Third Trimester Bleeding, Postpartum Hemorrhage, & Shock Management

1. Third Trimester Bleeding, Postpartum Hemorrhage, & Shock Management UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series

2. Objectives for Third Trimester Bleeding • List the causes of third trimester bleeding • Describe the initial evaluation of a patient with third trimester bleeding • Differentiate the signs and symptoms of third trimester bleeding • Describe the maternal and fetal complications of placenta previa and abruption placenta • Describe the initial evaluation and management plan for acute blood loss • List the indications and potential complications of blood product transfusion

3. Objectives for Postpartum Hemorrhage • Identify the risk factors for postpartum hemorrhage • Construct a differential diagnosis for immediate and delayed postpartum hemorrhage • Develop an evaluation and management plan for the patient with postpartum hemorrhage

4. Rationale (why we care….) • 4-5% of pregnancies complicated by 3rd trimester bleeding • Immediate evaluation needed • Significant threat to mother & fetus (consider physiologic increase in uterine blood flow) • Consider causes of maternal & fetal death • Priorities in management (triage!)

5. Vaginal Bleeding: Differential Diagnosis • Common: • Abruption, previa, preterm labor, labor • Less common: • Uterine rupture, fetal vessel rupture, lacerations/lesions, cervical ectropion, polyps, vasaprevia, bleeding disorders • Unknown • NOT vaginal bleeding!!! • (happens more than you think!)

6. Initial Management for Third Trimester Bleeding • Stabilize patient – two large bore IVs if bleeding is heavy, EBL is significant or patient is clearly unstable • Auscultate fetal heart rate - Confirm reassuring pattern • Focused history • PE • Vitals • Brief inspection for petechiae, bruising • Careful inspection of vulva • Speculum exam of vagina and cervix – NO DIGITAL EXAM until r/o previa • Labs – CBC, coag profile, type and cross match • Ultrasound exam to assess placental location and fetal condition

7. Placental Abruption: Definition • Separation of placenta from uterine wall • Incidence • 0.5-1.5% of all pregnancies • Recurrence risk • 10% after 1st episode • 25% after 2nd episode

8. Cocaine Maternal hypertension Abdominal trauma Smoking Prior abruption Preeclampsia Multiple gestation Prolonged PROM Uterine decompression Short umbilical cord Chorioamnionitis Multiparity Placental abruption: Risk factors and associations

9. Placental Abruption: Symptoms • Vaginal bleeding • Abdominal or back pain • Uterine contractions • Uterine tenderness

10. Placental Abruption: Physical Findings • Vaginal bleeding • Uterine contractions • Hypertonus • Tetanic contractions • Non-reassuring fetal status or demise • Can be concealed hemorrhage

11. Placental Abruption: Laboratory Findings • Anemia • May be out of proportion to observed blood loss • DIC • Can occur in up to 10% (30% if “severe”) • First, increase in fibrin split products • Followed by decrease in fibrinogen

12. Placental Abruption: Diagnosis • Clinical scenario • Physical exam • NOT DIGITAL PELVIC EXAMS UNTIL RULE OUT PREVIA • Careful speculum exam • Ultrasound • Can evaluate previa • Not accurate to diagnose abruption

13. Placental Abruption: Management • Physical exam • Continuous electronic fetal monitoring • Ultrasound • Assess viability, gestational age, previa, fetal position/lie • Expectant mgmt • vaginal vs cesarean delivery • Available anesthesia, OR team for stat cesarean delivery

14. Placenta Previa: Definition • Placental tissue covers cervical os • Types: • Complete - covers os • Partial • Marginal - placental edge at margin of internal os • Low-lying • placenta within 2 cm of os

15. Placenta Previa: Incidence • Most common abnormal placentation • Accounts for 20% of all antepartum hemorrhage • Often resolves as uterus grows • ~ 1:20 at 24 wk. • 1:200 at 40 wk. • Nulliparous- 0.2% • Multiparous- 0.5%

16. Placenta Previa: Risk factors and associations • Prior cesarean delivery/myomectomy • Prior previa (4-8% recurrence risk) • Previous abortion • Increased parity • Multifetal gestation • Advanced maternal age • Abnormal presentation • Smoking

17. Placenta Previa: Symptoms • Painless vaginal bleeding • Spontaneous • After coitus • Contractions • No symptoms • Routine ultrasound finding • Avg gestational age of 1st bleed, 30 wks • 1/3 before 30 weeks

18. Placenta Previa: Physical Findings • Bleeding on speculum exam • Cervical dilation • Bleeding a sx related to PTL/normal labor • Abnormal position/lie • Non-reassuring fetal status • If significant bleeding: • Tachycardia • Postural hypertension • Shock

19. Placenta Previa: Diagnosis • Ultrasound • Abdominal 95% accurate to detect • Transvaginal(TVUS) will detect almost all • Consider what placental location a TVUS may find that was missed on abdominal • Physical/speculum exam • remember: no digital exams unless previa RULED OUT!

20. Placenta Previa: Management • Initial evaluation/diagnosis • Observe/admit to L&D • IV access, routine (maybe serial) labs • Continuous electronic fetal monitoring • Continuous at least initially • May re-evaluate later if stable, no further bleeding • Delivery???

21. Placenta Previa: Management • Less than 36 wks gestation - expectant management if stable, reassuring • Bed rest (negotiable) • No vaginal exams (not negotiable) • Steroids for lung maturation (<32 wks) • Possible mgmt at home after 1st bleed • 70% will have recurrent vaginal bleeding before 36 completed weeks requiring emergent cesarean

22. Placenta Previa: Management • 36+ weeks gestation • Cesarean delivery if positive fetal lung maturity by amniocentesis • Delivery vs expectant mgmt if fetal lung immaturity • Schedule cesarean delivery @ 37 weeks • Discussion/counseling regarding cesarean hysterectomy • Note: given stable maternal and reassuring fetal status, none of these management guidelines are absolute (this is why OB is so much fun!)

23. Placenta Previa: Other considerations • Placenta accreta, increta, percreta • Cesarean delivery may be necessary • History of uterine surgery increases risk • Must consider these diagnoses if previa present • Could require further evaluation, imaging (MRI considered now) • NOT the delivery you want to do at 2 am

24. Vasa Previa: Definition • In cases of velamentous cord insertion fetal vessels cover cervical os

25. Vasa Previa: Incidence • 0.1-1.0% • Greater in multiple gestations • Singleton - 0.2% • Twins - 6-11% • Triplets - 95%

26. Vasa Previa: Symptoms, Findings, Diagnosis • Painless vaginal bleeding • Fetal bleeding • Positive KleihauerBetke test • Ultrasound • Routine vs at time of symptoms

27. Vasa Previa: Management • If bleeding, plan for emergent delivery • If persistent bleeding, nonreassuring fetal status, STAT cesarean… not a time for conservative mgmt! • Fetal blood loss NOT tolerated

28. Third Trimester Bleeding: Other Etiologies • Cervicitis • Infection • Cervical erosion • Trauma • Cervical cancer • Foreign body • Bloody show/labor

29. Perinatal Morbidity and Mortality • Previa • Decreased mortality from 30% to 1% over last 60 years • Now emergent cesarean delivery often possible • Risk of preterm delivery • Abruption • Perinatal mortality rate 35% • Accounts for 15% of 3rd trimester stillbirths • Risk of preterm delivery • Most common cause of DIC in pregnancy • Massive hemorrhage --> risk of ARF, Sheehan’s, etc.

30. Postpartum Hemorrhage: Definition and Differential Diagnosis • EBL >500 cc, vaginal delivery • EBL >1000 cc, cesarean delivery • Differential Diagnosis: • Uterine atony • Lacerations • Uterine inversion • Amniotic fluid embolism • Coagulopathy

31. Risk Factors for Postpartum Hemorrhage • Prolonged labor • Augmented labor • Rapid labor • h/o prior PPH • Episiotomy • Preeclampsia • Overdistended uterus (macrosomia, twins, hydramnios) • Operative delivery • Asian or Hispanic ethnicity • Chorioamnionitis

32. Uterine Atony (same overall mgmt regardless of delivery type) • Recognition • Uterine exploration • Uterine massage • Medical mgmt: • Pitocin (20-80 u in 1 L NS) • Methergine (ergonovinemaleate 0.2 mg IM) • Not advised for use if hypertension • Hemabate (prostaglandin F2 mg IM or intrauterine)

33. Uterine Atony • B-lynch suture (to compress uterus) • Uterine artery ligation • Must understand anatomy • Risk of ureteral injury • Uterine artery embolization • Typically an IR procedure • Plan “ahead” and let them know you may need them • Hysterectomy (last resort) • Anesthesia involved • Whether in L&D room or the OR!!!

34. Lacerations • Recognition • Perineal, vaginal, cervical • All can be rather bloody! • Assistance • Lighting • Appropriate repair • Control of bleeding • Identify apex for initial stitch placement

35. Uterine Inversion • Uncommon, but can be serious, especially if unrecognized • Consider if difficult placental delivery • Consider if cannot recognize bleeding source • Consider… always! • Delayed recognition is bad news • Patient can have shock out of proportion to EBL • (though not all sources will agree on this)

36. Uterine Inversion • Management • Call for help • Manual replacement of uterus • Uterotonics to necessary to relax uterus & allow thorough manual exploration of uterine cavity • IV nitroglycerin (100 g) • Appropriate anesthesia to allow YOU to manually explore uterine cavity • Concern for shock… to be discussed (and managed by the help you’ve called into the room!) • Exploratory laparotomy may be necessary

37. Amniotic Fluid Embolism • High index of suspicion • Recognition • Again… call for help! • Supportive treatment • Replete blood, coagulation factors as able • Plan for delivery (if diagnose antepartum) if able to stabilize mom first

38. Management of Shock • Stabilize mother • Large-bore IV x 2 • Place patient in Trendelenburg position • Crossmatch for pRBCs (2, 4, more units) • Rapidly infuse 5% dextrose in lactated Ringer’s • Monitor urine output • Ins/Outs very important • (and often not well-recorded prior to emergency situation -- how many times did she really void while in labor??? How dehydrated was she when presented???) • By the way… get help (calling for help works quickly on L&D!)

39. Management of Shock • Serial labs • CBC and platelets • Prothrombin time (factors II, V, VII, X {extrinsic}) • Partial thromboplastin time (factors II, V, XIII, IX, X, XI {intrinsic})

40. Management of Shock Transfusion products

41. Indications for Transfusion • No universally accepted guidelines for replacement of blood components • If lab data available, most providers will transfuse patients with hemoglobin values less than 7.5 to 8 g/dL • If no labs, it is reasonable to transfuse 2 units of packed red blood cells (pRBCs) if hemodynamics do not improve after the administration of 2 to 3 liters of normal saline and continued bleeding is likely.

42. Management of Shock Risks of blood transfusion

43. Management of Shock • Risks of blood transfusion • Immunologic reactions • Fever - 1/100 • Hemolysis- 1/25,000 • Fatal hemolytic reaction - 1/1,000,000

44. Management of Shock • Delivery • Vaginally unless other obstetrical indication, i.e. fetal distress, herpes, etc. • Best to stabilize mother before initiating labor or going to delivery

45. Bottom Line Concepts • Common causes of third trimester bleeding - Abruption, previa, preterm labor, labor • NO DIGITAL EXAMS until placenta previa has been ruled out • Ultrasound – can use to evaluate previa but not accurate to diagnose abruption • Postpartum hemorrhage refers to EBL >500 cc, vaginal delivery or EBL >1000 cc, cesarean delivery • Most common cause of PPH – uterine atony • No universal rule for when to transfuse – decision made with clinical judgment and based on each patient’s individual circumstance and presentation

46. References and Resources • APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 23, 27 (p48-49, 56-57). • Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 12, 21 (p133-39, 207-11). • Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 10 (p128-136). • Baron F, Hill WC. “Placenta previa, placenta abruption”, Clinical Obstetrics and Gynecology, Sep 1998 41(3) pp527-532. • Benedetti T. Obstetric hemorrhage, in obstetrics: normal and problem pregnancies, Gabbe S, Niebyl J, Simpson J, 3rd ed. New York: Churchill Livingston 1996, pp161-184. • Hertzberg B. “Ultrasound evaluation of third trimester bleeding,” The Radiologist, July 1997 4(4) pp227-234. • Sheiner E, Shohan-Vardi I. “Placenta previa: obstetric risk factors and pregnancy outcome,” Journal of Maternal-Fetal Medicine, December 2001 10(6) pp414-418. • Jacobs, Allan J. “Management of postpartum hemorrhage at vaginal delivery.” UpToDate. May 2011