Episode 159 — Postpartum Hemorrhage With Juanita Henao
Highlights
- Postpartum Hemorrhage Risk Factors
Summary:
The most common cause of postpartum hemorrhage is uterine adenie. Lacerations of the uterus of the cervix, tears and abnormal pleasantation are other main causes. Women who have known placenta previa or placenta creta can be at risk for postpartum hemorrhage.
Transcript:
Speaker 1
Yeah. No, perfect. Thank you. So let's talk about causes. What causes? Why does some women have postpartum hemorrhage and some don't? What causes it?
Speaker 2
All right. So the most common cause of postpartum hemorrhage is uterine adenie. Let's remember that uterine adenie is a failure of the uterus to contract after delivery of the neonate. And this contributes to around 70 to 80% of the cases of postpartum hemorrhage. All their causes are retained products of conception, like we discussed briefly, lacerations of the uterus of the cervix, tears, you know, vaginal tears, uterine rupture, abnormal pleasantation, meaning placenta previa, placenta creta, placenta abruption, quagulopathy. Those are basically the main causes.
Speaker 1
Okay. And so these are also some, we've kind of also got some risk factors here, right? So women who have known placenta previa or placenta creta, which you can sometimes, you know, find that a prepartum with or before birth, right? While they're pregnant by doing an ultrasound, et cetera, would be at risk for postpartum hemorrhage. Are there other risk factors that you might know beforehand that you say this is a high risk patient? (Time 0:05:29)
- Are You Using Pitocin to Treat Uterine Adenie?
Summary:
The receptors for pitocin can get desensitized you know, with higher doses. This is called tachyphylaxis in pharmacology and pitocin has this property. So if you have a patient that is being augmented and she's getting high doses of pitocin for these nutrients, the receptors will get the sensitized and then when you give more oxytocin, you're not going to achieve the same effect.
Transcript:
Speaker 1
Great. All right. Now, what is interesting to me is augmentation with pitocin. You know, I think a lot of people would think, oh, you know, gee, don't we use pitocin to treat uterine adenie? Why is it also a risk factor? Now, you know, you tell me, is it because, you know, if you use it for augmentation of labor, you kind of are, you know, using it too soon and now it doesn't work as well to treat adenie?
Speaker 2
Yeah. So what happens with pitocin is that the receptors for pitocin can get desensitized you know, with higher doses of pitocin. So if you have a patient that is being augmented and she's getting high doses of pitocin for these nutrients, the receptors will get the sensitized and then when you give more oxytocin, you're not going to achieve the same effect. This is called tachyphylaxis in pharmacology and pitocin has this property. So that's why.
Speaker 1
Gotcha. All right. That makes a lot of sense. Now, I'm going to ask you, I remember getting a talk once, I think when I was a resident saying that we really drastically overdose pitocin in general. (Time 0:07:14)
- Preventive Management of Postpartum Hemorrhage
Summary:
The American College of Obstetricians and Gynecology recommend that hospitals have protocols in place to help coordinate the responsive management of postpartum hemorrhage. These include, you know, team responses, accurate estimation of blood loss, recognition of early signs of hypoglyphic shock,. Things like that that help improve morbidity and mortality. So prevention and recognition of risk factors are key.
Transcript:
Speaker 1
Yeah, that's great. So it sounds like, you know, what you said, preparation is key. So it's not, we don't have a lot of kind of, you know, medications we give to try to prevent it other than oxytocin. No, and unfortunately we don't. Yeah. So prevention and recognition of risk factors are key.
Speaker 2
And actually, now we're talking about the ache of the American College of Obstetricians and Gynecology, they actually recommend that hospitals have protocols in place to help coordinate the responsive management of postpartum hemorrhage. And these include, you know, team responses, accurate estimation of blood loss, recognition of early signs of hypoglyphic shock, things like that that help improve morbidity and mortality.
Speaker 1
Yeah, that sounds that exactly. So, you know, once it obviously having to scramble to get blood once it happens as opposed to having the blood ready beforehand, right? Big difference. Exactly. Great. All right. Well, so as you said, let's talk about now, since we, we can only do so much to prepare, or maybe we didn't have any risk factors. So we, we didn't know it was going to happen. Now we have a woman who is having a postpartum hemorrhage. What can we do to treat it? (Time 0:12:23)
- Tranexamic Acid in Preventing Postpartum Hemorrhage
Summary:
The only other medication that it's been used in countries like the UK is an other synthetic analog of oxytocin called carbatozin. Unfortunately there's not much for preventive agents. Tranexamic acid may decrease the maternal mortality associated with postpartum hemorrhage, according to a study.
Transcript:
Speaker 2
So unfortunately there's not much for preventive agents. I did an extensive search and I couldn't find anything that was like in the horizon. The only other medication that it's been used in countries like the UK is an other synthetic analog of oxytocin that's called carbatozin, which is, you know, synthetic oxytocin that has half like of 40 minutes compared to 10, six to 10 minutes for the oxytocin that we use. So that being said, this medication can be administered as a single dose without the need of an infusion. However, it also has, you know, the same side effects of hypertension, tachycardia, nausea, that the oxytocin that we use, so it's not ideal. But it's something that, you know, another countries are starting to use with promising results. Unfortunately, there's no, you know, any other prophylactic agents that I know of, something that's maybe interested to mention as far as treatment of the, you know, postpartum hemorrhage once it occurred is the use of tranexamic acid. So there was a, yeah, there was an interesting trial that's called a woman trial that is one of the most, the biggest randomized control, double blind trials that have been done in the world of obstetric anesthesia that studied the use of tranexamic acid in the prevention of maternal mortality associated with a postpartum hemorrhage. And this study actually showed that a tranexamic acid may decrease the maternal mortality associated with PPH. And they recommend it's used within three hours of the onset of the hemorrhage. (Time 0:21:20)