Post on 15-Dec-2015
Bleeding in Pregnancy: Bleeding in Pregnancy: Antepartum & Postpartum Antepartum & Postpartum
HemorrhageHemorrhage
OB & GY Dept. First Hospital, Xi’An Jiao Tong University
Learning ObjectivesLearning Objectives
Definition of Post Partum HemorrhageDefinition of Post Partum Hemorrhage
Management of PPHManagement of PPH
Risk Factors for PPHRisk Factors for PPH
Differential Diagnosis of Third Trimester Differential Diagnosis of Third Trimester BleedingBleeding
Management of Placenta Previa and Abruptio Management of Placenta Previa and Abruptio Placenta Placenta
““Worst Case Scenario”Worst Case Scenario”
An insulin dependent diabetic was induced for An insulin dependent diabetic was induced for suspect fetal macrosomia and delivered a 4300 suspect fetal macrosomia and delivered a 4300 gram male infant because of late decelerations. gram male infant because of late decelerations. A low forceps delivery was done. An episiotomy A low forceps delivery was done. An episiotomy was done. Thee was a Shoulder Dystocia. was done. Thee was a Shoulder Dystocia. Immediately after delivery of the placenta the Immediately after delivery of the placenta the patient bled uncontrollably and the patient bled uncontrollably and the anesthesiologist yelled, “The patient is in anesthesiologist yelled, “The patient is in shock.” There is a 4shock.” There is a 4thth degree perineal laceration degree perineal laceration and the uterus is “boggy” and there is a left side and the uterus is “boggy” and there is a left side wall laceration as well. wall laceration as well.
Definitions of Postpartum HemorrhageDefinitions of Postpartum Hemorrhage
1. Estimated blood loss
a. > 500 mL with vaginal birth
b. > 1000 mL with cesarean delivery
c. > 1500 mL with cesarean hysterectomy
Decline from antepartum to postpartum hematocrit of > 10%
2. Postpartum hematocrit < 27%
3. Transfusion of red blood cells
Risk Factors of Postpartum Hemorrhage: Risk Factors of Postpartum Hemorrhage: Results of Logistic RegressionResults of Logistic Regression
Vaginal BirthVaginal Birth
(N=9.598)(N=9.598)
Cesarean DeliveriesCesarean Deliveries
(N=3.052)(N=3.052)
Anesthesia (general vs. epidural)Anesthesia (general vs. epidural) ---- 2.942.94
AmnionitisAmnionitis NSNS 2.692.69
Episiotomy (mediolateral vs. none/midline)Episiotomy (mediolateral vs. none/midline) 4.674.67 ----
Labor abnormalitiesLabor abnormalities
Protracted active phaseProtracted active phase
Arrest of descent (present vs. absent)Arrest of descent (present vs. absent)
----
2.912.91
2.402.40
1.901.90
Lacerations (cervical/vaginal/perineal vs. none)Lacerations (cervical/vaginal/perineal vs. none) 2.052.05 NSNS
Multiple gestations (twins vs. singletons)Multiple gestations (twins vs. singletons) 3.313.31 NSNS
Preeclampsia (present vs. absent)Preeclampsia (present vs. absent) 5.025.02 2.182.18
Prior postpartum hemorrhage (present vs. absent)Prior postpartum hemorrhage (present vs. absent) 3.553.55 NSNS
Third stage (>30 minutes vs. <30 minutes)Third stage (>30 minutes vs. <30 minutes) 7.567.56 ----
Postpartum HemorrhagePostpartum Hemorrhage
An event, not a diagnosis.An event, not a diagnosis.
Excessive blood lossExcessive blood loss
AtonyAtony
Abnormal Implantation SiteAbnormal Implantation Site– Placenta AccretaPlacenta Accreta– Uterine InversionUterine Inversion
Genital Tract InjuryGenital Tract Injury– Cervical or Vaginal LacerationsCervical or Vaginal Lacerations– Pelvic HematomaPelvic Hematoma
Postpartum HemorrhagePostpartum HemorrhageVaginal BirthVaginal Birth
Antepartum - postpartum Antepartum - postpartum >> 10% (Hct) 10% (Hct)Risk FactorsRisk Factors
Prolonged 3Prolonged 3rdrd stage of labor stage of labor
Preeclampsia Preeclampsia
Mediolateral episiotomy Mediolateral episiotomy
Combs CA et al, obstet Gnecol. 1991:77:63Combs CA et al, obstet Gnecol. 1991:77:63
Postpartum HemorrhagePostpartum HemorrhageC/SC/S
Risk FactorsRisk Factors
General anesthesiaGeneral anesthesia
AmnionitisAmnionitis
PreeclampsiaPreeclampsia
Combs CA et al, obstet Gynecol 1991:77;77Combs CA et al, obstet Gynecol 1991:77;77
Postpartum HemorrhagePostpartum HemorrhageVaginal BirthVaginal Birth
Postpartum Hct <27% or Blood Postpartum Hct <27% or Blood TransfusionTransfusion
Risk FactorsRisk FactorsEstimated blood loss Estimated blood loss >> 500 ml 500 mlMarginal previaMarginal previaPlacental abruptionPlacental abruptionThird stage of labor Third stage of labor >> 30 minutes 30 minutesChorioamnionitis Chorioamnionitis
Nicol B et al obstet Gynecol 1997;90:514Nicol B et al obstet Gynecol 1997;90:514
Postpartum HemorrhagePostpartum HemorrhageAntepartum - Postpartum Antepartum - Postpartum >> 10% (Hct) 10% (Hct)
Risk FactorsRisk Factors
PreeclampsiaPreeclampsia
Disorders of active phase of laborDisorders of active phase of labor
Native American ethnicityNative American ethnicity
Previous PPHPrevious PPH
Maternal weight Maternal weight >> 250 lbs 250 lbs
Postpartum HemorrhagePostpartum Hemorrhage
Knowing the risk factors associated with Knowing the risk factors associated with postpartum hemorrhage means the postpartum hemorrhage means the obstetricians can effectively manage at-risk obstetricians can effectively manage at-risk patients.patients.
One can ancticipate those patients where there One can ancticipate those patients where there is a greater likelihood of a postpartum is a greater likelihood of a postpartum hemorrhagehemorrhage
Postpartum HemorrhagePostpartum Hemorrhage
Medical ManagementMedical ManagementAtony - Bimanual compression Atony - Bimanual compression
- 15 methyl PGF 2- 15 methyl PGF 2: 0.25 mg 15’: 0.25 mg 15’ IM or intra-myometriumIM or intra-myometrium - Methylergonovine : 0.2 mg 1M- Methylergonovine : 0.2 mg 1M
No IV => severe hypertensionNo IV => severe hypertension - Misoprostol (100 mg) rectally - Misoprostol (100 mg) rectally
Postpartum HemorrhagePostpartum Hemorrhage
PreventionPrevention
Vaginal deliveriesVaginal deliveries
Active Management of 3Active Management of 3rdrd stage of labor stage of labor
Uterotonic agentsUterotonic agents
Cesarean deliveriesCesarean deliveries
Spontaneous delivery placentaSpontaneous delivery placenta
Repair uterine incision in situRepair uterine incision in situ
Management of Postpartum HemorrhageManagement of Postpartum Hemorrhage
Surgical Options
Prostaglandin or M ethergineor Both
Bimanual Compression
Atony
M anualExplorationor Curettage
Ultrasound
Retained
SurgicalOptions
AbnormalImplantation
Placenta
SurgicalRepair
Laceration or Rupture
Vital Signs/HelpI.V. / Oxygen
Foley CatheterFlow Sheet
Postpartum Hemorrhage
Postpartum HemorrhagePostpartum Hemorrhage
Surgical ManagementSurgical ManagementUterine artery ligationUterine artery ligationHypogastic artery ligationHypogastic artery ligationOvarian vesselsOvarian vesselsB-Lynch techniqueB-Lynch techniqueSelective arterial embolizationSelective arterial embolizationHysterectomyHysterectomy
HematomaHematoma
Pelvic HematomaPelvic Hematoma
VulvarVulvar
VaginalVaginal
RetroperitonealRetroperitoneal
Risk FactorsRisk Factors
EpisiotomyEpisiotomy
PrimiparityPrimiparity
PreeclampsiaPreeclampsia
Multiple gestationMultiple gestation
Vulvovaginal varicosities Vulvovaginal varicosities
Prolonged 2Prolonged 2ndnd stage of labor stage of labor
Clotting abnormalitiesClotting abnormalities
HematomaHematoma
Vulvar hematomaVulvar hematoma
Laceration of vessels in the superficial fascia Laceration of vessels in the superficial fascia of pelvic triangleof pelvic triangle
Volume supportVolume support
< 3 cm: observation< 3 cm: observation
>> 3 cm: surgical evacuation with suture 3 cm: surgical evacuation with suture closure and dressing compressionclosure and dressing compression
HematomaHematoma
– Vaginal hematomaVaginal hematoma
–Accumulation of blood above the pelvic Accumulation of blood above the pelvic diaphragmdiaphragm
–More associated with forceps deliveriesMore associated with forceps deliveries
–Incision and evacuationIncision and evacuation
–Vaginal packing for 12 – 18 hoursVaginal packing for 12 – 18 hours
HematomaHematoma
Retroperitoneal hematomasRetroperitoneal hematomas
Sudden onset of hypotensive shockSudden onset of hypotensive shock
Laceration of a branch of hypogastric arteryLaceration of a branch of hypogastric artery
Inadequate hemostasis of the uterine arteries (C/S)Inadequate hemostasis of the uterine arteries (C/S)
Rupture of low transverse scarRupture of low transverse scar
Surgical exploration and ligation of the Surgical exploration and ligation of the hypogastric vesselhypogastric vessel
Potential Complications of Potential Complications of Puerperal HematomasPuerperal Hematomas
• Transfusion• Coagulation Defects• Anemia• Fever• Reformation• Deep vein thrombosis• Scarring with resultant dyspareunia• Fistula Formation• Prolonged Hospitalization and Recuperation
Placenta Accreta/Increta/PercretaPlacenta Accreta/Increta/Percreta
Accreta: villi attatched to myometrium Accreta: villi attatched to myometrium (85%)(85%)
Increta: villi invading the myometrium Increta: villi invading the myometrium (15%)(15%)
Percreta: villi beneath or through the uterine Percreta: villi beneath or through the uterine serosa (5%)serosa (5%)
Placenta Accreta/Increta/PercretaPlacenta Accreta/Increta/Percreta
Risk factorsRisk factors
Early 30sEarly 30s
Parity (2 or 3 prior births)Parity (2 or 3 prior births)
Prior C/SPrior C/S
H/O of D& CH/O of D& C
Prior manual placental removalPrior manual placental removal
Prior retained placentaPrior retained placenta
InfectionInfection
Postpartum AccretaPostpartum Accreta
Postpartum hemorrhagePostpartum hemorrhage
39 – 64%39 – 64%
2600 ml (without previa)2600 ml (without previa)
4700 ml (with previa)4700 ml (with previa)
Placenta Accreta/Increta/PercretaPlacenta Accreta/Increta/Percreta
Postpartum hemorrhagePostpartum hemorrhage
Conservative ManagementConservative Management
HysterectomyHysterectomy
Placenta Accreta/Percreta/IncretaPlacenta Accreta/Percreta/Increta
Conservative managementConservative management
Leaving the placenta in placeLeaving the placenta in place
Localized resection and repairLocalized resection and repair
Oversewing a defect (esp percreta)Oversewing a defect (esp percreta)
Blunt disection/curretageBlunt disection/curretage
Uterine InversionUterine Inversion
1/2000 1/2000 1/6400 1/6400
Partial delivery of placentaPartial delivery of placenta
Rapid onset of maternal shockRapid onset of maternal shock
DegreeDegree– 1st (Incomplete)1st (Incomplete)
- Corpus does not pass through the cervix- Corpus does not pass through the cervix– 22ndnd (Complete) (Complete)
- Corpus passes through the cervix- Corpus passes through the cervix– 33rdrd (Prolapse) (Prolapse)
- Corpus extends through vaginal introitus- Corpus extends through vaginal introitus
Uterine InversionUterine InversionTreatmentTreatment
– Fluid therapyFluid therapy– Restoration of uterusRestoration of uterus– Pushing the fundus with a fisted hand along the Pushing the fundus with a fisted hand along the
axis of vagina through cervix back into pelvisaxis of vagina through cervix back into pelvis
If failedIf failed- TerbutalineTerbutaline- Mg SO4Mg SO4- General anesthesiaGeneral anesthesia- Laparotomy Laparotomy
Uterine RuptureUterine Rupture
1.1. 0.05% for all pregnancies0.05% for all pregnancies
2.2. 0.8% after a previous low transverse c/s0.8% after a previous low transverse c/s
3.3. 75% in prior classical c/s75% in prior classical c/s
4.4. 25% in prior uterine myomectomy25% in prior uterine myomectomy
Uterine RuptureUterine RuptureRisk FactorsRisk Factors
– Surgical procedures of uterusSurgical procedures of uterus
C/S, myomectomy, perforation, cornual C/S, myomectomy, perforation, cornual resection, hysteroscopic or laparoscopic resection, hysteroscopic or laparoscopic injuries, penetrating abdominal woundsinjuries, penetrating abdominal wounds
• • Grand multiparity Grand multiparity
Obstetric traumaObstetric trauma
Fetal macrosomiaFetal macrosomia
MalpresentationMalpresentation
Breech extractionBreech extraction
Instrumental vaginal deliveriesInstrumental vaginal deliveries
Uterine RuptureUterine Rupture
Symptoms and signsSymptoms and signs
Ripping lower abdominal PainRipping lower abdominal Pain
Referred Shoulder PainReferred Shoulder Pain
Vaginal HemorrhageVaginal Hemorrhage
Fetal BradycardiaFetal Bradycardia
Loss of fetal presentation partLoss of fetal presentation part
Uterine RuptureUterine Rupture
ManagementManagement
HysterectomyHysterectomy
Repair Repair recurrent rupture: 19% recurrent rupture: 19%
Third Trimester Bleeding:Third Trimester Bleeding:Antepartum HemorrhageAntepartum Hemorrhage
Placental AbruptionPlacental Abruption
Placental PreviaPlacental Previa
““Real Life Situation”Real Life Situation”A patient calls you by telephone and tells you A patient calls you by telephone and tells you that she has some vaginal bleeding with some that she has some vaginal bleeding with some crampy lower abdominal pain at 32 weeks crampy lower abdominal pain at 32 weeks gestation. She is hypertensive and has used gestation. She is hypertensive and has used drugs in the past as well. She has had 2 drugs in the past as well. She has had 2 previous CS and was transfused with the last previous CS and was transfused with the last one. She was told that she had a placenta one. She was told that she had a placenta previa earlier in her pregnancy with her previa earlier in her pregnancy with her ultrasound exam at 20 weeks.ultrasound exam at 20 weeks.
Placental AbruptionPlacental Abruption
External hemorrhage
Concealed hemorrhage
Total
Partial
1/200 – 1/1550 deliveries
Perinatal mortality: 25%
Recurrence: 4 – 12.5%
Placental AbruptionPlacental Abruption
Risk Factors RR
•Increased Maternal age and parity N/A
•Preeclampsia 2.1 – 4.0
•Chronic hypertension 1.8 – 3.0
•PROM 2.4 – 3.0
•Smoking 1.4 – 1.9
•Cocaine N/A (13%)
•Prior abruption 10 – 25
Placental AbruptionPlacental Abruption
Symptoms & Signs Frequency (%)
•Vaginal bleeding 78
•Uterine tenderness or back pain 66
•Fetal distress 60
•High frequency of contractions 17
•Hypertonus 17
•Idiopathic preterm labor 22
•IUFD 15
Placental AbruptionPlacental Abruption
Gestational age
Maternal status
Fetal status
Correct maternal hypovolemia, anemia, hypoxia
? Tocolysis
Vaginal vs. C/S
Management
Placental PreviaPlacental Previa
Risk Factors
•Increased maternal age
•Increase parity
•Smoking
•Prior C/S
One: 2X – 3X (0.5-0.75%)
Two: 1.9%
Three: 4.1%
•Diagnosis: U/S (TVU), MRI
Placental PreviaPlacental Previa
GA at U/S (wk) Previa or Bleeding at Delivery
• < 20 2.3%
• 20 – 25 3.2%
• 25 – 30 5.2%
• 30 – 35 24%