Transcript Postpartum Hemorrhage

Bleeding in Pregnancy:
Antepartum & Postpartum
Hemorrhage
OB & GY Dept. First Hospital, Xi’An Jiao Tong University
Learning Objectives
Definition of Post Partum Hemorrhage
Management of PPH
Risk Factors for PPH
Differential Diagnosis of Third Trimester
Bleeding
Management of Placenta Previa and Abruptio
Placenta
“Worst Case Scenario”
An insulin dependent diabetic was induced for
suspect fetal macrosomia and delivered a 4300
gram male infant because of late decelerations. A
low forceps delivery was done. An episiotomy
was done. Thee was a Shoulder Dystocia.
Immediately after delivery of the placenta the
patient bled uncontrollably and the
anesthesiologist yelled, “The patient is in shock.”
There is a 4th degree perineal laceration and the
uterus is “boggy” and there is a left side wall
laceration as well.
Definitions 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:
Results of Logistic Regression
Vaginal Birth
(N=9.598)
Cesarean Deliveries
(N=3.052)
Anesthesia (general vs. epidural)
--
2.94
Amnionitis
NS
2.69
Episiotomy (mediolateral vs. none/midline)
4.67
--
Labor abnormalities
Protracted active phase
Arrest of descent (present vs. absent)
-2.91
2.40
1.90
Lacerations (cervical/vaginal/perineal vs. none)
2.05
NS
Multiple gestations (twins vs. singletons)
3.31
NS
Preeclampsia (present vs. absent)
5.02
2.18
Prior postpartum hemorrhage (present vs. absent)
3.55
NS
Third stage (>30 minutes vs. <30 minutes)
7.56
--
Postpartum Hemorrhage
An event, not a diagnosis.
Excessive blood loss
Atony
Abnormal Implantation Site
– Placenta Accreta
– Uterine Inversion
Genital Tract Injury
– Cervical or Vaginal Lacerations
– Pelvic Hematoma
Postpartum Hemorrhage
Vaginal Birth
Antepartum - postpartum > 10% (Hct)
Risk Factors
Prolonged 3rd stage of labor
Preeclampsia
Mediolateral episiotomy
Combs CA et al, obstet Gnecol. 1991:77:63
Postpartum Hemorrhage
C/S
Risk Factors
General anesthesia
Amnionitis
Preeclampsia
Combs CA et al, obstet Gynecol
1991:77;77
Postpartum Hemorrhage
Vaginal Birth
Postpartum Hct <27% or Blood
Transfusion
Risk Factors
Estimated blood loss > 500 ml
Marginal previa
Placental abruption
Third stage of labor > 30 minutes
Chorioamnionitis
Nicol B et al obstet Gynecol 1997;90:514
Postpartum Hemorrhage
Antepartum - Postpartum > 10% (Hct)
Risk Factors
Preeclampsia
Disorders of active phase of labor
Native American ethnicity
Previous PPH
Maternal weight > 250 lbs
Postpartum Hemorrhage
Knowing the risk factors associated with
postpartum hemorrhage means the
obstetricians can effectively manage at-risk
patients.
One can ancticipate those patients where there
is a greater likelihood of a postpartum
hemorrhage
Postpartum Hemorrhage
Medical Management
Atony - Bimanual compression
- 15 methyl PGF 2: 0.25 mg 15’
IM or intra-myometrium
- Methylergonovine : 0.2 mg 1M
No IV => severe hypertension
- Misoprostol (100 mg) rectally
Postpartum Hemorrhage
Prevention
Vaginal deliveries
Active Management of 3rd stage of
labor
Uterotonic agents
Cesarean deliveries
Spontaneous delivery placenta
Repair uterine incision in situ
Management of Postpartum Hemorrhage
Postpartum Hemorrhage
Vital Signs/Help
I.V. / Oxygen
Foley Catheter
Flow Sheet
Atony
Placenta
Laceration or Rupture
Bimanual Compression
Retained
Abnormal
Implantation
Prostaglandin or Methergine
or Both
Ultrasound
Surgical
Options
Surgical Options
Manual
Exploration
or Curettage
Surgical
Repair
Postpartum Hemorrhage
Surgical Management
Uterine artery ligation
Hypogastic artery ligation
Ovarian vessels
B-Lynch technique
Selective arterial embolization
Hysterectomy
Figure
Hematoma
Pelvic Hematoma
Vulvar
Vaginal
Retroperitoneal
Risk Factors
Episiotomy
Primiparity
Preeclampsia
Multiple gestation
Vulvovaginal varicosities
Prolonged 2nd stage of labor
Clotting abnormalities
Hematoma
Vulvar hematoma
Laceration of vessels in the
superficial fascia of pelvic triangle
Volume support
< 3 cm: observation
> 3 cm: surgical evacuation with
suture closure and dressing
compression
Hematoma
– Vaginal hematoma
–Accumulation of blood above
the pelvic diaphragm
–More associated with forceps
deliveries
–Incision and evacuation
–Vaginal packing for 12 – 18
hours
Hematoma
Retroperitoneal hematomas
Sudden onset of hypotensive shock
Laceration of a branch of hypogastric
artery
Inadequate hemostasis of the uterine
arteries (C/S)
Rupture of low transverse scar
Surgical exploration and ligation of the
hypogastric vessel
Potential Complications of
Puerperal Hematomas
• Transfusion
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Coagulation Defects
Anemia
Fever
Reformation
Deep vein thrombosis
Scarring with resultant dyspareunia
Fistula Formation
Prolonged Hospitalization and Recuperation
Placenta Accreta/Increta/Percreta
Accreta: villi attatched to myometrium
(85%)
Increta: villi invading the myometrium
(15%)
Percreta: villi beneath or through the uterine
serosa (5%)
Placenta Accreta/Increta/Percreta
Risk factors
Early 30s
Parity (2 or 3 prior births)
Prior C/S
H/O of D& C
Prior manual placental removal
Prior retained placenta
Infection
Postpartum Accreta
Postpartum hemorrhage
39 – 64%
2600 ml (without previa)
4700 ml (with previa)
Placenta Accreta/Increta/Percreta
Postpartum hemorrhage
Conservative Management
Hysterectomy
Placenta Accreta/Percreta/Increta
Conservative management
Leaving the placenta in place
Localized resection and repair
Oversewing a defect (esp percreta)
Blunt disection/curretage
Uterine Inversion
1/2000  1/6400
Partial delivery of placenta
Rapid onset of maternal shock
Degree
– 1st (Incomplete)
- Corpus does not pass through the cervix
– 2nd (Complete)
- Corpus passes through the cervix
– 3rd (Prolapse)
- Corpus extends through vaginal introitus
Uterine Inversion
Treatment
– Fluid therapy
– Restoration of uterus
– Pushing the fundus with a fisted hand along the
axis of vagina through cervix back into pelvis
If failed
- Terbutaline
- Mg SO4
- General anesthesia
- Laparotomy
Uterine Rupture
1. 0.05% for all pregnancies
2. 0.8% after a previous low transverse c/s
3. 75% in prior classical c/s
4. 25% in prior uterine myomectomy
Uterine Rupture
Risk Factors
– Surgical procedures of uterus
C/S, myomectomy, perforation, cornual
resection, hysteroscopic or laparoscopic
injuries, penetrating abdominal wounds
• Grand multiparity
Obstetric trauma
Fetal macrosomia
Malpresentation
Breech extraction
Instrumental vaginal deliveries
Uterine Rupture
Symptoms and signs
Ripping lower abdominal Pain
Referred Shoulder Pain
Vaginal Hemorrhage
Fetal Bradycardia
Loss of fetal presentation part
Uterine Rupture
Management
Hysterectomy
Repair  recurrent rupture: 19%
Third Trimester Bleeding:
Antepartum Hemorrhage
Placental Abruption
Placental Previa
“Real Life Situation”
A patient calls you by telephone and tells you
that she has some vaginal bleeding with some
crampy lower abdominal pain at 32 weeks
gestation. She is hypertensive and has used
drugs in the past as well. She has had 2
previous CS and was transfused with the last
one. She was told that she had a placenta
previa earlier in her pregnancy with her
ultrasound exam at 20 weeks.
Placental Abruption
External hemorrhage
Concealed hemorrhage
Total
Partial
1/200 – 1/1550 deliveries
Perinatal mortality: 25%
Recurrence: 4 – 12.5%
Placental Abruption
Risk Factors
•Increased Maternal age and parity
RR
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 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 Abruption
DIC
Acute renal failure
Couvelaire uterus
Placental Abruption
Management
Gestational age
Maternal status
Fetal status
Correct maternal hypovolemia, anemia, hypoxia
? Tocolysis
Vaginal vs. C/S
Placenta Previa
Incidence: 0.3- 0.7 %
Definitions:
Total
Partial
Marginal
Low-lying
Tubal Occlusion:
Placental 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 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%
Placental Previa
Management
?
Preterm
 ? Fetal lung maturity
 ? Labor
 ? Severe hemorrhage
 Vaginal delivery vs. C/S