Management of Obstetrical Hemorrhage

Jeffrey Stern, M.D.

Incidence of Obstetrical Hemorrhage

• 4% of SVD • 6.4 % of C-sections • 13% of maternal deaths (1:10,000 to 1:1,000) • 10% risk of recurrence

Etiology of Obstetrical Hemorrhage: Antepartum

• Placenta previa • Abruption • Coagulopathy: ITP/pre-eclampsia, FDIU

Etiology of Obstetrical Hemorrhage: Intrapartum

• Placenta previa • Abruption • Abnormal placentation • Genital tract lacerations: (2.4 odds ratio) • Uterine rupture • Coagulopathy: infection, abruption, amniotic fluid embolism

Etiology of Postpartum Hemorrhage (Primary)

(Within 24 hours of delivery) • Uterine atony (3.3 odds ratio) • Induction or Augmentation of labor (1.4 odds ratio) • Retained products of conception (3.5 odds ratio) • Placenta accreta, increta, percreta (3.3 odds ratio) • Coagulopathy • Fetal death in utero • Uterine inversion – may need MgSO4, Halothane, Terbutaline, NTG • Amniotic fluid embolism

Etiology of Postpartum Hemorrhage (Secondary)

(After 24 hours of delivery to 6 weeks postpartum) • 0.5-2% of patients • Infection • Retained products of conception with atony • Placental site involution • Rx: D+C, ABX, uterotonic medications

Uterine Atony: 1 in 20 to 1 in 100 deliveries

(80% of PPH) • Uterine over distension (Polyhydramnios, Multiple gestations, Macrosomia) • Prolonged labor: “uterine fatigue” (3.4 odd ratio) • Precipitory labor • High parity • Chorioamnionitis • Halogenated anesthetic • Uterine inversion

Treatment of Uterine Atony

• Message fundus continuously • Uterotonic agents • Foley catheter/Bakri balloon (500cc) • Uterine packing usually ineffective but can temporize • Modified B-Lynch stitch (#2chromic) – Uterine, utero-ovarian, hypogastric artery ligation – Subtotal/Total abdominal hyst.

Treatment of Uterine Atony

• Oxytocin – 90% success – 10-40 units in 1 liter NS or LR rapid infusion • Methylergonovine (Methergine) 90% success – 0.2 mg IM q 2-4 hours max. 5 doses; avoid with hypertension • Prostaglandin F2 Alpha (Hemabate) 75% success – 250 micrograms IM, intramyometrial, repeat q 20-90 min. max. 8 doses; Avoid if asthma/Hi BP • Prostaglandin E2 suppositories (Dinoprostone, Prostin E2) 75% success – 20 mg per rectum q 2 hours; avoid with hypotension • Prostaglandin PGE 1 Misoprostol (Cytotec) 75% - 100% success – 1000 microgram per rectum or sublingual (ten 100 micrograms tabs/five 200 micrograms tabs)

Retained Products of Conception: Etiology

• Succentiurate lobe • Placenta accreta, increta, percreta • Previous C-section; hysterotomy • Previous puerperal curettage • Previous placenta previa • High parity

Management of Retained Products of Conception

• Examine placenta carefully • Manual exploration of uterus • Careful curettage-Banjo curret

Placenta Accreta, Increta, Percreta: Risk Factors

• High Parity • Previous placenta previa • Previous C-section • GTN • Advanced maternal age • Previous uterine abnormal placentation

Management of Abnormal Placentation

• Placenta will not separate with usual maneuvers • Curettage of uterine cavity • Localized resection and uterine repair: (Vasopressin 1cc/10cc N.S-sub endometrial) • Leave placenta in situ – If not bleeding: Methotrexate – Uterus will not be normal size by 8 weeks • Uterine, utero-ovarian, hypogastric artery ligation • Subtotal/total abdominal hysterectomy

Uterine Inversion: 1 in 2500 Deliveries

• Risk factors: Abnormal placentation, excessive cord traction • Treatment – Manual replacement – May require halothane/general anesthesia – Remove placenta after re-inversion – Uterine tonics and massage after placenta is removed – May require laparotomy

Coagulopathy

• Hereditary • Acquired – Preganancy induced hypertension – Abruption – Sepsis – Fetal death in utero – Amniotic fluid embolism – Massive blood loss

Genital Tract Laceration and Hematomas: Etiology

• Macrosomia • Forceps • Episiotomy • Precipitous delivery • C-section incision extension • Uterine rupture

Therapy of Genital Tract Lacerations

• Superficial lacerations and small hematomas: expectant • Large laceration – Repair in layers – Consider a drain

Hematomas

• Below pelvic diaphragm: (vulva, paracolpos, ischiorectal fossa) – Leave alone if possible – Legate bleeder - often difficult to find – Pack open – Drain – May need combined abdominal/perineal approach • Above the pelvic diaphragm – Laparotomy- especially if expanding – Combined abdominal/perineal approach

Selective Artertial Embolization by Angiography

• Clinically stable patient – Try to correct coagulopathy • Takes approximately 1-6 hours to work • Often close to shock, unstable, require close attention • Can be used for expanding hematomas • Can be used preoperatively, prophylactically for patients with accreta • Analgesics, anti-nausea medications, antibiotics

Selective Artertial Embolization by Angiography

• Real time X-Ray (Fluoroscopy) • Access right common iliac artery • Single blood vessel best • Embolize both uterine or hypogastric arteries • Sometimes need a small catheter distally to prevent reflux into non target vessels • May need to treat entire anteriordivision or even all of the internal iliac artery.

• Risks: Can embolize nearby organs and presacral tissue, resulting in necrosis • Technique – Gelfoam pads – Temporary, allows recanalization – Autologous blood clot or tissue – Vasopressin, dopamine, Norepinephrine – Balloons, steel coils

Evaluate for Ovarian Collaterals May need to embolize

Mid Embolization “Pruned Tree Vessels”

Post Embolization

Post Embolization Pre Embo Post Embo

Uterine Rupture

• Scarred versus scarless uterus • Uterine scar dehiscence: separation of scar without rupture of membranes – 2-4% of deliveries after previous transverse uterine incision – Morbidity is usually minimal unless placenta is underneath or it tears into the uterine vessels – Diagnosis after vaginal delivery • Often asymptomatic, incidental finding • Difficult to diagnose because lower uterine segment is very thin • Therapy is expectant if small and asymptomatic – Diagnosed at C-section: Simple debridement and layered closure

Uterine Rupture Etiology

• Previous uterine surgery - 50% of cases – C-section, Hysterotomy, Myomectomy • Spontaneous (1/1900 deliveries) • Version-external and internal • Fundal pressure • Blunt trauma • Operative vaginal delivery • Penetrating wounds

Uterine Rupture Etiology

• Oxytocics • Grand multiparity • Obstructed labor • Fetal abnormalities-macrosomia, malposition, anomalies • Placenta percreta • Tumors: GTN, cervical cancer • Extra-tubal ectopics

Classic Symptoms of Uterine Rupture

• Fetal distress • Vaginal bleeding • Cessation of labor • Shock • Easily palpable fetal parts • Loss of uterine catheter pressure

Uterine Rupture

• Myth: Uterine incisions which do not enter the endometrial cavity will not • subsequently rupture • Type of closure: no relation to tensile strength – Continuous or interrupted sutures: chromic, vicryl, Maxon – Inverted or everted endometrial closure • Degree of complications – Inciting event- spontaneous, traumatic – Gestational age – Placental site in relation to rupture site – Presence or absence of uterine scar • Scar: 0.8 mortality rate • No scar: 13% mortality rate – Location of scar • Classical scar- majority of catastrophic ruptures • Transverse scar- less vascular; less likely to involve placenta – Extent of rupture

Management of Uterine Rupture

• Laparotomy – Debride and repair in 2-3 layers of Maxon/PDS – Subtotal Hysterectomy – Total Hysterectomy

Pregnancy After Repair of Uterine Rupture

• Not possible to predict rupture by HSG/Sono/MRI • Repair location – Classical -------------------------48% – Low transverse------------------16% – Not recorded---------------------36% • Re-rupture-------------------12% • Maternal death--------------1% • Perinatal death--------------6% • (Plauche, W.C 1993)

Modified Smead-Jones Closure

• Running looped #1 PDS/Maxon – Contaminated wounds/under tension • Additional Interruptured sutures - 2 cm apart – Fascial edges should be approximated – No tension