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Emergency Medicine > OBSTETRICS AND GYNECOLOGY
Pregnancy, Postpartum Hemorrhage
Article Last Updated: May 30, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: Michael P Wainscott, MD, Residency Director, Professor, Division of Emergency Medicine, Department of Surgery, University of Texas Southwestern Medical Center
Michael P Wainscott is a member of the following medical societies: American College of Emergency Physicians
Editors: Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University; John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center; Pamela L Dyne, MD, Associate Professor, Program Director, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine
Author and Editor Disclosure
Synonyms and related keywords:
PPH, postpartum bleeding, postpartum hemorrhage, vaginal delivery, cesarean delivery, birth, blood loss after birth, blood loss after delivery, uncomplicated delivery
Background
Postpartum hemorrhage (PPH) is a potentially life-threatening complication of both vaginal and cesarean delivery. Traditionally, PPH was defined as blood loss greater than 500 mL in a vaginal delivery and greater than 1,000 mL in a cesarean delivery. However, studies have revealed that an uncomplicated delivery often results in blood loss of more than 500 mL without any compromise of the mother's condition. These findings resulted in adoption of a broader definition for PPH. Any bleeding that results in signs and symptoms of hemodynamic instability, or bleeding that could result in hemodynamic instability if untreated, is considered PPH. Blood loss of greater than 1,000 mL with an vaginal delivery or a decrease in postpartum hematocrit level greater than 10% of the prenatal value also can be considered PPH.
Temporally, PPH can be divided into (1) early PPH that occurs within 24 hours after delivery and (2) late PPH that occurs 24 hours to 6 weeks after delivery.
Frequency
United States
The exact incidence of PPH is difficult to determine. A reasonable consensus is that 1-10% of pregnancies are complicated by PPH, with the actual number in the range of 2-4%.
Mortality/Morbidity
- PPH can cause severe morbidity and mortality.
- According to CDC data, 17% of maternal mortality is due to hemorrhage. PPH is thought to be the cause in one third to one half of these cases.
- Possible complications include exposure to blood products, the need for surgical intervention, and the need for permanent sterilization to control bleeding.
Race
Some study findings suggest that the incidence of PPH Asian and Hispanic women is increased compared with that of other women.
Age
PPH occurs in women of childbearing age.
History
In addition to asking the standard questions about the prenatal period, request information about previous episodes of PPH, prior cesarean section, parity, and history of multiple fetuses or polyhydramnios.
- Ascertain if the patient or family has a history of coagulation disorders or excessive bleeding with surgical procedures or menses.
- Obtain information about medications, with emphasis on medications for hypertension (calcium-channel blockers) or heart disease (eg, digoxin, warfarin). This information is important if the coagulopathy develops and the patient requires transfusions.
- Determine if the placenta has already been delivered.
Physical
In a woman with excessive postpartum bleeding, simultaneously perform the physical examination and resuscitation. Focus the examination on determining the cause of the bleeding. The patient may not have the typical hemodynamic changes of shock early in the course of the hemorrhage due to physiologic maternal hypervolemia. Occult PPH always is an important consideration when unstable hemodynamic findings are present without evidence of excessive blood loss.
- Bimanual palpation of the uterus may reveal bogginess, atony, or uterine enlargement, with a large amount of accumulated blood. Palpation may also reveal hematomas in the perineum or pelvis.
- During suctioning, careful visual inspection of the cervix and vagina under good light may reveal the presence and extent of lacerations.
- Examine the placenta for missing portions, which suggest the possibility of retained placental tissue.
- Check for oozing from skin puncture sites or intravenous sites in patients with excessive bleeding as this could indicate a coagulopathy.
Causes
- The most frequent cause of PPH is uterine atony, a condition in which the uterine corpus does not constrict properly, allowing continued blood loss from the placental site. Risk factors for atony include the following:
- Overdistended uterus (eg, multiple gestation, fetal macrosomia, hydramnios)
- Fatigued uterus (eg, augmented or prolonged labor, amnionitis)
- Obstructed uterus (eg, retained placenta or fetal parts, placenta accreta)
- The second most frequent cause is trauma to the uterus, cervix, and/or vagina. Risk factors for trauma include the following:
- Delivery of a large infant
- Instrumentation or intrauterine manipulation (eg, forceps, vacuum)
- Vaginal birth after cesarean section (VBAC)
- Episiotomy
- Disorders of coagulation and thrombocytopenia, preexisting or occurring during the second or third stage of labor, may be associated with excessive bleeding.
- Trauma during delivery may result in hematomas in the perineum or pelvis. These hematomas may be palpable and should be suspected if the patient has unstable vital signs and little or no external bleeding.
- Uterine inversion may be associated with hemorrhage of approximately 2 L. No definitive study findings have demonstrated the relationship between traction on the umbilical cord and uterine inversion, although many clinicians indicate that a correlation may exist.
- Uterine rupture may be associated with little vaginal bleeding, but it should be considered in the presence of severe abdominal pain and unstable hemodynamic findings.
- Other risk factors for PPH include the following:
- Preeclampsia
- Previous PPH
- Asian or Hispanic ethnicity
- Nulliparity or multiparity
Other Problems to be Considered
Lacerations of the cervix or vagina
Maternal coagulopathy
Retained placenta
Uterine atony
Uterine inversion
Uterine rupture
Lab Studies
- Complete blood count
- This is determined to evaluate the hemoglobin and hematocrit (H&H) levels.
- In a patient with acute hemorrhage, several hours may pass before these levels change to reflect the blood loss and platelet count.
- Look for thrombocytopenia.
- The prothrombin time (PT) and activated partial thromboplastin time (aPTT) are assessed to determine if a coagulation disorder is present.
- Fibrinogen level to check for consumptive coagulopathy. Levels are normally elevated to 300-600 in pregnancy, so low or low-normal values could indicate consumptive coagulopathy.
Imaging Studies
- Ultrasonography may be helpful in revealing abnormalities within the uterine cavity and occult hematomas.
- Angiography may be used, with possible embolization of bleeding vessels.
Other Tests
- D-dimer tests (monoclonal antibody test) may be performed to determine if levels of serum fibrin degradation products are increased. This finding indicates a coagulation disorder.
Prehospital Care
Emergency medical service (EMS) providers may arrive before or after delivery of the fetus. They must be vigilant and prepared for potential complications in the third stage of labor, including PPH. After delivery, these providers have two patients. They must assess both patients, set priorities for their care, and divide responsibilities accordingly.
- Treatment for the newborn is the same as in any other prehospital delivery. Treatment includes suctioning, drying, and warming.
- EMS providers should quickly assess the condition of the mother and provide oxygen, and then perform gentle massage of the uterine fundus and monitor the patient for delivery of the placenta or excessive bleeding.
- If the patient continues hemorrhaging, despite uterine massage, the EMS providers should initiate resuscitative efforts similar to those for any patient in hemorrhagic shock. These include the following: (1) establishment of vascular access with a large-bore intravenous catheter, (2) infusion of crystalloid solution, (3) keeping the patient warm and dry, and (4) rapid transport to the nearest appropriate hospital with obstetric facilities.
- Some paramedic-level EMS providers use oxytocin in the prehospital setting. An infusion of oxytocin may be started in accordance with standing orders or with agreement of the online medical control physician.
- The EMS providers should transport the patient with PPH to the nearest appropriate hospital with obstetric facilities as quickly as possible. In rural areas, the patient's condition may need to be stabilized first in the ED of a small community hospital; then, the patient can be rapidly transferred to another hospital with greater capabilities for handling this emergent condition.
Emergency Department Care
The patient with suspected or obvious PPH requires immediate intervention, similar to any patient with hemorrhage. In addition to initiating resuscitative measures, carefully evaluate the patient to determine the cause of the hemorrhage, and initiate specific treatments.
- Resuscitative measures include the following: (1) administration of 100% oxygen; (2) placement of several intravenous lines with large-bore catheters and infusion of crystalloid solutions (isotonic sodium chloride or lactated Ringer solution warmed, if possible); and (3) cardiac, blood pressure, pulse, pulse oximetry monitoring.
- Obtain samples for laboratory tests, with special instructions to the laboratory personnel regarding determination of the cause of bleeding.
- Type and cross match packed red blood cells for transfusion. If the patient is in critical condition, type-specific blood may be needed. Transfuse these with blood warmers; in patients in unstable condition, warmers permitting rapid infusion are preferred. Platelets and FFP may also be necessary.
- Assess the uterus with bimanual examination. A soft, boggy uterus signifies atony, and uterine massage will stimulate uterine contractions and frequently stops uterine hemorrhage. Exercise caution not to use excessive pressure on the fundus of the uterus; this may increase the risk of uterine inversion. Massaging a hard, contracted uterus can actually impede detachment of the uterus and may increase bleeding. A contracted uterus should initiate a prompt search for lacerations, retained parts, or both.
- If uterine inversion occurs or has already occurred, gently push the uterus back into position. Fortunately, when this inversion occurs on an emergency basis, the cervix generally does not have time to contract firmly around the inverted uterus.
- Oxytocin as 20 units in 1L LR at 600 mL/h should be initiated to stimulate and maintain uterine contraction and control hemorrhage. The next drug would be 15-methyl-prostaglandin as 0.25 mg IM. Caution is advised when these agents are considered for the treatment of patients with hypertension.
- Check the placenta for evidence of missing placental tissue, which still may be attached to the wall of the uterus, causing excessive bleeding. Removal of retained tissue can be difficult and painful. Depending on the skill of the ED physician, it may be wise to let the obstetrician manage removal of retained tissue with use of the hand or an instrument. If bleeding is severe, the ED physician may wrap gauze around one hand, then gently insert it into the uterus and gently sweep the inner wall of the uterus to remove retained placenta tissue.
- The cervix and vagina must be thoroughly inspected for any trauma (laceration or hematoma). Direct pressure over lacerations in the perineum, cervix, vagina, or uterus may help control bleeding. Perineal, vaginal, and cervical lacerations should be repaired. Most authors do not recommend packing the uterus with gauze, although a few still advocate this in extreme circumstances. A case report of successful hemorrhage control with uterine packing with gauze soaked in thrombin exists.
- If the patient has coagulopathy, consider the transfusion of fresh frozen plasma. If the patient is thrombocytopenic, consider platelet transfusion.
- In cases of uterine inversion or manual extraction of placenta or fetal parts, prophylactic antibiotics should be given to prevent amnionitis.
- In cases of uterine rupture, emergent laparotomy is required.
- Ergotamines (eg, ergonovine, methylergonovine) are less frequently used due to occasional dramatic hypertension and no proven benefit over oxytocin alone.
Consultations
Immediate consultation with an obstetrician is vital for a patient with PPH. In centers where rapid arterial embolization can be achieved, consultation with interventional radiology should be obtained. Studies report over a 90% success rate in stopping bleeding, which can prevent hysterectomy.
- Notify personnel in the anesthesiology and labor and delivery departments, operating room, and blood bank that the patient may have to be moved.
- If, for stabilization, a patient is brought to a hospital without obstetric services, initiate resuscitative efforts and transfer the patient as quickly as possible to a hospital with obstetric services for definitive care.
- Therapies under study: Several medications are or have undergone study for PPH.
- Misoprostol (1 mg PR, an inexpensive prostaglandin E1 analogue) has been used in several descriptive case studies and a randomized controlled trial with good success at controlling PPH in cases refractory to oxytocin.
- Recombinant factor VIIa (40-90 mcg/kg, a clotting factor used for hemorrhage in patients with factor deficiencies undergoing testing for hemorrhage from several other sources including variceal and obstetric) has been reportedly dramatically effective in several case reports and a case series for PPH refractory to oxytocin.
Medications used to control PPH are in the category of oxytocic drugs. These drugs stimulate contraction of the uterine muscle, helping to control PPH.
Drug Category: Oxytocics
Useful in the treatment and prophylaxis of PPH.
| Drug Name | Oxytocin (Pitocin) |
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| Description | Produces rhythmic uterine contractions, can stimulate the gravid uterus, and has vasopressive and antidiuretic effects. Can be used to control postpartum bleeding or hemorrhage. Some suggest its prophylactic use in the third stage of labor; one study of 1000 deliveries revealed a 40% reduction in the rate of PPH. |
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| Adult Dose | Add 20 U of oxytocin to 1 L of crystalloid
Administer fluid at rate high enough to control uterine atony
If 20 units are added to 1 L, infuse at rate of 200-600 mL/h
Add 20 units of oxytocin to 1 L of crystalloid
Administer fluid at rate high enough to control uterine atony
If 20 units are added to 1 L, infuse at rate of 200-600 mL/h |
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| Pediatric Dose | >12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; pregnant patients with severe toxemia, unfavorable fetal positions, and a contracting uterus with hypertonic or hyperactive patterns; labor in which vaginal delivery should be avoided (eg, invasive cervical carcinoma, cord presentation or prolapse, active herpes genitalis, total placenta previa, vasa previa) |
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| Interactions | Pressor effect of sympathomimetics may increase when used concomitantly with oxytocic drugs, causing postpartum hypertension |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Rapid bolus may cause hypotension, myocardial arrhythmias, or cardiac arrest; higher doses may cause diuresis, making it difficult to monitor urine output as a measure of resuscitation; an overstimulated uterus can be hazardous to the mother and fetus; hypertonic contractions can occur in a patient whose uterus is hypersensitive to oxytocin, regardless of appropriate administration; has intrinsic antidiuretic effect that, when administered with continuous infusion in a patient receiving fluids by mouth, can cause water intoxication |
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| Drug Name | Ergonovine (Ergotrate Maleate) |
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| Description | Used to prevent and treat PPH due to uterine atony by producing firm contraction of the uterus within minutes. Although it is intended primarily for IM administration, a faster response can be achieved with IV use. Compared with IM route, IV route has a higher incidence of adverse effects; IV use should be reserved for emergencies (eg, excessive uterine bleeding). Severe uterine bleeding may require repeated doses, but it seldom requires more than one injection q2-4h. |
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| Adult Dose | 0.2 mg IM/IV; repeat q2-4h prn |
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| Pediatric Dose | <12 years: Not established
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; not for use to induce labor or to treat possible spontaneous abortion; toxemia |
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| Interactions | None reported |
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| Pregnancy | X - Contraindicated in pregnancy
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| Precautions | Discontinue if ergotism develops; caution in heart disease, hypertension, mitral-valve stenosis, venoatrial shunts, sepsis, obliterative vascular disease, hepatic or renal impairment |
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| Drug Name | Methylergonovine (Methergine) |
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| Description | Acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding and shortens the third stage of labor. Administer IM during puerperium, during delivery of placenta, or after delivering anterior shoulder. Also may be given IV, over no less than 60 seconds, but it should not be administered routinely, because it may provoke hypertension or a stroke. Monitor BP closely when administering IV. |
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| Adult Dose | 0.2 mg IM/IV repeat q2-4h if required |
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| Pediatric Dose | <12 years: Not established
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; glaucoma; Tourette syndrome; anxiety |
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| Interactions | Concurrent administration of methylergonovine with vasoconstrictors or other ergot alkaloids may produce additive effect |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Caution in sepsis, obliterative vascular disease, hepatic or renal insufficiency |
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| Drug Name | Carboprost (Hemabate) |
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| Description | Prostaglandin similar to F2-alpha (dinoprost), but it has a longer duration and produces myometrial contractions that induce hemostasis at placentation site, which reduces postpartum bleeding. |
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| Adult Dose | 250 mcg IM q15-90min; not to exceed 2 mg |
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| Pediatric Dose | <12 years: Not established
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; pelvic inflammatory disease |
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| Interactions | Increases toxicity of oxytocic agents |
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| Pregnancy | X - Contraindicated in pregnancy
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| Precautions | Caution in cardiovascular disease, asthma, hypotension or hypertension, adrenal disease, diabetes, renal or hepatic disease, compromised uterus, and jaundice; do not inject IV (may induce hypertension and bronchospasm) |
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| Drug Name | Misoprostol (Cytotec) |
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| Description | Synthetic prostaglandin E 1 analog. Abortifacient effect results from increased frequency of uterine contractions. May be used alone or as part of regimen with mifepristone up to 49 d LMP or MTX up to 63 d LMP. |
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| Adult Dose | 1000 mcg PR for 1 dose |
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| Pediatric Dose | <12 years: Not established
>12 years: Administer as in adults |
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| Contraindications | Previous cesarean section, allergy to prostaglandins; pregnant patients with severe toxemia, unfavorable fetal positions, and a contracting uterus with hypertonic or hyperactive patterns; labor in which vaginal delivery should be avoided (eg, invasive cervical carcinoma, cord presentation or prolapse, active herpes genitalis, total placenta previa, vasa previa) |
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| Interactions | Increases toxicity of oxytocic agents |
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| Pregnancy | X - Contraindicated in pregnancy
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| Precautions | Can produce uterine atony, uterine rupture, amniotic fluid embolus
Different dosing regimen administered prior to delivery |
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| Drug Name | Recombinant factor VIIa (Novo-Seven) |
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| Description | Man made activated protein that promotes thrombosis. |
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| Adult Dose | 40-90 mcg/kg IV |
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| Pediatric Dose | <12 years: 40-90 mcg/kg IV
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity to product, mouse, hamster, or cow proteins |
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| Interactions | None reported |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| Precautions | Monitor for signs of thrombosis or activation of coagulation system; thrombotic events may increase in patients with advanced atherosclerotic disease, crush injury, sepsis, and disseminated intravascular coagulation; may also cause hypertension |
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Further Inpatient Care
- Patients with PPH require admission to hospital's labor and delivery area and evaluation by an obstetrician on an emergency basis.
- Continue the intravenous infusion of oxytocin until the obstetrician evaluates the patient.
- The patient requires cardiac, blood pressure, pulse, and pulse oximetry monitoring until the obstetrician decides that intensive monitoring is no longer needed.
- Continue oxygen administration.
- Perform further gentle uterine massage, if needed, to control bleeding.
- The patient should not ingest anything by mouth (NPO) until her condition is stable.
Transfer
- If patient is being treated in an ED without direct access to obstetric services, transfer patient to another hospital with such services.
- Stabilize the patient as much as possible and transfer her rapidly, in accordance with transfer laws, regulations, and rules.
Deterrence/Prevention
- Early recognition of the risk factors for PPH may aid patient management without necessarily preventing PPH. Once identified, PPH should be treated aggressively. Warn the patient that the risk of PPH may increase after this episode, depending on the cause.
- Some patients have PPH even if they do not have risk factors.
Complications
- Complications associated with blood transfusion
- Consumptive coagulopathy
- Disseminated intravascular coagulation (DIC)
- Other bleeding disorders
- Multiple organ failure associated with circulatory collapse and decreased organ perfusion
- Need for hysterectomy and loss of child-bearing potential
- Need for emergent surgical intervention and potential complications
Prognosis
- The prognosis depends on the cause of the PPH, its duration, the amount of blood loss, comorbid conditions, and the effectiveness of treatment. Prompt diagnosis and treatment are essential.
Patient Education
Medical/Legal Pitfalls
- Some typical vaginal deliveries are associated with blood loss of more than 500 mL. However, the ED physician should assume that the patient with blood loss greater than 500 mL and ongoing bleeding has PPH.
- Resuscitation should be started while evaluating the patient for the cause of PPH.
- Early uterine massage and administration of oxytocic agents (unless contraindicated) are important.
- Early emergent consultation with obstetrician is essential.
- Assume that occult hemorrhage in the uterus or hematoma is present in patients in the third stage of labor who have unstable vital signs and little or no external bleeding.
- Early recognition of coagulopathy may be life saving.
Special Concerns
- Remember that 2 patients—the mother and the newborn—require evaluation and intervention, as needed.
- Because of the hemodynamic changes in pregnancy, the clinical picture (especially the blood pressure) of the patient may change little until the hemorrhage is severe.
- Alvarez M, Lockwood CJ, Ghidini A. Prophylactic and emergent arterial catheterization for selective embolization in obstetric hemorrhage. Am J Perinatol. Sep-Nov 1992;9(5-6):441-4. [Medline].
- Bobrowski RA, Jones TB. A thrombogenic uterine pack for postpartum hemorrhage. Obstet Gynecol. May 1995;85(5 Pt 2):836-7. [Medline].
- Boulleret C, Chahid T, Gallot D, et al. Hypogastric arterial selective and superselective embolization for severe postpartum hemorrhage: a retrospective review of 36 cases. Cardiovasc Intervent Radiol. Jul-Aug 2004;27(4):344-8. [Medline].
- Bouwmeester FW, Jonkhoff AR, Verheijen RH, van Geijn HP. Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII. Obstet Gynecol. Jun 2003;101(6):1174-6. [Medline].
- Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ. Feb 21 2003;52(2):1-8. [Medline].
- Cunningham FG, MacDonald PC, Gant NF, et al. Abnormalities of the third stage of labor. In: William's Obstetrics. 1993: 615-20.
- Cunningham FG, et al. Obstetrical Hemorrhage. In: William's Obstetrics. 21s ed. 2001:619-669.
- Dildy GA. Postpartum hemorrhage: new management options. Clin Obstet Gynecol. Jun 2002;45(2):330-44. [Medline].
- Druelinger L. Postpartum emergencies. Emerg Med Clin North Am. Feb 1994;12(1):219-37. [Medline].
- Gilbert WM, Moore TR, Resnik R. Angiographic embolization in the management of hemorrhagic complications of pregnancy. Am J Obstet Gynecol. Feb 1992;166(2):493-7. [Medline].
- Gilstrap LC III, Ramin SM. Postpartum hemorrhage. Clin Obstet Gynecol. Dec 1994;37(4):824-30. [Medline].
- Goldberg CC, Kallen MA, McCurdy CM. Effect of intrapartum use of oxytocin on estimated blood loss and hematocrit change at vaginal delivery. Am J Perinatol. Aug 1996;13(6):373-6. [Medline].
- Hofmeyr GJ, Ferreira S, Nikodem VC, et al. Misoprostol for treating postpartum haemorrhage: a randomized controlled trial [ISRCTN72263357]. BMC Pregnancy Childbirth. Aug 6 2004;4(1):16.
- Mendelson MH. Postpartum emergencies. In: Harwood-Nuss AL, ed. The Clinical Practice of Emergency Medicine. 3rd ed. 2000: 331-3.
- Michalakes CJ, Pundt MR, Kerryann BB. Obstetrics and disorders of pregnancy. In: Aghababian RV, ed. Emergency Medicine: The Core Curriculum. 1998: 598-600.
- Nordstrom L, Fogelstam K, Fridman G. Routine oxytocin in the third stage of labour: a placebo controlled randomised trial. Br J Obstet Gynaecol. Jul 1997;104(7):781-6. [Medline].
- O''Brien P, El-Refaey H, Gordon A, et al. Rectally administered misoprostol for the treatment of postpartum hemorrhage unresponsive to oxytocin and ergometrine: a descriptive study. Obstet Gynecol. Aug 1998;92(2):212-4. [Medline].
- Petrovic O, Zupanic M, Rukavina B. Placenta accreta: postpartum diagnosis and a potentially new mode of management using real-time ultrasonography. J Clin Ultrasound. Mar-Apr 1994;22(3):204-8. [Medline].
- Prendiville WJ. The prevention of post partum haemorrhage: optimising routine management of the third stage of labour. Eur J Obstet Gynecol Reprod Biol. Oct 1996;69(1):19-24. [Medline].
- Roberts WE. Emergent obstetric management of postpartum hemorrhage. Obstet Gynecol Clin North Am. Jun 1995;22(2):283-302. [Medline].
- Sherer DM, Abulafia O, Anyaegbunam AM. Intra- and early postpartum ultrasonography: a review. Part II. Obstet Gynecol Surv. Mar 1998;53(3):181-90. [Medline].
- Soriano D, Dulitzki M, Schiff E. A prospective cohort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage. Br J Obstet Gynaecol. Nov 1996;103(11):1068-73. [Medline].
- Varner M. Postpartum hemorrhage. Crit Care Clin. Oct 1991;7(4):883-97. [Medline].
- Wittich AC, Salminen ER, Hardin EL. Uterine packing in the combined management of obstetrical hemorrhage. Mil Med. Mar 1996;161(3):180-2. [Medline].
- Zahn CM, Yeomans ER. Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas. Clin Obstet Gynecol. Sep 1990;33(3):422-31. [Medline].
Pregnancy, Postpartum Hemorrhage excerpt Article Last Updated: May 30, 2006
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