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)