Postpartum hemorrhage - Revision history

Danbot: Strip excess bold

2026-03-22T09:35:30Z

Strip excess bold

← Revisión anterior		Revisión del 09:35 22 mar 2026
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	==Management==		==Management==
	''Treat underlying cause: ~~'''T'''one~~, ~~'''T'''rauma~~, ~~'''T'''issue~~, ~~'''T'''hrombosis~~''		''Treat underlying cause: Tone, Trauma, Tissue, Thrombosis''
	*Consider [[Fluid resuscitation]] vs [[blood products]] for hemodynamic instability		*Consider [[Fluid resuscitation]] vs [[blood products]] for hemodynamic instability
	*Early [[tranexamic acid]] (TXA) reduces death due to bleeding<ref>Ducloy-Bouthors AS et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15(2):R117.</ref><ref>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. 2017 Apr 26. pii: S0140-6736(17)30638-4.</ref>		*Early [[tranexamic acid]] (TXA) reduces death due to bleeding<ref>Ducloy-Bouthors AS et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15(2):R117.</ref><ref>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. 2017 Apr 26. pii: S0140-6736(17)30638-4.</ref>
	**Give as soon as possible relative to bleeding onset		**Give as soon as possible relative to bleeding onset
	**1 g IV of TXA over 10 min, with 2nd dose 30 min later if continual bleed ~~'''~~OR~~'''~~ bleed restarts within 24 hrs after 1st dose<ref>Shakur H et al. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010 Apr 16;11:40.</ref>		**1 g IV of TXA over 10 min, with 2nd dose 30 min later if continual bleed OR bleed restarts within 24 hrs after 1st dose<ref>Shakur H et al. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010 Apr 16;11:40.</ref>
	**No difference between placebo and TXA in adverse events, including thromboembolism		**No difference between placebo and TXA in adverse events, including thromboembolism
	**All-cause mortality and hysterectomy not reduced with TXA		**All-cause mortality and hysterectomy not reduced with TXA
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	**External uterine massage stimulates uterine contraction		**External uterine massage stimulates uterine contraction
	**Bimanual massage: One fist is placed intravaginally in the anterior fornix. Other hand massages the fundus while compressing against the vaginal hand.		**Bimanual massage: One fist is placed intravaginally in the anterior fornix. Other hand massages the fundus while compressing against the vaginal hand.
	*[[Oxytocin]] (Pitocin) ~~'''~~1st-line and most important drug~~'''~~		*[[Oxytocin]] (Pitocin) 1st-line and most important drug
	**IV options:		**IV options:
	***20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>		***20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>
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	*Examine for tears in vaginal, cervical, and perineal areas under good lighting and suction		*Examine for tears in vaginal, cervical, and perineal areas under good lighting and suction
	*Suture [[lacerations]] - simple running or figure of eight with 3-0 or 2-0 absorbable		*Suture [[lacerations]] - simple running or figure of eight with 3-0 or 2-0 absorbable
	*Deep lacerations such as those by the cervix may require ~~'''~~OR~~'''~~		*Deep lacerations such as those by the cervix may require OR
	*Drain hematomas >3 cm		*Drain hematomas >3 cm

Danbot: Add MedicationDose SMW entries for oxytocin, misoprostol, methylergonovine, tranexamic acid; doses verified against ACOG/WHO guidelines

2026-03-20T17:41:42Z

Add MedicationDose SMW entries for oxytocin, misoprostol, methylergonovine, tranexamic acid; doses verified against ACOG/WHO guidelines

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 *Admit
 *May require OR for any of the above etiologies not responsive to first-line treatments
 ==See Also==

Rossdonaldson1: /* Evaluation */

2024-12-04T16:52:12Z

Evaluation

← Revisión anterior		Revisión del 16:52 4 dic 2024
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	==Evaluation==		==Evaluation==
	*Clinical diagnosis

	===Work-up===		===Work-up===
	*Quantitative blood loss (QBL): Volumetric containers (V-drapes) can quantify vaginal blood loss		*Quantitative blood loss (QBL): Volumetric containers (V-drapes) can quantify vaginal blood loss
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	*Coags		*Coags
	*Type and cross		*Type and cross

			===Diagnosis===
			*Clinical diagnosis

	==Management==		==Management==

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2024-04-17T20:10:29Z

Video

← Revisión anterior		Revisión del 20:10 17 abr 2024
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	==References==		==References==
	<references/>		<references/>

	~~==Video==~~
	~~{{#widget:YouTube\|id=dz2gYz4FQcY}}~~

	[[Category:OBGYN]]		[[Category:OBGYN]]

Patricklin at 05:55, 4 December 2023

2023-12-04T05:55:43Z

← Revisión anterior		Revisión del 05:55 4 dic 2023
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	==Background==		==Background==
	*Leading cause of maternal death worldwide		*Leading cause of maternal death worldwide
			**Approx 3% to 5% of obstetric patients will experience PPH<ref>Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017 Apr 1;95(7):442-449. PMID: 28409600.</ref>
			**In the US, 11% of maternal deaths are caused by hemorrhage<ref>Bienstock JL, Eke AC, Hueppchen NA. Postpartum Hemorrhage. N Engl J Med. 2021 Apr 29;384(17):1635-1645. doi: 10.1056/NEJMra1513247. PMID: 33913640; PMCID: PMC10181876.</ref>

	===Causes===		===Causes===
	*Uterine atony (responsible for 80% of cases)		*Uterine atony (responsible for 80% of cases)
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	*Uterine inversion		*Uterine inversion
	*Underlying [[coagulopathy\|coagulation abnormalities]]		*Underlying [[coagulopathy\|coagulation abnormalities]]
			*Abnormal placentation: [[Placenta previa]], [[placenta accreta]]

	==Clinical Features==		==Clinical Features==
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	==Evaluation==		==Evaluation==
			*Clinical diagnosis

	===Work-up===		===Work-up===
			*Quantitative blood loss (QBL): Volumetric containers (V-drapes) can quantify vaginal blood loss
	*CBC		*CBC
			*CMP
	*Coags		*Coags
	*Type and cross		*Type and cross

	~~===Evaluation===~~
	*Clinical diagnosis

	==Management==		==Management==
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	===Tone===		===Tone===
	''[[Uterine atony]] (boggy uterus)''		''[[Uterine atony]] (boggy uterus)''
	*Bimanual ~~Massage~~		*Assess intravaginally for lower segment atony, which may occur even when the fundus is well-contracted
			*Uterine massage
			**External uterine massage stimulates uterine contraction
			**Bimanual massage: One fist is placed intravaginally in the anterior fornix. Other hand massages the fundus while compressing against the vaginal hand.
	*[[Oxytocin]] (Pitocin) '''1st-line and most important drug'''		*[[Oxytocin]] (Pitocin) '''1st-line and most important drug'''
	**IV options:		**IV options:
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	***80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>		***80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>
	**IM option (if no IV):		**IM option (if no IV):
	***10 IU IM x 1		***10 IU IM x 1
	*[[Misoprostol]] (Cytotec)		*[[Misoprostol]] (Cytotec)
	**600mcg SL or 1000 mcg rectally		**600mcg SL or 1000 mcg rectally
	*[[Methylergonovine]] (Methergine)		*[[Methylergonovine]] (Methergine)
	**0.2mg IM q2-4 hrs		**0.2mg IM q2-4 hrs
	**Relative contraindication in patients with hypertension or [[Preeclampsia]]; may consider in severely unstable BP		**Relative contraindication in patients with hypertension or [[Preeclampsia]]; may consider in severely unstable BP
	*[[Carboprost]] (Hemabate)		*[[Carboprost]] (Hemabate)
	**250mcg IM q15 min (avoid in patients with asthma)		**250mcg IM q15 min (avoid in patients with asthma)
	*Bakri balloon placement		*Bakri balloon placement
	**Fill with warm 500ml NS (or large/multiple Foleys or pack)		**Fill with warm 500ml NS (or large/multiple Foleys or pack)
	**Use US to place to top of fundus and ensure no retained placenta		**Use US to place to top of fundus and ensure no retained placenta
			*Uterine/vaginal packing
			**Kerlix packing may be utilized when balloon is not available, but can result in increased rates of iatrogenic foreign body and infection
			*Uterine artery embolization
			**May be considered in a stable patient, if bleeding persists

	===Trauma===		===Trauma===
	''Genital tract tear''		''Genital tract tear''
	*Examine for tears under good lighting and suction		*Examine for tears in vaginal, cervical, and perineal areas under good lighting and suction
	*Suture [[lacerations]] - figure of eight with 3-0 or 2-0 absorbable		*Suture [[lacerations]] - simple running or figure of eight with 3-0 or 2-0 absorbable
	*Deep lacerations such as those by the cervix may require '''OR'''		*Deep lacerations such as those by the cervix may require '''OR'''
	*Drain hematomas >3 cm		*Drain hematomas >3 cm
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	===Tissue===		===Tissue===
	''Retained placental tissue''		''Retained placental tissue''
	*Evaluate placenta for retained products		*Evaluate placenta for pieces that may become retained products
	*Pelvic exam may be normal other than blood		**Pelvic exam may be normal other than blood
	*Detect with US		**Detect with manual exam or US
	*Manual removal		*Manual removal
			**Adequate anesthesia and uterine relaxants may be needed (if no atony noted)
			**Manual exploration of uterine cavity with sterile gloves, removal of placental fragments
	*Curettage		*Curettage

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	==Disposition==		==Disposition==
	*Admit		*Admit
			*May require OR for any of the above etiologies not responsive to first-line treatments

	==See Also==		==See Also==

Rossdonaldson1: /* Tone */

2021-09-22T19:59:02Z

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← Revisión anterior		Revisión del 19:59 22 sep 2021
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	***20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>		***20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>
	***80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>		***80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>
	**~~'''OR''' 10 units~~ IM if no IV		**IM option (if no IV):
			***10 IU IM x 1
	*[[Misoprostol]] (Cytotec)		*[[Misoprostol]] (Cytotec)
	**600mcg SL or 1000 mcg rectally		**600mcg SL or 1000 mcg rectally

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2021-09-22T19:58:12Z

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← Revisión anterior		Revisión del 19:58 22 sep 2021
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	''[[Uterine atony]] (boggy uterus)''		''[[Uterine atony]] (boggy uterus)''
	*Bimanual Massage		*Bimanual Massage
	*[[Oxytocin]] (Pitocin) ''1st line and most important drug''		*[[Oxytocin]] (Pitocin) '''1st-line and most important drug'''
	**IV options:		**IV options:
	***20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>		***20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>

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2021-09-22T19:57:42Z

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← Revisión anterior		Revisión del 19:57 22 sep 2021
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	**IV options:		**IV options:
	***20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>		***20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>
	**80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>		***80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>
	**'''OR''' 10 units IM if no IV		**'''OR''' 10 units IM if no IV
	*[[Misoprostol]] (Cytotec) 600mcg SL or 1000 mcg rectally		*[[Misoprostol]] (Cytotec)
	*[[Methylergonovine]] (Methergine) 0.2mg IM q2-4 hrs ~~(relative~~ contraindication in patients with hypertension or [[Preeclampsia]] - may consider in severely unstable BP)		**600mcg SL or 1000 mcg rectally
	*[[Carboprost]] (Hemabate) 250mcg IM q15 min (avoid in patients with asthma)		*[[Methylergonovine]] (Methergine)
	*Bakri balloon placement~~, fill~~ with warm 500ml NS (or large/multiple Foleys or pack) ~~- use~~ US to place to top of fundus and ensure no retained placenta		**0.2mg IM q2-4 hrs
			**Relative contraindication in patients with hypertension or [[Preeclampsia]]; may consider in severely unstable BP
			*[[Carboprost]] (Hemabate)
			**250mcg IM q15 min (avoid in patients with asthma)
			*Bakri balloon placement
			**Fill with warm 500ml NS (or large/multiple Foleys or pack)
			**Use US to place to top of fundus and ensure no retained placenta

	===Trauma===		===Trauma===

Rossdonaldson1: /* Tone */

2021-09-22T19:56:34Z

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← Revisión anterior		Revisión del 19:56 22 sep 2021
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	''[[Uterine atony]] (boggy uterus)''		''[[Uterine atony]] (boggy uterus)''
	*Bimanual Massage		*Bimanual Massage
	*[[Oxytocin]] (Pitocin)		*[[Oxytocin]] (Pitocin) ''1st line and most important drug''
	**1st line and most important drug		**IV options:
	**20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>		***20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>
			**80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>
	**'''OR''' 10 units IM if no IV		**'''OR''' 10 units IM if no IV
	**In one study: Oxytocin 80 units in 500 cc NS bag run wide open (80 units decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>
	*[[Misoprostol]] (Cytotec) 600mcg SL or 1000 mcg rectally		*[[Misoprostol]] (Cytotec) 600mcg SL or 1000 mcg rectally
	*[[Methylergonovine]] (Methergine) 0.2mg IM q2-4 hrs (relative contraindication in patients with hypertension or [[Preeclampsia]] - may consider in severely unstable BP)		*[[Methylergonovine]] (Methergine) 0.2mg IM q2-4 hrs (relative contraindication in patients with hypertension or [[Preeclampsia]] - may consider in severely unstable BP)

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2021-09-22T19:54:34Z

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← Revisión anterior		Revisión del 19:54 22 sep 2021
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	*Bimanual Massage		*Bimanual Massage
	*[[Oxytocin]] (Pitocin)		*[[Oxytocin]] (Pitocin)
	**1st line and most important drug ~~- Oxytocin~~ 20 IU in 1 L of ~~saline may be infused~~ at ~~a rate of~~ 250 mL ~~per hour. As much as~~ 500 mL ~~can be infused~~ over 10 minutes ~~without complications such as hypotension.~~ <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>		**1st line and most important drug
			**20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) <ref>Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82. PMID: 17390600.</ref>
	**'''OR''' 10 units IM if no IV		**'''OR''' 10 units IM if no IV
	**In one study: Oxytocin 80 units in 500 cc NS bag run wide open (80 units decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>		**In one study: Oxytocin 80 units in 500 cc NS bag run wide open (80 units decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). <ref>Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.</ref>