OB Hemorrhage
ADU-15
Diagnosis
Cumulative Blood Loss (intrapartum and postpartum) > 1000mL in vaginal or cesarean delivery or blood loss associated with signs or symptoms of hypovolemia within 24 hours after delivery
Call for help
- Ask: "Who will be the crisis manager?"
- Crisis manager designates checklist reader
- Crisis manager designates a person to monitor estimated blood loss
Announce vital signs and cumulative blood loss every 10 minutes
Open IV fluids and establish adequate IV access
- Warm patient and fluids
- Insert bladder catheter
- Consider arterial access
Turn FiO2 to 100% or start supplemental oxygen
- Minimize volatile anesthetics
Prepare for transfusion
- Assign 1 person as primary contact with Blood Bank
- Activate massive transfusion protocol
- Request rapid transfuser device
Send STAT labs
- CBC, BMP, Type and Screen, fibrinogen, PT, aPTT, lactate
- Viscoelastography
Give uterotonic agents and tranexamic acid
Begin transfusion
- Transfuse with products in ratio of 4 PRBCS : 4 FFP : 1 Platelet
- Target fibrinogen > 200 mg/dL
- 10 units cryoprecipitate, expected rise 100 mg/dL
- Fibrinogen concentrate 4g, expected rise 100 mg/dL
Surgical team: perform exam and uterine massage
- Consider the differential diagnosis (see box)
- Consider D+C, laceration repair, uterine tamponade
- If bleeding unresponsive, consider uterine artery ligation or hysterectomy, or Interventional Radiology for embolization
Drugs
| Oxytocin (Pitocin) | 3 units IV BOLUS or 5-10 units IM BOLUS |
|---|---|
| Oxytocin (Pitocin) | — followed by — |
| Oxytocin (Pitocin) | 10 - 40 units in 500 - 1000 mL IV INFUSION |
| Oxytocin (Pitocin) | Caution in hypotension |
| Methylergonovine maleate (Methergine) | 0.2 mg IM q 2 - 4 hours |
| Methylergonovine maleate (Methergine) | DO NOT administer IV |
| Methylergonovine maleate (Methergine) | Caution in hypertension, cardiac disease |
| Carboprost tromethamine (Hemabate) | 250 MICROgrams q 15 - 90 min IM x8 max |
| Carboprost tromethamine (Hemabate) | DO NOT administer IV |
| Carboprost tromethamine (Hemabate) | Caution in asthma, HTN |
| miSOPROStol (Cytotec) | 800 - 1000 MICROgrams PR/buccal/SL x1 dose |
| Tranexamic Acid (TXA) | 1000mg IV over 10 min, repeat x1 after 30 min |
| Calcium Chloride | 1g per 5 units product |
| Calcium Chloride | —or— |
| Calcium Gluconate | 1g per 3 units product |
DIFFERENTIAL diagnosis
- Tone (uterine atony)
- Trauma (lacerations or uterine rupture)
- Tissue (retained placenta)
- Thrombin (clotting factor deficiency)