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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
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
Hemodynamic Resuscitation
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
International
Antepartum
Hemorrhage
Antepartum
Hemorrhage
International
International
Antepartum
Hemorrhage
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
International
Antepartum
Hemorrhage
International
Antepartum
Hemorrhage
International
Antepartum
Hemorrhage
PREVIA
Assess maturity
Maturity
Immaturity
International
Antepartum
Hemorrhage
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
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
Thrombin
- coagulopathy
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
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
0.1
1
Odds Ratio (95% Confidence Interval)
10
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
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
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
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
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
- appropriate analgesia
- good exposure and lighting
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
International
Postpartum
Antepartum
Hemorrhage
Hemorrhage
Management - ABC s
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