Prevention and Management of Postpartum Hemorrhage
JANICE M. ANDERSON, M.D., Forbes Family Medicine Residency Program, Western Pennsylvania Hospital Forbes Regional Campus, Monroeville, Pennsylvania
DUNCAN ETCHES, M.D., M.CL.SC., University of British Columbia Faculty of Medicine, Vancouver, British Columbia
Postpartum hemorrhage, the loss of more than 500 mL of blood after delivery, occurs in up to 18 percent of births and is the most common maternal morbidity in developed countries. Although risk factors and preventive strategies are clearly documented, not all cases are expected or avoidable. Uterine atony is responsible for most cases and can be managed with uterine massage in conjunction with oxytocin, prostaglandins, and ergot alkaloids. Retained placenta is a less common cause and requires examination of the placenta, exploration of the uterine cavity, and manual removal of retained tissue. Rarely, an invasive placenta causes postpartum hemorrhage and may require surgical management. Traumatic causes include lacerations, uterine rupture, and uterine inversion. Coagulopathies require clotting factor replacement for the identified deficiency. Early recognition, systematic evaluation and treatment, and prompt fluid resuscitation minimize the potentially serious outcomes associated with postpartum hemorrhage. (Am Fam Physician 2007;75:875-82. Copyright © 2007 American Academy of Family Physicians.)
Postpartum hemorrhage, defined as the loss of more than 500 mL of blood after delivery, occurs in up to 18 percent of births.1,2 Blood loss exceeding 1,000 mL is considered physiologically significant and can result in hemodynamic instability.3 Even with appropriate management, approximately 3 percent of vaginal deliveries will result in severe postpartum hemorrhage.4 It is the most common maternal morbidity in developed countries and a major cause of death worldwide.1,3
Complications from postpartum hemorrhage include orthostatic hypotension, anemia, and fatigue, which may make maternal care of the newborn more difficult. Postpartum anemia increases the risk of postpartum depression.5 Blood transfusion may be necessary and carries associated risks.6 In the most severe cases, hemorrhagic shock may lead to anterior pituitary ischemia with delay or failure of lactation (i.e., postpartum pituitary necrosis).7,8 Occult myocardial ischemia, dilutional coagulopathy, and death also may occur.9 Delayed postpartum hemorrhage, bleeding after 24 hours as a result of sloughing of the placental eschar or retained placental fragments, also can occur.10...
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