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International

Antepartum
Obstetrical
Hemorrhage
Hemorrhage

Obstetrical Hemorrhage

International

Obstetrical
Antepartum
Hemorrhage
Hemorrhage

Principles

Prompt diagnosis
Recognize reserve and ability to compensate
Resuscitate vigorously
Identify underlying cause
Treat underlying cause

International

Antepartum
Hemorrhage

Antepartum Hemorrhage

Antepartum
Hemorrhage

International

Objectives

Definitions and Incidence


Etiology and Risk Factors
Diagnosis
Management
- maternal and fetal assessment
- appropriate resuscitation
- no vaginal exam prior to determining
placental location
Individual Causes

International

Antepartum
Hemorrhage

Definition
vaginal bleeding between 20 weeks and delivery

Incidence
2% to 5% of all pregnancies
various causes of antepartum haemorrhage
- abruptio placenta
40% - 1% of pregnancies
- unclassified
35%
- placenta previa
20% - % of pregnancies
- lower genital tract lesion 5%
- other

International

Antepartum
Hemorrhage

Etiology of APH
Cervical
contact bleeding (e.g. intercourse, pap, neoplasia, examination)
inflammation (e.g. infection)
effacement and dilatation (e.g. labour, cervical incompetence)
Placental
abruptio
previa
marginal sinus rupture
Vasa previa
Other - abnormal coagulation

International

Antepartum
Hemorrhage

Diagnostic Procedures
History and physical - No digital pelvic exam
Ultrasound
definitive test for previa
less useful in abruptio
Electronic Fetal Monitoring
for fetal compromise and uterine tone
Speculum
do ultrasound first if possible
No digital pelvic exam

International

Antepartum
Hemorrhage

Laboratory
CBC, blood type, Rh, Coombs
coagulation status
INR, PTT, fibrinogen or TCT
2 - 4 units of PRBC cross matched as appropriate
bedside clot test
Kleihauer-Betke or Neirhaus test
vaginal and/or maternal blood
fetal lung maturity indices if appropriate

International

Antepartum
Hemorrhage

Vaginal Bleeding
Risk Factors

Tests (No vaginal exam)

Fetal / Maternal Assessment


Mother or fetus unstable

Mother and fetus stable

Hemodynamic Resuscitation

Labs / Fetal Monitoring


U/S vaginal exam

Mother or fetus unstable


Delivery

Expectant
consider ongoing loss, etiology, gestation

International

Antepartum
Hemorrhage

Management - ABC s
talk to and observe mother and fetus
large bore IV access
crystalloid (N/S)
CBC and coagulation status
cross-match and type
get HELP!

International

Antepartum
Hemorrhage

Hemodynamic Resuscitation
early aggressive resuscitation to protect fetus and
maternal organs from hypoperfusion and to prevent DIC
stabilize vital signs
large bore IV crystalloid infusion, plasma expanders
follow hemoglobin and coagulation status
oxygen
consumption is up 20% in pregnancy

International

Antepartum
Hemorrhage

Fetal Considerations

lateral position increases cardiac output up to 30%


consider amniocentesis for lung indices
external fetal and labor monitoring
Kleihauer-Betke if suspected abruption

post-trauma monitor at least 4 hours for evidence of


fetal insult, abruptio, fetal maternal transfusion

International

Antepartum
Hemorrhage

Abruptio Placenta - Definition


premature separation of normally implanted placenta

Abruptio Placenta - Classification


Total - fetal death
Partial - fetus may tolerate up to 30-50% abruption

Antepartum
Hemorrhage

International

Risk Factors for Abruption

hypertension: gestational and pre-existing


abdominal trauma
cocaine or crack abuse
previous abruption
overdistended uterus
multiple gestation, polyhydramnios
smoking, especially >1 pack/day

International

Antepartum
Hemorrhage

Clinical Presentation of Abruption


vaginal bleeding usually painful, unremitting
presence of risk factor
hemodynamic status may not correlate with
amount of vaginal blood loss - concealed abruptio
may be evidence of fetal compromise
uterus - tender, irritable, contracting or tetanic
ultrasound rules out previa and may show clot

Antepartum
Hemorrhage

International

ABRUPTION
Live Fetus

Dead Fetus
coagulopathy
Delivery
(watch for DIC)
Assess Maturity

Maturity
Vaginal delivery or C/S

Immaturity
Steroids plus expectancy
Transfusion? Transfer?

International

Antepartum
Hemorrhage

Placenta Previa - Definition


placenta covers or lies near the cervix

Placenta Previa - Classification


total
partial
marginal

- entirely covers the os


- partially covers the os
- close enough to the os to increase risk
of bleeding as cervical effacement and
dilatation occur

International

Antepartum
Hemorrhage

Risk Factors for Previa


previous placenta previa
previous caesarian section or uterine surgery
multiparity (5% in grand multiparous patients)
advanced maternal age
multiple gestation
smoking

International

Antepartum
Hemorrhage

Clinical Presentation of Previa


vaginal bleeding usually painless (unless in labour)
maternal hemodynamic status corresponds to
amount of vaginal blood loss
well tolerated by fetus unless maternal instability
uterus - non-tender, not irritable, soft
may have abnormal lie
ultrasound shows previa

International

Antepartum
Hemorrhage

PREVIA
Assess maturity

Maturity

Immaturity

Delivery by C/S (consider accreta)


May try vaginal if marginal

Steroids plus expectancy


Transfusion? Transfer?

International

Antepartum
Hemorrhage

Vasa Previa - Definition


blood vessels in the membranes run across the cervix
requires a vellamentous insertion or succenturiate lobe

Complication
ex-sanguination following amniotomy or ROM

Diagnosis
Apt test or Kleihauer test on vaginal blood
terminal fetal bradycardia initial tachycardia or sinusoidal FH

Prognosis
fetal mortality as high as 50-70%

International

Antepartum
Hemorrhage

Conclusions

assess maternal status and stability


assess fetal well-being
resuscitate appropriately
assess cause of bleeding - avoid vaginal exam
expectant management if appropriate
deliver if indicated based on maternal or fetal status

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Postpartum
Hemorrhage

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Objectives
Definition
Etiology
Risk Factors
Prevention
Management

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Traditional Definition
blood loss of > 500 mL following vaginal delivery
blood loss of > 1000 mL following cesarean delivery

Functional Definition
any blood loss that has the potential to produce or
produces hemodynamic instability

Incidence
about 5% of all deliveries

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Etiology of Postpartum
Hemorrhage
Tone

- uterine atony

Tissue

- retained tissue/clots

Trauma

- laceration, rupture, inversion

Thrombin

- coagulopathy

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Risk Factors for PPH - Antepartum


previous PPH or manual removal
placental abruption, especially if concealed
intrauterine fetal demise
placenta previa
gestational hypertension with proteinuria
overdistended uterus (e.g. twins, polyhydramnios)
pre-existing maternal bleeding disorder (e.g. ITP)

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Risk Factors for PPH - Intrapartum


operative delivery - cesarean or assisted vaginal
prolonged labour
rapid labour
induction or augmentation
chorioamnionitis
shoulder dystocia
internal podalic version and extraction of second twin
acquired coagulopathy (e.g. HELLP, DIC)

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Risk Factors for PPH Postpartum


lacerations or episiotomy
retained placenta/placental abnormalities
uterine rupture
uterine inversion
acquired coagulopathy (e.g. DIC)

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Prevention
be prepared
active management of the third stage
- prophylactic oxytocin with delivery or with delivery
of anterior shoulder
10 U IM or 5 U IV bolus
20 U/L N/S IV run rapidly
- early cord clamping and cutting
- gentle cord traction with suprapubic countertraction

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Active v.s Expectant Third Stage


Management
Outcome
(subjects)
PPH > 500 mL (n=4636)
PPH > 1000 mL (n=4636)
Maternal Hb < 91 (n=4256)
Blood transfusion (n=4829)
Therapeutic oxytocin (n=4829)
Nausea (n=3407)
Manual removal (n=4829)
Cochrane Library
Issue 1, 2000

0.1

1
Odds Ratio (95% Confidence Interval)

10

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Diagnosis - Is this a PPH?


consider risk factors
observe vaginal loss
express blood from vagina following C/S
REMEMBER
- blood loss is consistently underestimated
- ongoing trickling can lead to significant blood loss
- blood loss is generally well tolerated to a point

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Diagnosis - What is the cause?


assess the fundus
inspect the lower genital tract
explore the uterus
- retained placental fragments
- uterine rupture
- uterine inversion
assess coagulation

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

C
B
A
A = airway
B = breathing
C = circulation

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Management - ABC s
talk to and observe patient
large bore IV access (16 gauge)
crystalloid - lots!
CBC
cross-match and type
get HELP!

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Management - Assess the fundus


simultaneous with ABC s
atony is the leading cause of PPH
if boggy bimanual massage
- rules out uterine inversion
- may feel lower tract injury
- evacuate clot from vagina and/or cervix
- may consider manual exploration at this time

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Management - Bimanual Massage

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Management - Oxytocin
5 units IV bolus
20 units per L N/S IV wide open
10 units intramyometrial given transabdominally

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Management - Manual Exploration


if no response to bimanual massage and oxytocin
then proceed to exploration
manual exploration will:
- rule out uterine inversion
- palpate cervical injury
- remove retained placenta or clot from uterus
- rule out uterine rupture or dehiscence

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Replacement of Inverted Uterus

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Replacement of Inverted Uterus

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Management - Additional Uterotonics


ergotamine - caution in hypertension
- 0.25 mg IM or 0.125 mg IV
- maximum dose 1.25 mg
Hemabate (carboprost) - asthma is relative contraindication
- 15 methyl-prostaglandin F2
- 0.25 mg IM or intramyometrial
- Maximum dose 2 mg
Cytotec (misoprostol) - caution in asthma
- 400 mg pr or po

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Management - Bleeding with firm


uterus
explore the lower genital tract
requirements

- appropriate analgesia
- good exposure and lighting

appropriate surgical repair


- may temporize with packing

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Management - Continued uterine


bleeding
possible coagulopathy - INR, PTT, TCT, fibrinogen
if coagulation is abnormal:
- correct with clotting factors, platelets
if coagulation is normal:
- prepare for O.R. (may consider embolization)
- rule out uterine rupture, inadequate incision repair
- consider uterine/hypogastric ligation, hysterectomy

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Management - ABC s

ENSURE that you are always


ahead with your resuscitation!!!!
consider need for Foley catheter, CVP, arterial line, etc
consider need for more expert help

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Conclusions

be prepared
practice prevention
assess the loss
assess maternal status
resuscitate vigorously and appropriately
diagnose the cause
treat the cause

International

Postpartum
Antepartum
Hemorrhage
Hemorrhage

Management - Evolution
Panic
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness

International

Antepartum
Postpartum
Hemorrhage

Keep your bloody fingers


off the cervix!