What is the management for postpartum hemorrhage with no laceration on exam?

From the Guidelines

Management of postpartum hemorrhage (PPH) with no laceration on exam should focus on uterine atony, which is the most common cause, and initial management includes uterine massage and administration of uterotonics, starting with oxytocin 10-40 units IV infusion or 10 units IM, as recommended by recent guidelines 1. The most common cause of early PPH is related to uterine atony or lack of effective uterine contraction after delivery, which is typically a clinical diagnosis in >75% of patients 1. Initial management includes:

• Uterine massage
• Administration of uterotonics, starting with oxytocin 10-40 units IV infusion or 10 units IM
• If bleeding continues, add methylergonovine 0.2 mg IM every 2-4 hours (contraindicated in hypertension), misoprostol 800-1000 mcg rectally, or carboprost tromethamine (Hemabate) 250 mcg IM every 15-90 minutes (maximum 8 doses)
• Bimanual uterine compression should be performed while medications are being prepared
• Fluid resuscitation with crystalloids or blood products is essential to maintain hemodynamic stability, with transfusion initiated if hemoglobin drops below 8 g/dL or with ongoing significant bleeding, and consideration of tranexamic acid 1 g IV within 3 hours of birth if bleeding persists 1 If medical management fails, proceed to more invasive measures such as intrauterine balloon tamponade, uterine artery embolization, or surgical interventions including B-Lynch suture, uterine artery ligation, or hysterectomy as a last resort, with consideration of fibrinogen replacement with cryoprecipitate or fibrinogen concentrate, and other clotting factors as needed 1. These interventions work by promoting uterine contraction, as the contracted myometrium compresses blood vessels at the placental site, reducing blood flow and facilitating clot formation. Key considerations include:
• Monitoring of haemostatic function in obstetric haemorrhage, with laboratory testing or point-of-care testing, including plasma fibrinogen concentration or equivalent 1
• Use of hemorrhage checklists to ensure all options are considered and no details are neglected 1
• Ongoing attention to blood loss, hemoglobin, electrolytes, blood gas, and coagulation parameters to inform replacement needs 1

From the Research

Management of Postpartum Hemorrhage with No Laceration on Exam

• The management of postpartum hemorrhage (PPH) with no laceration on exam involves several steps, including the assessment of the cause of the hemorrhage and the implementation of appropriate interventions 2, 3, 4, 5, 6.
• Retained placenta is a significant cause of PPH, and its management is crucial to prevent maternal morbidity and mortality 2, 3, 5, 6.
• Manual removal of the placenta (MROP) is a common procedure used to manage retained placenta, but it may lead to massive hemorrhage and other complications 5, 6.
• The use of uterotonics, such as misoprostol, oxytocin, and carboprost, may be effective in reducing bleeding and promoting uterine contraction 2.
• Ultrasound-guided instrumental removal of the placenta is a technique that may be used to manage retained placenta, especially in cases where manual extraction is not possible or is unsuccessful 3.
• Immediate postpartum ultrasound evaluation may be useful in identifying retained placental tissue and guiding further management 4.

Risk Factors for Retained Placenta and PPH

• A history of abortion, assisted reproductive technology (ART), instrumental delivery, and delivery of small-for-gestational-age infant are independent risk factors for retained placenta requiring MROP 5.
• ART is an independent risk factor for PPH in patients who undergo MROP 5.
• The implementation of standardized operating procedures for retained placenta may contribute to a reduction in maternal morbidity 6.

Treatment Decisions

• Clinicians should consider patient transfer to a higher-level facility and preparation of sufficient blood products before initiating MROP in cases of ART pregnancies 5.
• The use of ultrasound and doppler sonography may be helpful in the third stage of labor to diagnose abnormalities of placentation 6.