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Postpartum Hemorrhage from Atony Unresponsive to First Line Uterotonics

6/1/2017 - Efua Leke, MD

Mentor:  Tiffany A. Moore-Simas, MD

Editor:  Christine R. Isaacs, MD

Postpartum hemorrhage (PPH), a leading cause of maternal morbidity, is associated with one-quarter of obstetric mortality worldwide.  Risk factors are well established, however PPH most often occurs without warning.  The most common etiology of postpartum hemorrhage is uterine atony.

First line uterotonic management to prevent uterine atony is routine oxytocin (Pitocin) administration soon after (or during) fetal delivery.   When there is ongoing blood loss in the setting of atony, repeat administration via continuous intravenous (IV) infusion or intramuscular (IM) dosing is appropriate.  Second line agents for the medical management of persistent atony include Methylergonovine (Methergine), which can be given 0.2 mg IM every 2-4 hours and should be avoided in the setting of hypertension, and 15-methyl PGF-2 alfa (Carboprost, Hemabate), which can be given 0.25 mg IM every 15 minutes up to a maximum of 8 doses.  Hemabate should be avoided in asthmatic patients.  Misoprostol (Cytotec) is not more effective than oxytocin and takes longer to reach peak concentrations, especially when given rectally.  Misoprostol may have a role in low resource settings where other agents are not immediately available, but should not be used as the sole therapy in the initial management of unresponsive uterine atony.

Simultaneous management of atony-related PPH includes bladder emptying, bimanual uterine examination, evacuation of clots or identified retained products, and fundal massage.  In addition, there should be adequate IV access, monitoring of hemodynamic status, and anesthesia support. With persistent bleeding, effective leadership and teamwork is needed to concurrently redose uterotonics while replacing intravascular volume with fluids and blood products including the repletion of coagulation factors as appropriate.  Massive transfusion protocols and simulation training are designed to facilitate efficient patient management in the case of severe blood loss.

When atony persists and remains unresponsive to initial physical exam and pharmacologic interventions, ultrasound evaluation be performed to assess for retained products and prompt dilation and curettage performed.  Tamponade techniques including uterine packing, Foley catheter placement, Sengstaken-Blakemore tube, and specialized commercial products including the Bakri or Ebb balloon.  Choice should be guided by product availability and provider experience.  Vascular embolization by interventional radiology can be considered when available for stable patients with continued blood loss.  Arterial embolization has shown success rates of up to 91% for controlling hemorrhage.

With failure of non-surgical measures, exploratory laparotomy should be performed, typically via vertical midline skin incision to optimize exposure and allow for additional measures including:

  • Bilateral uterine vessel ligation (O’Leary stitch technique)
  • Uterine compression sutures (B-Lynch technique)
  • Hemostatic square suturing of the anterior and posterior uterine wall (Cho technique)
  • Hypogastric artery ligation
  • Hysterectomy

Hysterectomy is typically employed as a last resort after less morbid options have been exhausted, but may be necessary as a life-saving procedure.

Additional Reading:

Postpartum hemorrhage. ACOG Practice Bulletin No. 76. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1039–48.

Initial Approval:  January 2017

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