Postpartum Hemorrhage Algorithm

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Postpartum Hemorrhage Algorithm

The following algorithm is based the California Maternal Quality Care Collaborative OB Hemorrhage Protocol.

Stage 0
Blood Loss less than 500ml with Vaginal delivery; less than 1000 ml with cesarean section. Stable vital signs

All women receive active management of 3rd stage Oxytocin IV infusion or 10 Units IM
Vigorous fundal massage for 15 seconds minimum

Stage 1
Blood Loss > 500ml Vaginal delivery; > 1000 ml cesarean section
15% Vital Sign change -or-HR equal to or greater than 110, BP equal to or less than 85/45 O2 Sat less than 95%, pallor, delayed capillary refill, or decreased urine output. can indicate
Decreased urine output, decreased BP and tachycardia may be late signs of compromise

Call for help.
Provide adequate ventilation
Assist airway protection
Establish large-bore intravenous access
Supplemental O2 5-7 L/min by tight face mask
Prepare 2 units of packed red cells.
Evaluate for atony, lacerations, hematoma, inverted uterus , retained tissue, accreta, coagulopathy.
Medication for uterine atony
- Oxytocin
  10-40 units in 1 liter NS or LR IV rapid infusion
- Methylergonovine (Methergine)
  0.2 milligrams intramuscular q 2-4 hrs up to 5 doses

Stage 2
1000-1500 ml estimated blood loss with continued bleeding.

Move to operating room
Transfuse 2 Units PRBCs per clinical signs
Consider thawing 2 Units FFP
Order CBC, PT/INR/PTT, Fibrinogen
- Warm blood products and infusions to prevent hypothermia, coagulopathy and arrhythmias
Medication for uterine atony

Prostaglandin F2 Alpha (Hemabate)
250 micrograms intramuscular, intramyometrial, repeat q 15-90 minutes,
maximum 8 doses
Prostaglandin E2 suppositories (Dinoprostone, Prostin E2)
20 milligrams per rectum q 2 hrs
Misoprostol (Cytotec)
1000 micrograms per rectum

Surgical intervention
- Vaginal Birth:
- Atony Bimanual Fundal Massage
- Retained POC: Dilation and Curettage
- Lower segment/Implantation site/Atony: Intrauterine Balloon
- Laceration/Hematoma: Packing, Repair as Required
Cesarean Birth:
- Continued Atony: B-Lynch Suture/Intrauterine Balloon
- Continued Hemorrhage: Uterine Artery Ligation
- Hypogastric Ligation (experienced surgeon only)

Stage 3
Estimated blood loss gretaer than 1500 ml with continued blood loss.

Activate massive transfusion protocol (MTP),
- MTP "Pack", to be sent from the Blood Bank is:
  - 4 units PRBC
  - 2 OR 4 units FFP
  - 1 apheresis pack of platelets
- Obtain CBC , PT/INR/PTT, and fibrinogen every 4 hours after the standard MTP "Pack" is given. Laboratory studies should be monitored for at least 24 hours after discontinuing the protocol.
- Note: 10 units cryoprecipitate should be given for fibrinogen <100mg/dl
If bleeding continues after 2 MTP packs have been administered, or women is refusing transfusions (e.g. Jehovah Witnesses) , consider recombinant activated factor VII (rFVIIa, NovoSeven®) 60 mcg/kg. May repeat in 30 minutes
Surgical intervention
- B-Lynch Suture/Intrauterine Balloon
- Uterine Artery Ligation
- Hypogastric Ligation (experienced surgeon only)
- Hysterectomy

REFERENCES:

1.http://www.cmqcc.org/resources/ob_hemorrhage/ob_hemorrhage_protocol_tools_release_1_2
2. Burtelow M, Riley E, Druzin M, Fontaine M, Viele M, Goodnough LT. How we treat: management of life-threatening primary postpartum hemorrhage with a standardized massive transfusion protocol. Transfusion. 2007 Sep;47(9):1564-72. PMID: 17725718
3. Malone , MD , LTC USAF, SGRS, D.L., Hess , MD , MPH, J. R., & Fingerhut, MD, A., (2006). Massive Transfusion Practices Around the Globe and a Suggestion for Common Massive Transfusion Protocol. J Trauma , 60, S91-S96.
4. Sobieszczyk S, Breborowicz GH. The use of recombinant factor VIIa in A Textbook of PostPartum Hemorrhage (ed C. B-Lynch et al.). Sapiens Publishing 2006; p 250
5. Franchini M, Franchi M, Bergamini V, Salvagno GL, Montagnana M, Lippi G. A Critical Review on the Use of Recombinant Factor VIIa in Life-Threatening Obstetric Postpartum Hemorrhage. Semin Thromb Hemost 2008; 34: 104-12.
6. O'Connell KA, Wood JJ, Wise RP, Lozier JN, Braun MM. Thromboembolic adverse events after use of recombinant human coagulation factor VIIa. JAMA 2006; 295: 293-8.
7. Hemabate (carboprost tromethamine) package insert. Pharmacia & Upjohn Co., Division of Pfizer Inc, NY, NY 10017. FDA rev date: march 2006
8. . O'Brien P, et al. Rectally administered misoprostol for the treatment of postpartum hemorrhage unresponsive to oxytocin and ergometrine: a descriptive study.Obstet Gynecol. 1998 Aug;92(2):212-4. PMID: 9699753
9. Methergine package insert. Novartis Pharmaceuticals Corporation East Hanover, New Jersey 07936. FDA Rev date: 4/26/2007

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