Peripartum Hemorrhage
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Transcript Peripartum Hemorrhage
Peripartum Hemorrhage
Anita M. Backus, M.D.
Associate Clinical Professor, UCLA School of Medicine
Director of Obstetric Anesthesia, UCLA Medical Center
Peripartum Hemorrhage
Causes
of maternal death in US, 1987-90
(9.1/100,000)
– hemorrhage: 28.7% (*)
– embolism: 19.7% (*)
– pregnancy-induced hypertension: 17.6% (*)
– infection: 13.1% (*)
– cardiomyopathy: 5.6% (*)
– anesthesia: 2.5% (*)
* compared with 1979-86
Antepartum Hemorrhage
4%
of women may develop antepartum
hemorrhage.
Causes:
– placenta previa (1/200)
– placental abruption (1/100)
– uterine rupture (<1% in scarred uterus)
– vasa previa (1/2000-3000)
Placenta Previa
Definitions:
– Total:
covers the cervical os
– Partial:
covers part of the os
– Marginal: lies close to, but does not cover, the os
Risk factors:
– multiparity
– advanced maternal age
– prior C/S or other uterine surgery
– prior placenta previa
Placenta Previa: Diagnosis
Painless
vaginal bleeding in 2nd/3rd trimester
Confirmed by ultrasound
Vaginal exams are avoided
Up to 10% may have simultaneous abruption
Maternal shock is uncommon with 1st
presentation of bleeding
Placenta Previa:
Obstetric Management
If
possible, delay delivery until fetus is mature
Indications for delivery:
– active labor
– documented fetal lung maturity
– 37 weeks gestational age
– excessive bleeding
– development of another obstetric
complication mandating delivery
Placenta Previa:
Anesthetic Management
Evaluation
on arrival:
– airway
– volume status
– large bore IV access
– type and cross
– HCT
Patient
has bleeding risk during surgery
– OB may have to cut into placenta to remove baby
– lower uterine implantation site does not contract as
well as normal fundal site
– risk of placenta accreta (esp. if prior C/S)
Placenta Previa:
Anesthetic Management II
Large
bore IV(s)
Low threshold for type and cross / blood in room
If active hemorrhage, GA, RSI, ketamine (0.5-1.0
mg/kg) or etomidate (0.3 mg/kg), succinylcholine
Maintenance: 50/50 nitrous oxide and oxygen (may omit
nitrous if severe fetal distress) + low concentration
inhalational agent if tolerated
After delivery: pitocin and or omit halogenated agent;
nitrous oxide, add opioid
Be alert for placenta accreta, massive blood loss, C-hyst
May require invasive monitoring (aline, CVP)
Placenta Previa:
Anesthetic Management III
Elective,
not in labor
– regional anesthesia (spinal vs.
epidural) preferred
In labor, not hemorrhaging
– regional anesthesia preferred
Importance of history of prior C/S’s
Placental Abruption
Premature
separation of placenta from
endometrium
Diagnosis: vaginal bleeding, uterine
tenderness, uterine tone
Risk factors:
– HTN
– multiparity
– AMA
– smoking
– PROM
– cocaine
– trauma
– h/o abruption
Placental Abruption II
Complications
– shock
– acute renal failure
– DIC (coagulopathy in 10% of these pts.)
– fetal distress/demise
“Hidden” blood loss may approach 2500 cc
Placental Abruption:
Obstetric Management
Depends
on fetal maturity, size of
abruption, presence of fetal distress
– continuation of pregnancy
– induction/augmentation of labor
– Cesarean section
Placental Abruption:
Anesthetic Management
Be
alert for possibility of coagulopathy
and/or hypovolemia before considering
regional anesthesia
For stat C/S, GA most appropriate if
known or suspected hypovolemia or
DIC
– ketamine (or etomidate)
– volume resuscitation
– invasive monitoring
Uterine Rupture vs. Dehiscence
Uterine
scar dehiscence:
– fetal membranes remain intact, fetus is not
extruded intraperitoneally, separation limited
to old scar, peritoneum overlying is intact
– usually no fetal distress / mat. hemorrhage
Uterine rupture:
– separation of scar extension, rupture of
fetal membranes with extrusion
– results in fetal distress / mat. hemorrhage
– fetal mortality = 35%
Uterine Rupture II
Diagnostic
features:
– vaginal bleeding
– hypotension
– cessation of labor
– fetal distress
– pain present in only 10%
– postpartum hemorrhage may be a sign
Treatment: uterine repair, arterial ligation,
hysterectomy (may be preferred)
Comparison of Presentation of
Abruption v. Previa v. Rupture
abd. pain
vag. blood
DIC
acute fetal
distress
abruption
previa
rupture
present
old
common
common
absent
fresh
rare
rare
variable
fresh
rare
common
Vasa Previa
“Umbilical
vessels separate in the membranes
at a distance from the placental margin and
some of the vessels (fetal) cross the internal os
and occupy a position ahead of the presenting
part of the fetus.”
ROM may cause fetal exsanguination.
High fetal mortality (50-75%)
Risk factor: multiple gestation (esp., triplets)
Vasa Previa II
Diagnosis
– moderate vag bleeding + fetal distress
– vessels may be palpable thru dilated cervix
– vessels may be visible on ultrasound
Difficult to distinguish clinically from abruption
Can look for fetal Hb (Kleihauer-Betke test) or
nucleated RBC’s in shed blood
Rx: C/S, resuscitation of infant (volume)
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)