Case: Post-Partum Hemorrhage
A 24 year-old G2P1 female at 38 weeks of pregnancy arrives by EMS after delivering the ambulance. You work at a community emergency department with no in-house OB/GYN. In-house pediatricians will take over care fo the newborn. At time of arrival, EMS has clamped and cut the cord.
Initial Vitals: HR 110, RR 28, BP 110/60, SpO2 98%
Exam: Diaphoretic, tearful female. AOX3. Umbilical cord with clamp coming out of vagina. Gravid abdomen.
Flow of Case:
Patient arrives tearful, but stable. Cord was cut and clamped. The placenta is delivered.
Upon repeat exam:
Patient becomes hypotensive, tachycardic and less responsive. Gurney sheets are soaked through with blood with active vaginal bleeding.
What are the next steps?
Consider all causes of post-partum hemorrhage
o Most common etiologies: uterine atony > trauma/lacerations> retained products> coagulopathy
Have a step-wise process to evaluate for the above causes
o Sweep briefly for retained products
o Check placenta to see if it is intact
o Look for lacerations
o Begin bimanual uterine massage (see below)
Image from: https://www.aafp.org/afp/2007/0315/p875.html
o Check for DIC w/ labs: low fibrinogen, thrombocytopenia and elevated PT/PTT, INR and d-dimer
Medications for PPH
o Oxytocin (Pitocin): 40 units into 1L NS infused at 200-500ml/hr, then titrate to effect
Note: IV bolus can lead to hypotension!
If no IV access, can give 10 units IM
o Methylergonovine (Methergin): 0.2 unit IM
Contraindication: hypertension or pre-eclampsia
o Carboprost (hemabate): 0.25 mG IM
Contraindication: asthma (can cause bronchospasm)
o Misoprostal: 800-1000 units rectally or sub-lingual
o TXA: 1g over ten minutes
o Remember balanced resuscitation (1:1:1) and O negative blood
Note: these are suggested doses based on literature review,. These may vary based on hospital protocols or availability. Please always check with your pharmacist or OB/GYN when giving these medications.
References:
Management of postpartum hemorrhage in the emergency department – First10EM. First10EM. https://first10em.com/2015/06/22/management-of-postpartum-hemorrhage-in-the-emergency-department. Published June 22, 2015. Accessed November 27, 2020.
Written by Emily DeDonato, MD
Cook County Health, Simulation Fellow
For more Sim information: https://www.chicagosimfellowship.com/features.