When a patient presents with bleeding, initial assessment must include vital signs, complete blood count, and obviously physical examination. The initial vital signs may suggest the need for fluid resuscitation, and placing one or two large-bore IVs is appropriate. The initial focus of the physical examination is the uterus. Palpation of the uterine fundus should suggest whether it is firm and well-contracted or boggy and soft, suggesting atony. Uterine atony is initially treated with an intravenous infusion of oxytocin (40 units of oxytocin/L of lactated ringers solution or normal saline). Examination of the uterus also has a secondary role. When the uterus is atonic, blood and clot build up in the uterine cavity, which by their presence can make uterine contraction difficult, causing more bleeding and clot. The atonic uterus should be massaged to squeeze out the clots, and occasionally, a manual sweep of the clots is necessary. If oxytocin alone is insufficient to maintain uterine contraction, a number of other options can be tried. The prostaglandin E1 analogue misoprostol has been successfully used to control PPH. The dosage has ranged widely and the route of administration has included rectal, oral, sublingual, and buccal (1,2,3). Reasonable dosing would include up to 1,000 µg rectally or 600 µg sublingual or buccally. This is an off-label use for misoprostol. Prostaglandin E2 is also available (20 mg given rectally), but it is more likely to cause fever, nausea, and diarrhea. Prostaglandin E2 is also not heat stable, so if it has not been stored properly, it will loose efficacy. Prostaglandin F2α (Hemabate) is also used (250 µg given intramuscularly, intracervically, or intramyometrially) but can cause bronchoconstriction in asthmatics, so a past medical history must be obtained that specifically asks about asthma and reactive airway disease. This dose may be repeated every 10 minutes up to a total of three doses. These prostaglandins have largely replaced the former second-line agent, the ergot alkaloid methylergonovine maleate (Methergine). Methylergonovine maleate is usually given as 0.2 mg intramuscularly, but it may be administered at the same dose orally. If the atony persists despite these treatments, other etiologies must be considered, particularly retained placenta or membranes. In the setting of delayed PPH, ultrasound may be a useful modality to examine the cavity, and if retained products of conception are seen, a gentle dilation and curettage, often with suction, should be performed. One must recognize that an overly aggressive curettage of the endometrial cavity after a delivery is the main risk factor for Asherman syndrome, so these procedures must be performed with great care. In the setting of an immediate PPH, ultrasound is less useful because it frequently looks like there is significant debris in the cavity after an uncomplicated delivery. Instead, the evaluation consists of carefully examining the placenta and membranes (if available) to look for evidence of a retained portion of the placenta or a succenturiate lobe. Direct evaluation of the cavity may be performed by a digital examination with palpation once adequate anesthesia is available. If that examination is suggestive of retained products that cannot be manually removed, then a gentle curettage should be performed with care.

If there is no evidence of retained products of conception or uterine bleeding persists despite their removal, other nonsurgical approaches are available. Intrauterine balloon tamponade is an effective treatment for PPH, particularly those related to bleeding from the lower uterine segment such as a relative low placental implantation (4). This balloon is useful both in terms of treating atony and also as a means of deciding who will probably need surgical management (4). In centers that have interventional radiology services available, embolization of the uterine arteries or hypogastric arteries will frequently control bleeding and avoid surgery. The interuterine balloon may also be placed to decrease hemorrhage while the IR team is being assembled. If these nonsurgical methods fail and it is clear that the etiology of the bleeding is uterine rather than from another site, a laparotomy will be required. Surgical ligation of the uterine or hypogastric arteries may decrease the pulse pressure and control the bleeding adequately. If uterine atony persists, the B-Lynch Brace suture has been shown to be an effective measure. This stitch uses rapidly absorbable sutures to squeeze the uterus in an attempt to simulate the ongoing uterine massage or compression. The B-Lynch has been combined with an intrauterine balloon tamponade to maximize compression in a technique referred to as the “uterine sandwich” (5). If all of these surgical measures fail, hysterectomy may be required. This is usually performed as a supracervical hysterectomy because it can be difficult to identify the cervix after a vaginal delivery, and the surgeon usually leaves the cervix to make sure none of the vaginal is taken.

Because chorioamnionitis and endometritis may increase the likelihood of uterine atony, signs such as an elevated white blood cell count, c-reactive protein, uterine fundal tenderness, and fever should be evaluated. If there is suspicion of infection, appropriate treatment includes admission to the hospital for inpatient intravenous antibiotics.

In an immediate PPH, evaluation for other etiologies would include a careful examination of the vagina and the cervix for lacerations. Bleeding lacerations should be repaired with an intermediate-duration absorbable suture. In a delayed PPH when the bleeding is from a prior repair, antibiotic coverage is appropriate. If the repair does not appear infected, a few stitches can be placed to address the bleeding. If the repair is broken down and appears badly infected, a full repair is best postponed until the infection is well-controlled with antibiotics.

Finally, in some patients, there may be coagulopathies, either because of inherent bleeding disorders or because of disseminated intravascular coagulation secondary to their ongoing PPH. Coagulation parameters should be measured, and blood product components replaced as necessary. A number of obstetrical disorders, including familial thrombophilias with a bad obstetric history, a history of thromboembolism, and antiphospholipid antibody syndrome, are now treated with anticoagulation, at both prophylactic and therapeutic doses. A careful history of past medical conditions and medications once again plays an important role here.

Superficial thrombophlebitis is the most common thrombosis identified during pregnancy occurring in 11 per 1,000 deliveries (6). Patients present with pain, redness, and warmth over the affected area. The affected vein may be swollen, but this may be hard to identify. Occasionally, the clot itself is palpable as a “cord.” Superficial thrombosis poses no direct risk to the patient beyond discomfort. It is usually treated with heat, elevation, analgesics (especially aspirin), and occasionally, anticoagulation. If there is evidence of cellulitis, prescription of an antibiotic with coverage for skin flora (e.g., Staphylococcus and Streptococcus) such as dicloxacillin is appropriate. Superficial thrombophlebitis, particularly of the saphenous vein, can progress to deep venous thrombosis, so if there is any question of the extent of the clot, appropriate studies to rule out deep vein thrombosis must be obtained.

Unlike the more benign superficial thrombophlebitis, DVT poses a direct risk to the patient because it may lead to a pulmonary embolism (PE). Consequently, it is of utmost importance to accurately identify and expeditiously treat this condition. The main complaint women present with is pain and leg swelling. This is usually unilateral leg swelling, which helps distinguish it from the normal lower extremity swelling of pregnancy. If a clot reaches the inferior vena cava, bilateral swelling may occur, which can lead to the false

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