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Severe Delayed Postpartum Hemorrhage after Cesarean Section
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2018 Ó 2018 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
https://doi.org/10.1016/j.jemermed.2018.04.010
Clinical Communications: OB/GYN SEVERE DELAYED POSTPARTUM HEMORRHAGE AFTER CESAREAN SECTION Nirav Patel, DO and Michael Radeos, MD, MPH Emergency Medicine Department, Coney Island Hospital, Brooklyn, New York Corresponding Address: Nirav Patel, DO, Emergency Medicine Department, Coney Island Hospital, 2601 Ocean Parkway, Brooklyn, NY 11215
, Abstract—Background: Severe secondary or delayed postpartum hemorrhage (PPH) is rare and affects 0.23–3% of all pregnancies. It happens between 24 hours to 12 weeks postdelivery. These PPHs occur more often during normal vaginal delivery; only a small subset of these PPHs occur after cesarean section. The top differential diagnoses of both primary and secondary PPH are different, and as a result, the management may be different. Although uterine atony causes 80% of primary PPHs, extensive literature review exposed the rarity of it in the setting of secondary PPH. Case Report: A 27-year-old woman presented to the emergency department 1 week after a cesarean section for severe vaginal bleeding that started an hour earlier. The patient required rigorous uterine massage for approximately 30 min along with oxytocin, carboprost, methergine, and misopristol before bleeding subsided. She required 1 unit of O– blood transfusion during resuscitation and still had a hemoglobin drop of 2.7 g/dL from arrival to after bleeding subsided. Why Should An Emergency Physician Be Aware of This?: PPH is a life-threatening condition that emergency physicians rarely encounter and may be uncomfortable managing. It is important to be familiar with the differential diagnosis of both primary and secondary PPH and the management of each of the causes. Ó 2018 Elsevier Inc. All rights reserved.
INTRODUCTION Severe secondary or delayed postpartum hemorrhage (PPH) is rare and affects 0.23–3% of all pregnancies (1,2). These PPHs occur more often during normal vaginal delivery; a small subset of PPHs occur after cesarean section (1–3). Furthermore, #60% of cases are caused by retained products of pregnancy (1). Other causes include endometritis, abnormally heavy return of menses, pseudoaneurysm of the uterine artery, hematoma, and subinvolution of the placental bed (1). The generally accepted definition of secondary PPH is significant blood loss that occurs between 24 h and 12 weeks postpartum (4,5). Unlike primary PPH, the quantity of blood loss is not specifically described in literature. The severity is often defined by the need for surgical intervention or blood transfusions (1–3,6). Most of these cases are managed conservatively, but some may require operative intervention (2). It is important to know the differential diagnosis and management while also involving the specialist as soon as possible. CASE REPORT
, Keywords—bleeding; C-section; cesarean section; delayed postpartum hemorrhage; delayed PPH; hemorrhage; hemorrhagic shock; postpartum hemorrhage; PPH; secondary postpartum hemorrhage; secondary PPH; txa; tranexamic acid; uterine atony
A 27-year-old gravida 2 para 2 woman status post uneventful repeat cesarean section 1 week earlier presented to our emergency department with heavy vaginal bleeding for 1 hour. She stated that she used 4 pads in the previous hour. The bleeding was accompanied with lower abdominal cramping. She denied any bleeding or
Reprints are not available from the authors.
RECEIVED: 9 October 2017; FINAL SUBMISSION RECEIVED: 23 January 2018; ACCEPTED: 10 April 2018 1
2
N. Patel and M. Radeos
pain until the hour before arrival. Presenting vital signs included blood pressure of 99/69 mm Hg, a heart rate of 105 beats/min, a respiratory rate of 14 breaths/min, and she was afebrile. She was alert and oriented and in no distress. An intravenous (IV) line was started and laboratory assessments were drawn. The patient was taken for an immediate pelvic examination. During the transfer to the gynecology examination table, the patient had an episode of syncope. She was immediately taken to the resuscitation area for a second IV to be inserted and for an emergency blood transfusion. Examination revealed profuse bleeding and a large boggy uterus. Uterine massage was initiated. A gynecology consultant was paged and O– blood was ordered. Oxytocin (40 units IV, 20 units intramuscularly [IM]) was given without improvement of the bleeding or the uterine atony. The gynecologist recommended carboprost (250 mcg IM), methergine (0.2 mg IM), and misoprostol (1000 mcg rectally). At that time, her blood pressure was 80/50 mm Hg and her heart rate was around 110 beats/min. One unit of O– blood was transfused along with 2 more liter boluses of intravenous normal saline. Initial hemoglobin was 10.8 g/dL with no baseline hemoglobin available. After 30 min of continuous uterine massage, the patient’s bleeding significantly decreased. Her hemoglobin level after 1 unit of blood was 8.1 g/dL. Her pelvic examination, after secession of the bleeding, revealed no vaginal or cervical laceration and her transvaginal ultrasound did not uncover any retained products. She was then admitted to labor and delivery for monitoring. Further laboratory workup did not reveal any coagulopathy, platelet, or genetic disorders. She was discharged 2 days later. DISCUSSION PPH is one of the leading causes of maternal mortality worldwide. In France, 25.8% of maternal deaths are caused by hemorrhage (3). However, secondary PPH after cesarean section is not well described in the literature. This case is unusual because of the physical examination findings of a large boggy uterus and the absence of retained products found on ultrasound. Although uterine atony causes 80% of primary PPH, extensive literature review exposed the rarity of it in the setting of secondary PPH (7). Another interesting aspect of the case was the delayed onset of her hemorrhage. Her hemoglobin on arrival was 10.8 g/dL and repeat testing after bleeding subsided showed a hemoglobin of 8.1 g/dL. This second hemoglobin was taken after 1 unit of O– blood had been transfused. Our patient had a considerable blood loss in the emergency department. Fortunately, in this case, her symptoms resolved after bimanual massage and medication administration.
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Postpartum hemorrhage is a life-threatening emergency that emergency physicians rarely encounter and can have difficulty managing. It is important to be comfortable with the management done in the emergency department and be familiar with the management that can be done by a specialist. It is important to note that the treatment of PPH is evolving. Newer studies have shown how transexamic acid, if given within 3 h, can have a meaningful impact in reducing PPH (8). Another option is a Bakri balloon, which may be able to tamponade the bleeding. It is important to notify the specialist as quickly as possible because some of these cases may require embolization done by an interventional radiologist or a hysterectomy if bleeding is not controlled with medical management. Secondary PPH is quite rare, and therefore it is prudent to approach it in a stepwise manner to both identify the disorder and to manage it. Although sources vary considerably, placental retention caused 30% of secondary PPH followed by subinvolution of the placental bed in approximately 13%. Other less common causes include endometritis, pseudoaneurysm of the uterine artery, and excessive return of menses. Almost 17% of causes were undetermined (1). The rationale for initial management of this condition appears to be that the uterus fails to contract secondary to either retained product or endometritis (5). Initially, the physical examination finding of a large uterus may prompt administration of oxytocin along with bimanual massage. If there is not improvement in the bleeding a few minutes after these interventions, an urgent consult to gynecology should be made and a bedside ultrasound should be performed to look for retained products. At this time tranexamic acid is indicated. If bedside ultrasound shows retained products, prompt removal of these products are indicated. In certain facilities, the ability to get an in-house gynecology consult may be limited. In this case, for any life-threatening bleeds, a Bakri balloon may be considered to tamponade any bleeding until the patient is able to reach definitive care. Rare causes of secondary PPH should be considered in patients with a normal-size uterus and no retained products on ultrasound. In these cases, it is imperative to get the patient to definitive care with the gynecologist. If stable, they may consider getting further imaging such as an angiogram on the pelvic vessels and look for causes such as aneurysms of the uterine artery (9). In 1 study of 60 patients with severe secondary PPH, 9 patients had interventional radiologist–guided arterial embolization with a 100% success rate (1). Many unstable patients may require hysterectomy (5).
Severe Delayed PPH After Cesarean Section
REFERENCES 1. Dossou M, Debost-Legrand A, De´chelotte P, et al. Severe secondary postpartum hemorrhage: a historical cohort. Birth 2015;42: 149–55. 2. Hoveyda F, MacKenzie IZ. Secondary postpartum haemorrhage: incidence, morbidity and current management. BJOG 2001;108: 927–30. 3. Debost-Legrand A, Rivie`re O, Dossou M, Vendittelli F. Risk factors for severe secondary postpartum hemorrhages: a historical cohort study. Birth 2015;42:235–41. 4. Abdul-Kadir R, McLintock C, Ducloy AS, et al. Evaluation and management of postpartum hemorrhage: consensus from an international expert panel. Transfusion 2014;54:1756–68.
3 5. Alexander J, Thomas PW, Sanghera J. Treatments for secondary postpartum haemorrhage. Cochrane Database Syst Rev 2002;1:CD002867. 6. Stafford I, Dildy GA, Clark SL, Belfort MA. Visually estimated and calculated blood loss in vaginal and cesarean delivery. Am J Obstet Gynecol 2008;199:519.e1–7. 7. Dildy GA 3rd. Postpartum hemorrhage: new management options. Clin Obstet Gynecol 2002;45:330–44. 8. 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;389: 2105–16. 9. Samad S, Jonetzko P, Hawkins AP, Booth J, Thorpe-Beeston G, Marwood R. An unusual cause of delayed postpartum haemorrhage following caesarean section. Emerg Med J 2009;26:621–2.
https://doi.org/10.1016/j.jemermed.2018.04.010
Clinical Communications: OB/GYN SEVERE DELAYED POSTPARTUM HEMORRHAGE AFTER CESAREAN SECTION Nirav Patel, DO and Michael Radeos, MD, MPH Emergency Medicine Department, Coney Island Hospital, Brooklyn, New York Corresponding Address: Nirav Patel, DO, Emergency Medicine Department, Coney Island Hospital, 2601 Ocean Parkway, Brooklyn, NY 11215
, Abstract—Background: Severe secondary or delayed postpartum hemorrhage (PPH) is rare and affects 0.23–3% of all pregnancies. It happens between 24 hours to 12 weeks postdelivery. These PPHs occur more often during normal vaginal delivery; only a small subset of these PPHs occur after cesarean section. The top differential diagnoses of both primary and secondary PPH are different, and as a result, the management may be different. Although uterine atony causes 80% of primary PPHs, extensive literature review exposed the rarity of it in the setting of secondary PPH. Case Report: A 27-year-old woman presented to the emergency department 1 week after a cesarean section for severe vaginal bleeding that started an hour earlier. The patient required rigorous uterine massage for approximately 30 min along with oxytocin, carboprost, methergine, and misopristol before bleeding subsided. She required 1 unit of O– blood transfusion during resuscitation and still had a hemoglobin drop of 2.7 g/dL from arrival to after bleeding subsided. Why Should An Emergency Physician Be Aware of This?: PPH is a life-threatening condition that emergency physicians rarely encounter and may be uncomfortable managing. It is important to be familiar with the differential diagnosis of both primary and secondary PPH and the management of each of the causes. Ó 2018 Elsevier Inc. All rights reserved.
INTRODUCTION Severe secondary or delayed postpartum hemorrhage (PPH) is rare and affects 0.23–3% of all pregnancies (1,2). These PPHs occur more often during normal vaginal delivery; a small subset of PPHs occur after cesarean section (1–3). Furthermore, #60% of cases are caused by retained products of pregnancy (1). Other causes include endometritis, abnormally heavy return of menses, pseudoaneurysm of the uterine artery, hematoma, and subinvolution of the placental bed (1). The generally accepted definition of secondary PPH is significant blood loss that occurs between 24 h and 12 weeks postpartum (4,5). Unlike primary PPH, the quantity of blood loss is not specifically described in literature. The severity is often defined by the need for surgical intervention or blood transfusions (1–3,6). Most of these cases are managed conservatively, but some may require operative intervention (2). It is important to know the differential diagnosis and management while also involving the specialist as soon as possible. CASE REPORT
, Keywords—bleeding; C-section; cesarean section; delayed postpartum hemorrhage; delayed PPH; hemorrhage; hemorrhagic shock; postpartum hemorrhage; PPH; secondary postpartum hemorrhage; secondary PPH; txa; tranexamic acid; uterine atony
A 27-year-old gravida 2 para 2 woman status post uneventful repeat cesarean section 1 week earlier presented to our emergency department with heavy vaginal bleeding for 1 hour. She stated that she used 4 pads in the previous hour. The bleeding was accompanied with lower abdominal cramping. She denied any bleeding or
Reprints are not available from the authors.
RECEIVED: 9 October 2017; FINAL SUBMISSION RECEIVED: 23 January 2018; ACCEPTED: 10 April 2018 1
2
N. Patel and M. Radeos
pain until the hour before arrival. Presenting vital signs included blood pressure of 99/69 mm Hg, a heart rate of 105 beats/min, a respiratory rate of 14 breaths/min, and she was afebrile. She was alert and oriented and in no distress. An intravenous (IV) line was started and laboratory assessments were drawn. The patient was taken for an immediate pelvic examination. During the transfer to the gynecology examination table, the patient had an episode of syncope. She was immediately taken to the resuscitation area for a second IV to be inserted and for an emergency blood transfusion. Examination revealed profuse bleeding and a large boggy uterus. Uterine massage was initiated. A gynecology consultant was paged and O– blood was ordered. Oxytocin (40 units IV, 20 units intramuscularly [IM]) was given without improvement of the bleeding or the uterine atony. The gynecologist recommended carboprost (250 mcg IM), methergine (0.2 mg IM), and misoprostol (1000 mcg rectally). At that time, her blood pressure was 80/50 mm Hg and her heart rate was around 110 beats/min. One unit of O– blood was transfused along with 2 more liter boluses of intravenous normal saline. Initial hemoglobin was 10.8 g/dL with no baseline hemoglobin available. After 30 min of continuous uterine massage, the patient’s bleeding significantly decreased. Her hemoglobin level after 1 unit of blood was 8.1 g/dL. Her pelvic examination, after secession of the bleeding, revealed no vaginal or cervical laceration and her transvaginal ultrasound did not uncover any retained products. She was then admitted to labor and delivery for monitoring. Further laboratory workup did not reveal any coagulopathy, platelet, or genetic disorders. She was discharged 2 days later. DISCUSSION PPH is one of the leading causes of maternal mortality worldwide. In France, 25.8% of maternal deaths are caused by hemorrhage (3). However, secondary PPH after cesarean section is not well described in the literature. This case is unusual because of the physical examination findings of a large boggy uterus and the absence of retained products found on ultrasound. Although uterine atony causes 80% of primary PPH, extensive literature review exposed the rarity of it in the setting of secondary PPH (7). Another interesting aspect of the case was the delayed onset of her hemorrhage. Her hemoglobin on arrival was 10.8 g/dL and repeat testing after bleeding subsided showed a hemoglobin of 8.1 g/dL. This second hemoglobin was taken after 1 unit of O– blood had been transfused. Our patient had a considerable blood loss in the emergency department. Fortunately, in this case, her symptoms resolved after bimanual massage and medication administration.
WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? Postpartum hemorrhage is a life-threatening emergency that emergency physicians rarely encounter and can have difficulty managing. It is important to be comfortable with the management done in the emergency department and be familiar with the management that can be done by a specialist. It is important to note that the treatment of PPH is evolving. Newer studies have shown how transexamic acid, if given within 3 h, can have a meaningful impact in reducing PPH (8). Another option is a Bakri balloon, which may be able to tamponade the bleeding. It is important to notify the specialist as quickly as possible because some of these cases may require embolization done by an interventional radiologist or a hysterectomy if bleeding is not controlled with medical management. Secondary PPH is quite rare, and therefore it is prudent to approach it in a stepwise manner to both identify the disorder and to manage it. Although sources vary considerably, placental retention caused 30% of secondary PPH followed by subinvolution of the placental bed in approximately 13%. Other less common causes include endometritis, pseudoaneurysm of the uterine artery, and excessive return of menses. Almost 17% of causes were undetermined (1). The rationale for initial management of this condition appears to be that the uterus fails to contract secondary to either retained product or endometritis (5). Initially, the physical examination finding of a large uterus may prompt administration of oxytocin along with bimanual massage. If there is not improvement in the bleeding a few minutes after these interventions, an urgent consult to gynecology should be made and a bedside ultrasound should be performed to look for retained products. At this time tranexamic acid is indicated. If bedside ultrasound shows retained products, prompt removal of these products are indicated. In certain facilities, the ability to get an in-house gynecology consult may be limited. In this case, for any life-threatening bleeds, a Bakri balloon may be considered to tamponade any bleeding until the patient is able to reach definitive care. Rare causes of secondary PPH should be considered in patients with a normal-size uterus and no retained products on ultrasound. In these cases, it is imperative to get the patient to definitive care with the gynecologist. If stable, they may consider getting further imaging such as an angiogram on the pelvic vessels and look for causes such as aneurysms of the uterine artery (9). In 1 study of 60 patients with severe secondary PPH, 9 patients had interventional radiologist–guided arterial embolization with a 100% success rate (1). Many unstable patients may require hysterectomy (5).
Severe Delayed PPH After Cesarean Section
REFERENCES 1. Dossou M, Debost-Legrand A, De´chelotte P, et al. Severe secondary postpartum hemorrhage: a historical cohort. Birth 2015;42: 149–55. 2. Hoveyda F, MacKenzie IZ. Secondary postpartum haemorrhage: incidence, morbidity and current management. BJOG 2001;108: 927–30. 3. Debost-Legrand A, Rivie`re O, Dossou M, Vendittelli F. Risk factors for severe secondary postpartum hemorrhages: a historical cohort study. Birth 2015;42:235–41. 4. Abdul-Kadir R, McLintock C, Ducloy AS, et al. Evaluation and management of postpartum hemorrhage: consensus from an international expert panel. Transfusion 2014;54:1756–68.
3 5. Alexander J, Thomas PW, Sanghera J. Treatments for secondary postpartum haemorrhage. Cochrane Database Syst Rev 2002;1:CD002867. 6. Stafford I, Dildy GA, Clark SL, Belfort MA. Visually estimated and calculated blood loss in vaginal and cesarean delivery. Am J Obstet Gynecol 2008;199:519.e1–7. 7. Dildy GA 3rd. Postpartum hemorrhage: new management options. Clin Obstet Gynecol 2002;45:330–44. 8. 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;389: 2105–16. 9. Samad S, Jonetzko P, Hawkins AP, Booth J, Thorpe-Beeston G, Marwood R. An unusual cause of delayed postpartum haemorrhage following caesarean section. Emerg Med J 2009;26:621–2.