What is the role of fluid resuscitation in the treatment of postpartum hemorrhage (PPH)?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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Answer

Fluid resuscitation of women experiencing obstetric hemorrhage is sometimes overly conservative. Possible reasons for this include (1) blood loss being generally underestimated both in volume and rapidity, (2) women initially compensating well for losses because of their good health and the hypervolemia of pregnancy, (3) concerns that overresuscitation leads to pulmonary edema, and (4) failure to appreciate the dynamics of fluid shifts in the body.

Immediately commence resuscitation. Raising the legs improves venous return and is consistent with the positioning used to diagnose and treat the underlying causes of bleeding. Administer oxygen and obtain intravenous access. All intravenous lines started on the labor ward for other reasons must be placed with cannulas of sufficient gauge if PPH develops. Twice as much fluid can be infused through a 14-gauge intravenous line compared with an 18-gauge intravenous line over the same time period. [33] During labor, place at least 1 intravenous line in women at risk for PPH; consider a second line in patients at very high risk.

Perform the initial resuscitation with large volumes of crystalloid solution, either normal saline (NS) or Lactated Ringer’s solution (LRS), through peripheral intravenous sites. Central venous access is not required for the vast majority of patients with PPH, but do not delay establishing such access if necessary. Draw blood for baseline measurements at this time. NS is a reasonable solution in the labor ward setting because of its low cost and compatibility with most drugs and blood transfusions. The risk of hyperchloremic acidosis is very low in the setting of PPH. If large amounts (>10 L) of crystalloid are being infused, a change to LRS can be considered.

Dextrose-containing solutions, such as 5% dextrose in water or diluted NS in 5% dextrose in water, have no role in the management of PPH. Remember that the loss of 1 L of blood requires replacement with 4-5 L of crystalloid because most of the infused fluid is not retained in the intravascular space but instead shifts to the interstitial space. This shift, along with oxytocin use, may result in peripheral edema in the days following PPH. Healthy kidneys easily excrete this excess fluid. Use wide-open initial infusion rates, with the goal of infusing the required replacement volume over minutes rather than hours. PPH of up to 1500 mL in a healthy pregnant woman can usually be managed by crystalloid infusion alone if the cause of bleeding is arrested. Blood loss in excess of this usually requires the addition of a PRBC transfusion.

Because a large portion of crystalloid fluid volume is lost to the interstitial space, the use of colloids in resuscitation has been examined. These solutions are largely retained within the intravascular space and include albumin, dextran, hydroxyethyl starch, and modified fluid gelatin. A meta-analysis in the Cochrane Library comparing resuscitation with colloid solutions versus crystalloid favored the use of crystalloids with respect to mortality. [34, 35]

For albumin or plasma protein fraction compared with NS, 18 trials reported data on mortality in 641 patients. The pooled relative risk from these trials was 1.52 (95% confidence interval, 1.08-2.13). The NS groups had a 1% mortality rate, versus an 11% mortality rate in the colloid group.

For dextran compared to NS, 8 trials compared reported data on mortality in 668 patients. The pooled relative risk was 1.24 (95% confidence interval, 0.94-1.65). Two other recent meta-analyses on the same topic reached the same conclusions.

Large volumes of colloid solutions (>1000-1500 mL/d) can have an adverse effect on hemostasis. No colloid solution has been demonstrated to be superior to NS, and, because of the expense and the risk of adverse effects with colloids, crystalloid is recommended. Given these findings, the authors recommend against the use of colloid solutions in resuscitation outside the setting of an RCT.


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