Rosen & Barkin's 5-Minute Emergency Medicine Consult (567 page)

Determined by medical condition and acuity of onset necessitating rapid diagnostic testing:

• Respiratory failure
  
• BP instability
  
• Inability to walk or care for self
  
• Inadequate pain control
  
• Poor control of underlying disease process
  
• Rapidly progressing symptoms
  

• Underlying medical condition stabilized
  
• No evidence or low risk of respiratory failure or autonomic instability
  
• Able to care for self
  
• Adequate pain control
  
• Access to outpatient follow-up for further testing or management
  

All patients require referral to primary care physician or neurology for ongoing testing and/or management

• Primary care physician
  
• Neurology
  
• Physical therapy
  

• Understanding that the potential causes of polyneuropathy are broad and a comprehensive search for the underlying cause will aid in management
  
• Recognizing those few causes that are at risk for respiratory failure or autonomic instability
  
• For most causes, treatment consists of controlling underlying disease process
  

• England JD, Gronseth GS, Franklin G, et al. Practice parameter: Evaluation of distal symmetric polyneuropathy: Role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation.
  Neurology.
  2009;72(2):177–184.
  
• Ralph JW. Assessment of polyneuropathy. In Minhas R, ed.
  Best Practice.
  BMJ Group. 2012.
  
• Rubin M. Peripheral Neuropathy. In: Porter RS, ed.
  Merck Manual Online
  . 2012.
  
• Tracy JA, Dyck PJ. Investigations and treatment of chronic inflammatory demyelinating polyradiculoneuropathy and other inflammatory demyelinating polyneuropathies.
  Curr Opin Neurol
  . 2010;23(3):242–248.
  

CODES

• 356.9 Unspecified hereditary and idiopathic peripheral neuropathy
  
• 357.4 Polyneuropathy in other diseases classified elsewhere
  
• 357.7 Polyneuropathy due to other toxic agents
  

BASICS

• Postpartum hemorrhage (PPH) after 20 wk gestation
  
• Primary: Hemorrhage occurring ≤24 hr after delivery
  
  • Also known as early PPH
    
• Secondary: Hemorrhage occurring >24 hr after delivery (but <12 wk):
  
  • Also known as delayed PPH
    
• Definitions:
  
  • >500 mL after vaginal delivery
    
  • >1,000 mL after C-section
    
• Occurs in 4% of vaginal deliveries
  
• Occurs in 6% of C-sections
  
• Leading cause of death in pregnancy worldwide
  
  • Accounts for 25% of pregnancy-related deaths
    
  • ∼50% of postpartum deaths are due to PPH
    
• 95% of PPH caused by:
  
  • Uterine atony (50–60%)
    
  • Retained placenta (20–30%)
    
  • Cervical/vaginal lacerations (10%)
    
• Complications:
  
  • Hypovolemic shock
    
  • Blood transfusion
    
  • Acute respiratory distress syndrome
    
  • Renal and/or hepatic failure
    
  • Sheehan syndrome
    
  • Loss of fertility
    
  • Disseminated intravascular coagulopathy (DIC)
    

• 4 Ts:
  
  • Tone
    
  • Tissue
    
  • Trauma
    
  • Thrombin
    
• Immediate:
  
  • Uterine atony
    
  • Lower genital lacerations
    
  • Retained placental tissue
    
  • Placenta accreta
    
  • Uterine rupture
    
  • Uterine inversion
    
  • Puerperal hematoma
    
  • Coagulopathies
    
• Delayed:
  
  • Retained products of conception
    
  • Postpartum endometritis
    
  • Withdrawal of exogenous estrogen
    
  • Puerperal hematoma
    
• Coagulopathies:
  
  • Pre-existing idiopathic thrombocytopenic purpura
    
  • Thrombotic thrombocytopenic purpura
    
  • Von Willebrand disease
    
  • DIC
    
• Associated conditions:
  
  • If bleeding is present at other sites, consider coagulopathy
    
• Risk factors:
  
  • Prior PPH
    
  • Advanced maternal age
    
  • Multiple gestations
    
  • Prolonged labor
    
  • Polyhydramnios
    
  • Instrumental delivery
    
  • Fetal demise
    
  • Anticoagulation therapy
    
  • Placental abruption
    
  • Fibroids
    
  • Prolonged use of oxytocin
    
  • C-section
    
  • Placenta previa and accreta
    
  • Chorioamnionitis
    
  • General anesthesia
    

DIAGNOSIS

• Ongoing blood loss, usually painless
  
• Significant hypovolemia, resulting in:
  
  • Tachycardia
    
  • Tachypnea
    
  • Narrow pulse pressure
    
  • Decreased urine output
    
  • Cool, clammy skin
    
  • Poor capillary refill
    
  • Altered mental status
    
• Maternal tachycardia and hypotension may not occur until blood loss >1,500 mL
  

• Condition is typically recognized by obstetrician soon after delivery
  
• Delayed PPH presents as copious vaginal/perineal bleeding
  
• Key historical elements:
  
  • Complications of delivery
    
  • Episiotomy
    
  • Prior clotting disorders
    
• Symptoms of hypovolemia:
  
  • Decreased urine output
    
  • Lightheaded
    
  • Syncope
    
  • Pale skin
    

Thorough exam of perineum, cervix, vagina, and uterus:

• External inspection
  
• Speculum exam
  
• Bimanual exam
  

• Abdomen and pelvic exam to assess for uterine atony, retained products, or other anatomic abnormality
  
• Type and cross-match for packed red blood cells
  
• Rapid hemoglobin determination
  

Diagnosis is chiefly based on clinical suspicion and exam

• CBC, platelets
  
• PT, PTT
  
• Fibrinogen level
  
• Type and cross-match
  

US to evaluate for retained products in delayed PPH or for evaluation of fluid concerning intrauterine or intra-abdominal hemorrhage

Manual exam preferred over ultrasonography:

• Greater sensitivity
  
• Both diagnostic and therapeutic
  

• Consider puerperal hematomas if perineal, rectal, or lower abdominal pain in conjunction with tachycardia and hypotension
  
• Retained products of conception
  

TREATMENT

• Monitor hemodynamics
  
• Aggressive IV fluids to maintain BP
  

• Attempt to simultaneously control bleeding and stabilize hemodynamic status
  
• Manage airway and resuscitate as indicated:
  
  • Supplemental oxygen
    
  • Cardiac monitor
    
• IV fluid resuscitation with normal saline or lactated Ringer solution
  
• Foley catheter
  

• Management of uterine atony:
  
  • Bimanual massage
    
  • Oxytocin (Pitocin) administered IV/IM
    
  • Methylergonovine (Methergine) or ergonovine (Ergotrate) IM if oxytocin fails:
    
    • Avoid if known hypertensive
      
    • Onset in minutes
      
  • 15-methyl prostaglandin F
    ^2α
    (PGF
    ^2α
    ; Hemabate) IM if above fails:
    
    • Relatively contraindicated in asthma
      
  • Surgery if medical intervention fails
    
• Inspect closely for genital tract laceration:
  
  • Repair required if ≥2 cm
    
  • Use 00 or 000 absorbable suture; continuous, locked recommended
    
• Management of uterine inversion (acute):
  
  • Reposition uterus using Johnson maneuver or Harris method:
    
    • Use left hand on abdominal wall to stabilize fundus of uterus
      
    • Place right hand with fingers spread into vagina and push steadily on inverted part to reduce
      
  • If unsuccessful, give terbutaline IV or magnesium sulfate to produce cervical relaxation, and reposition
    
  • Surgery if unsuccessful or if subacute or chronic inversion
    
• Management of coagulopathies in childbirth:
  
  • Fresh-frozen plasma, platelets, cryoprecipitate as indicated
    
  • Careful attention to volume status
    
  • Continuous reassessment
    
  • Active over expectant management
    
  • Immediate administration of uterotonics after delivery
    
  • Cord clamping and cutting without delay
    
  • Cord traction/uterine countertraction (Brandt–Andrews maneuver)
    
• Uterine tamponade
  
  • Can be used for atony or continued bleeding
    
  • Temporizing measures only
    
  • Balloon or packing can be used
    
  • May use a foley catheter, Rusch catheter, Sengstaken–Blakemore tube or
    
  • Surgical Obstetric Silicone (SOS) Bakri tamponade balloon
    
    • Specifically designed for control of PPH