and Int-1 9WNT)- dependent transcription factors
  2. Etiology/Risk Factors
    • Prolonged lochia and/or profuse hemorrhage
    • Uterus still enlarged and soft
  3. Epidemiology
    • Incidence/Prevalence
      • 13.3% of 26,023 patients with secondary PPH
      • Secondary PPH accounts for 1% of PPH cases

Diagnostics

  1. History/Symptoms
    • Bleeding after birth
  2. Labs
    • CBC +Diff, CMP
      • WBC count
    • ESR, CRP
    • PT, aPTT, INR
  3. Imaging
    • US, sonogram
      • Subinvolution of placental site
        • Visualizing the low resistance vessels present along
        • Inner third of the myometrium my aide in diagnosis
    • Doppler sonography, pulsed wave
      • Increased PSV with low-resistance waveform
        • Used for confirmation of sonogram findings
    • Contrast-enhanced MRI
      • Marked vascular dilation of the uterine wall
    • Angiography
      • Gold standard for AVM presence
        • Helps in possible in diagnosis of subinvolution
  4. Other Tests/Criteria
    • Full workup to exclude other causes of secondary postpartum hemorrhage

Treatment

  1. Initial/Prep/Goals
    • ABCs, IV access, monitor
      • Be prepared to treat DIC, shock
      • Correct anemia
  2. Medical/Pharmaceutical
    • Conservative treatment
      • Uterotonics
        • Oxytocin: 10 U IV at 20-40 mU/min until bleeding stops
      • Antibiotics PRN
  3. Surgical/Procedural
    • Conservative treatment
      • Curettage
        • Exclude retained placental products
      • Uterine tamponade
        • Gauze or
        • Bakri balloon
    • Ligation of uterine vessels
    • Hysterectomy
    • Percutaneous embolization of the uterine artery
      • Prior to hysterectomy, if hospital has equipment and personnel
  4. Complications
    • Hemorrhage
    • Death

Disposition

  1. Admit
    • Endometritis
    • Severe anemia
    • Hemorrhage
  2. Consult(s)
    • OB/GYN, radiology and surgery as needed
  3. Discharge/Follow-up Instructions
    • Ensure anemia resolved
    • Follow-up per care team orders
    • Counseling if warranted for patient

References

  1. Shakur H, Roberts I, Fawole B, et al [WOMAN Trial Collaborators]. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet Apr 26, 2017. Available at: http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/abstract. [Accessed July 2021]
  2. Winikoff B, Dabash R, Durocher J, Darwish E, Nguyen TN, Leon W, et al. Treatment of post-partum haemorrhage with sublingual misoprostol versus oxytocin in women not exposed to oxytocin during labour: a double-blind, randomised, non-inferiority trial. Lancet Jan 16, 2010;375(9710):210-216
  3. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol. Oct 2006;108(4):1039-1047
  4. Roemer H. Emergencies After 20 Weeks of Pregnancy and the Postpartum Period. In: Cline DM, Ma OJ, Cydulka RK, et al; (eds). Tintinalli's Emergency Medicine Manual, 7th ed., McGraw-Hill Companies, 2012;Chapter 61
  5. Nadel E, Talbot-Stern J. Obstetric and gynecologic emergencies. Emerg Med Clin North Am. May 1997;15(2):389-397
  6. Gill P, Patel A, Van Hook JW. Uterine Atony. StatPearls. Treasure Island, FL: StatPearls Publishing; Jul 10, 2020. Available at: https://www.ncbi.nlm.nih.gov/books/NBK493238/. [Accessed July 2021]
  7. Thakur M, Adekola HO, Asaad R, Gonik B. Secondary Postpartum Hemorrhage due to Spontaneous Uterine Artery Rupture after Normal Vaginal Delivery Managed by Selective Arterial Embolization. AJP Rep. 2016;6(4)
  8. TeachMeObGyn. Secondary Post-Partum Haemorrhage. Available at: https://teachmeobgyn.com/labour/puerperium/secondary-post-partum-haemorrhage/. [Accessed July 2021]
  9. Mogos MF, Salemi JL, Ashley M, Whiteman VE, Salihu HM. Recent trends in placenta accreta in the United States and its impact on maternal-fetal morbidity and healthcare-associated costs, 1998-2011. J Matern Fetal Neonatal Med. 2016;29(7):1077-82.
  10. Khong TY. The pathology of placenta accreta, a worldwide epidemic. J Clin Pathol. Dec 2008;61(12):1243-6
  11. Shepherd AM, Mahdy H. Placenta Accreta. StatPearls. Treasure Island, FL: StatPearls Publishing; Feb 25, 2021. Available at: https://www.ncbi.nlm.nih.gov/books/NBK563288/. [Accessed July 2021]
  12. American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Obstetric Care Consensus No. 7: Placenta Accreta Spectrum. Obstet Gynecol. Dec 2018;132(6)
  13. Goh WA, Zalud I. Placenta accreta: diagnosis, management and the molecular biology of the morbidly adherent placenta. J Matern Fetal Neonatal Med. 2016;29(11):1795-1800
  14. Garmi G, Salim R. Epidemiology, etiology, diagnosis, and management of placenta accreta. Obstet Gynecol Int. 2012; 2012
  15. Triantafyllidou O, Kastora S, Messini I, Kalampokis D. Subinvolution of the placental site as the cause of hysterectomy in young woman. BMJ Case Rep. 2021;14(2):e238945. Published 2021 Feb 8. doi:10.1136/bcr-2020-238945

Contibutor(s)

  1. Singh, Ajaydeep, MD

Updated/Reviewed: July 2021