4/10/05njm

**Q. Is there a role for calcium in the management of postpartum
hemorrhage?**

A. Consider calcium therapy to reverse any magnesium before invasive
action

**Case scenario**

A 20 year old gravida 1 para 0 at 39 weeks has just delivered a 3250 gm
healthy female infant after a prolonged second stage. The patient's
pregnancy was complicated by severe pre-eclampsia diagnosed on the basis
of serial blood pressures \> 160/110 and over 5 grams of protienuria.
The patient received magnesium sulfate prophylaxis with a 4 gram bolus
followed by 2 grams per hour IV. The patient received pitocin IV after
delivery of the fetal shoulder.

Soon after delivery of an intact placenta, the patient is noted to have
had a \> 1500 cc blood loss. The patient is then managed with pitocin
IV, two large bore IVs, crystalloid resuscitation, carboprost
tromethamine 250 mcg x 2 IM, uterine exploration, bimanual massage,
exploration of the uterus, and a thorough examination for trauma.

The patient's uterus was then packed with two 30 cc bulb foley
catheters. The patient's history is re-reviewed and no history of blood
dyscrasia is noted. The patient had received 1000 mcg of rectal
misoprostol, but has now developed a copious clear diarrhea from her
carboprost. The uterus is intermittently reported as firm and then boggy
by different providers.

The patient has received 2 units of packed red blood transfusion, but
continues to hemorrhage, as additional units are requested STAT. The
patient is becoming hemodynamically unstable. The interventional
radiology guideline only allows for treatment of stable patients from
9:00 am to 4:30 pm during weekdays. The operating room is prepared for
immediate surgery.

In the meantime, the attending staff member walks in to evaluate the
patient before she is rushed to the operative suite. The attending asks
the 2 senior residents in attendance one question. **What is that
question?**

"Has the patient received her calcium yet?"

The resident staff has done an excellent job of managing the patient's
postpartum hemorrhage, but prior to surgical intervention it is very
reasonable to attempt short term reversal of the patient's prophylactic
magnesium sulfate. The risk of postpartum hemorrhage, possibly related
to uterine atony from magnesium\'s tocolytic effects, has been noted in
one trial (Belfort et al).

Calcium gluconate (1 g intravenously over at 5 to 10 minutes) may be
administered to counteract magnesium toxicity, if necessary. As the
patient becomes more stable the magnesium can be restarted and the risk
of developing an eclamptic seizure in the meantime is small.

 

Another use for calcium can be to reverse the Magnesium sulfate before
starting a cesarean

delivery to decrease intra-operative blood loss. The magnesium sulfate
can be re-started 1 hour

after surgery.

On a slightly different tangent, there is a synergistic effect of
calcium with prostaglandin (Weinstein 1976, Droegemueller 1980) outside
the setting of postpartum hemorrhage. Though ineffective in this case,
the trial of rectal misoprostol may have been worth the effort.

**Other Resources:**

# Advanced Life Support in Obstetrics

<http://www.aafp.org/also.xml>

**Management of the third stage of labor**

<http://www.uptodateonline.com/application/topic.asp?file=labordel/10159&type=A&selectedTitle=4~8>

**Treatment of postpartum hemorrhage**

<http://www.uptodateonline.com/application/topic.asp?file=postpart/4483&type=A&selectedTitle=1~8>

**Abruptio placentae**

<http://www.uptodateonline.com/application/topic.asp?file=pregcomp/7939>

**Vaginal birth after cesarean delivery**

<http://www.uptodateonline.com/application/topic.asp?file=labordel/9085>

**Acute and chronic endometritis**

<http://www.uptodateonline.com/application/topic.asp?file=gen_gyne/8842>

**Indications for red cell transfusion**

<http://www.uptodateonline.com/application/topic.asp?file=transfus/8375>

**Use of red blood cells for transfusion**

<http://www.uptodateonline.com/application/topic.asp?file=transfus/5967>

**Clinical features, diagnosis, and treatment of disseminated
intravascular coagulation**

<http://www.uptodateonline.com/application/topic.asp?file=coagulat/10248>

**Diagnosis and management of placenta accreta**

<http://www.uptodateonline.com/application/topic.asp?file=pregcomp/17446&type=A&selectedTitle=3~8>

**Peripartum hysterectomy**

<http://www.uptodateonline.com/application/topic.asp?file=labordel/5088&type=A&selectedTitle=2~8>

**Disorders of fibrinogen**

<http://www.uptodateonline.com/application/topic.asp?file=coagulat/15933&type=A&selectedTitle=6~8>

Belfort MA; Anthony J; Saade GR; Allen JC Jr A comparison of magnesium
sulfate and nimodipine for the prevention of eclampsia. N Engl J Med
2003 Jan 23;348(4):304-11.

 Droegemueller W, Weinstein L, Milzer G. Low dose prostaglandin for late
second trimester

abortion. *Contemporary Obstet Gynecol* 1980; 15:19-22

Weinstein L, Droegemueller W, Greer B. The synergistic effect of calcium
and prostaglandin F2

in second trimester abortion - a pilot study. *Obstet Gynecol* 1976;
48:469-71