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Maternal Hemorrhage and Severe Hypertension/Pre-eclampsia: Identification and Management in the Emergency Department

This course reviews evidence-based recommendations to improve care and outcomes for pregnant and postpartum patients with hemorrhage or severe hypertension. Includes video case reviews and 2 AMA PRA Category 1 Credits™. CME expires on 9/15/2024.

In July 2020, the Joint Commission established new standards and elements of performance for maternal safety to improve the quality and safety of care for pregnant and postpartum patients. This course was developed as a source of role-specific education for emergency clinicians staffing hospitals and other accredited healthcare organizations striving to comply with the Joint Commission requirements.

Early recognition of unexpected heavy bleeding in the postpartum period allows for early intervention, which is critical to the reduction of maternal complications. This course reviews prophylactic measures, etiologies, and medical management of postpartum hemorrhage, including a management algorithm and a medication dosing table.

Gestational hypertension, including acute severe hypertension and pre-eclampsia, can occur in patients who are between 20 weeks' gestation and 6 weeks postpartum. Identification and early intervention in these hypertensive emergencies are necessary to prevent severe sequelae. This course reviews diagnostic criteria and medical management for maternal hypertension and pre-eclampsia, including a medication dosing table.

Additional resources are provided for management of pregnancy-related hemorrhage and severe hypertension/pre-eclampsia, including links to sample management algorithms, checklists, and protocols.

The course also features video case discussions, with Dr. Sam Ashoo walking viewers through representative cases from presentation through conclusion

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1. Introduction
2. Maternal Hemorrhage
   1. Case 1 - Presentation
   2. Prevention
      1. Risk Assessment
   3. Differential Diagnosis
   4. Case 1 - Update
   5. Medical Management
      1. Tone
      2. Trauma
      3. Tissue
      4. Thrombin
      5. Transfusion Therapy
         • Disseminated Intravascular Coagulation
   6. Case 1 - Conclusion
   7. Definitive Management
   8. Additional Resources
3. Maternal Severe Hypertension/Pre-eclampsia
   1. Case 2 - Presentation
   2. Case 2 - Update
   3. Medical Management
      1. Antihypertensive Medications
      2. Magnesium Sulfate
   4. Case 2 - Conclusion
   5. Definitive Management
   6. Additional Resources
4. Summary
5. Tables and Figures
   1. Table 1. Etiology of Postpartum Hemorrhage
   2. Table 2. “4 Ts” Mnemonic for Causes of Postpartum Hemorrhage
   3. Table 3. Medical Therapy for Postpartum Hemorrhage
   4. Table 4. Example of a Massive Transfusion Protocol
   5. Table 5. Diagnostic Criteria for Pre-eclampsia
   6. Table 6. Medications for Treatment of Acute Severe Hypertension in Pregnant and Postpartum Patients
   7. Figure 1. Algorithm for Management of Postpartum Hemorrhage
   8. Figure 2. Uterine Balloon Tamponade Devices
6. References

Introduction

According to the United States Centers for Disease Control and Prevention, approximately 700 women die each year due to complications of pregnancy or delivery,¹ and the rate of pregnancy-related mortality in the United States increased from 7.2 deaths per 100,000 live births in 1987 to 17.3 deaths per 100,000 live births in 2017.² In response to these data, the Joint Commission evaluated relevant literature to identify areas of care that would have the greatest impact on pregnancy-related mortality rates. Their review identified areas of high impact on the reduction of maternal mortality rates, including improved recognition and management of maternal hemorrhage and pregnancy-related severe hypertension/pre-eclampsia.

In 2019, the Joint Commission released a report establishing new standards and elements of performance for maternal safety that are intended to improve the quality and safety of care for pregnant and postpartum patients by establishing patient care requirements for accredited organizations. These elements include development of evidence-based written procedures and role-specific education for clinicians and staff for the management of maternal hemorrhage and maternal severe hypertension/pre-eclampsia.³ The requirements went into effect for Joint Commission–accredited hospitals and other healthcare organizations on July 1, 2020. 

This special report summarizes evidence-based recommendations and provides tools for the recognition and management of patients with maternal hemorrhage or severe hypertension/pre-eclampsia in the emergency department (ED). This information can also serve as a foundation to develop institutional protocols for accredited organizations that do not have existing protocols.

Maternal Hemorrhage

The American College of Obstetricians and Gynecologists (ACOG) defines maternal hemorrhage as cumulative blood loss >1000 mL or blood loss accompanied by signs and symptoms of hypovolemia, occurring within 24 hours after delivery.⁴ Other organizations, including the World Health Organization,⁵ use a more conservative definition of postpartum hemorrhage as >500 mL of blood loss within 24 hours after delivery, or differentiate by delivery type, setting thresholds of 500 mL for vaginal delivery and 1000 mL for cesarean delivery.⁴ ACOG recommends the use of objective methods to quantify blood loss, such as weighing blood-soaked drapes or using calibrated obstetric drapes. Visual methods of estimation have been shown to consistently underestimate blood loss.⁶

Case 1 - Presentation

A 24-year-old woman is brought to the ED by EMS following a syncopal episode that occurred 24 hours after she had an uncomplicated vaginal delivery at home. She reports persistent, heavy vaginal bleeding and pelvic pain since the delivery . . .

How would you manage this patient? Subscribe for evidence-based best practices and to discover the outcomes.

Tables and Figures

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