Continuing Education Column Management of Postpartum Hemorrhage Ahm Kim, MD Department of Obstetrics and Gynecology, Ulsan University College of Medicine Email : akim@amc.seoul.kr J Korean Med Assoc 2007; 50(12): 1096-1106 Abstract Despite recent improvements in the intensive care for postpartum hemorrhage, it remains one of the leading causes of maternal mortality and morbidity for obstetricians. Because it is difficult to prevent or predict postpartum hemorrhage, it is important to manage any such patients correctly and promptly. Management of postpartum hemorrhage may vary greatly among patients, depending on the etiology of the bleeding, available treatment options, and the patient's desire for future fertility. When managing postpartum hemorrhage, it is necessary to balance the use of conservative management with the need to control the bleeding and achieve hemostasis. Uterine massage and compression, and the administration of uterotonics such as oxytocin, ergometrine, and prostaglandins are primary, conservative, and noninvasive management techniques for patients with postpartum hemorrhage. Relatively noninvasive procedures such as curettage of remnant tissues, vaginal packing, repair of laceration, and percutaneous angiographic embolization can also be performed. In cases where these management techniques fail, surgical alternatives such as uterine or internal iliac artery ligation, uterine compression sutures, or hystrectomy are used. Surgical treatment of postpartum bleeding, performed as an appropriate and timely intervention, is lifesaving. The management of postpartum bleeding requires a multidisciplinary approach with timely and efficient communication between clinical specialists and preserving fertility. Keywords : Postpartum hemorrhage; Medical management; Surgical management 1096
Postpartum Hemorrhage Table 1. Etiology of Postpartum hemorrhage Primary: 24hours postdelivery Uterine atony most common Retained placenta especially placenta accreta Lower genital tract lacerations Uterine rupture Defects in coagulation Uterine inversion Secondary: > 24hours to 6 ~12weeks postdelivery Subinvolution of placenta site Retained products of contraception Infection Inherited coagulation defects 1097
Kim A Figure 1. Management of major postpartum hemorrhage (blood loss >1,000ml or clinical shock)(12). 1098
Postpartum Hemorrhage Table 2. Uterotonic Agents for Postpartum Hemorrhage(14) Medication Oxytocin (Pitocin) Methylergono vine (Methergin) 15methyl PGF 2 (Carboprost) Dinoprostone (Prostin E 2 ) Misoprostol (Cytotec, PGE 1 ) Dose 1040U in 1,000mL of normal saline or lactated Ringer solution 0.2mg 0.25mg 20mg 800~1,000mcg Primary Route (Alternate) IV (IM,IMM) IM (IMM) IM (IMM) Suppository: vaginal or rectal Rectally Frequency of Dose Continuous infusion Every 2~4h Every 1590min, not to exceed 8 doses Every 2h Abbreviations: IV, intravenously; IM, intramuscularly; IMM, intramyometrial *all agents can cause nausea and vomiting Side effects Usually none, but nausea,vomiting and water intoxication have been reported Hypertension, hypotension, n ausea, vomiting Vomiting, diarrhea, nausea, flushing or hot flashes, chills or shivering Vomiting, diarrhea, nausea, fever, headache, chills or shivering Comments and Contraindication No contraindication Contraindication include hypertension/ toxemia Contraindication includes active cardiac, pulmonary, renal, or hepatic disease Avoid if patient is hypotensive. Fever is common. Stored frozen, it must be thawed to room temperature 1099
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Postpartum Hemorrhage A B Figure 2. A 31 yearold female delivered a baby by vaginal birth at local clinic. A) Arterial angiogram shows that a pseudoaneurysm (arrow) of left uterine artery. B) Gelfoam and glue (1:1 mixture with lipiodol) embolization with use of microcatheter. Vascularity of left uterine artery has disappered on postembolization left internal iliac angiogram. 1101
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Kim A Peer Reviewer Commentary 1106