Transcript Peripartum Hemorrhage

Postpartum Hemorrhage
Dr.B Khani MD
Postpartum Hemorrhage
 EBL
> 500 cc
 10% of deliveries
 If within 24 hrs. pp = 1 pp hemorrhage
 If 24 hrs. - 6 wks. pp = 2 pp hemorrhage
 Causes
– uterine atony
– genital trauma
– retained placenta
– placenta accreta
– uterine inversion
Uterine Atony
 Most
common cause of pp hemorrhage
 Contraction of uterus is 1 mechanism for
controlling blood loss at delivery
– oxytocin and prostaglandins
 Risk factors
– multiple gestation
– chorioamnionitis
– macrosomia
– precipitous labor
– polyhydramnios
– tocolytics
– high parity
– halogenated agents
– prolonged labor
Uterine Atony: Treatment
 uterine
massage
 oxytocin:
– produced by posterior pituitary
– causes peripheral vasodilation, reflex tachycardia
– administered diluted in IV fluid, not IV push
– metabolized/excreted by liver, kidney, oxytocinase
 ergot derivatives
 prostaglandins
 If drugs fail, embolization of arterial supply, ligation, or
hysterectomy
Uterine Atony:
Ergot Derivatives
 ergonovine
and methylergonovine
(methergine)
– act via -adrenergic mechanism
– adverse effects: nausea/vomiting,
vasoconstriction (including coronary),
HTN, PAP
– relative contraindications: chronic
HTN, PIH, PVD, CAD
– dose: 0.2 mg IM (not IV), last 2-3 hrs.
Uterine Atony:
Prostaglandins

myometrial intracellular free Ca++, enhance
action of other oxytocics
 Side effects: fever, nausea/vomiting, diarrhea
 15-methyl PG F2 (Carboprost, Hemabate)
– may cause bronchospasm, altered VQ,
 shunt, hypoxemia, HTN
– 250 g IM or intramyometrially q 15-30 min,
up to max 2 mg.
– contraindications: asthma, hypoxemia
Genital Trauma
 Vaginal:
associated with forceps, vacuum, prolonged
2nd stage, multiple gestation, PIH
– Rx: I & D and packing
 Vulvar: bleeding from branches of pudendal arteries
 Retroperitoneal: least common, most dangerous
– laceration of branch of hypogastric during C/S (or
uterine rupture)
– Dx: CT
– Rx: expl. lap., ligation of hypogastric, hyst
Retained Placenta
 Obstetric
management:
– manual removal, oxytocin
 Anesthetic management:
– epidural or spinal anesthesia, if not
hypovolemic
– or MAC
– or GA (ketamine, RSI, intubate, 50%
nitrous, fentanyl)
– Uterine relaxation may be requested (NTG)
Placenta Accreta
 Definitions:
– accreta vera: adherence of placenta to myometrium
– increta:
invasion of placenta into myometrium
– percreta:
invasion of placenta to/thru the serosa
 Risk
factors:
– prior uterine trauma + placenta previa
Placenta Accreta II
 Placenta
previa + prior C/S v. accreta risk:
Number of prior C/S
0
1
2
3
4
 Rx:
Incidence of accreta
5%
24%
47%
40%
67%
uterine curettage, oversewing of plac. bed,
usually hysterectomy (accreta is most
common indication for C-hyst)
Uterine Inversion
 Low
mortality
 Risk factors:
– uterine atony
– inappropriate fundal pressure
– unbilical cord traction
– uterine anomaly
 Rx:
replace the uterus, oxytocin, Hemabate,
methergine
– may need uterine relaxation transiently
»NTG (50-100 g IV) vs. halogenated agent
»anecdotal reports of other nitrates, terb, Mg
Invasive Treatment Options for
Obstetric Hemorrhage
 Uterine
arteries are branches of internal iliacs
(major supply to uterus)
 Ovarian arteries also contribute during preg.
 Options
– angiographic embolization
– bil. surgical ligation of uterine, ovarian, internal
iliacs (preserves fertility): 42% success
– Cesarean or pp hysterectomy
»EBL 2500 cc (emergent), 1300 cc (elective)