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Obstetric Hemorrhage. Abike James MD Assistant Clinical Prof. Obstetrics and Gynecology University of Pennsylvania. Third Trimester Bleeding.

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obstetric hemorrhage

Obstetric Hemorrhage

Abike James MD

Assistant Clinical Prof. Obstetrics and Gynecology

University of Pennsylvania

third trimester bleeding
Third Trimester Bleeding

A 32 yo G2P1 presents at 36 weeks complaining of bright red vaginal bleeding. Upon further questioning she does admit to having had some light bleeding on 1 to 2 occasions last week. Her previous pregnancy was delivered at term by a Classical Cesarean Section for footling breech presentation.

differential diagnosis
Differential Diagnosis?
  • Placenta Previa
  • Uterine Rupture
  • Placental Abruption
  • Vasa Previa
  • Laceration
  • Vaginal mass
placenta previa
Placenta Previa
  • Painless third-trimester bleeding
  • Complicates 4-6% pregnancies between 10 and 20 wks, 0.5% pregnancies >20 weeks
  • Risk factors
    • Increasing parity, maternal age, prior c/s, curettages for sab’s/tab’s
  • Placental tissue overlying the internal os. Types?
    • Complete previa (20-30%)
    • Partial previa (does not completely cover)
    • Marginal (proximate to os)
  • Management: pelvic rest, u/s, IV, T+S, C/S
associated conditions
Associated Conditions
  • Placenta accreta, increta, percreta
    • Risk inc w/ inc no. of prior c/s (50% risk in pt w/ previa and 2 prior c/s)
  • Vasa Previa
    • Vessels traverse the membranes in the lower uterine segment in advance of the fetal head.
    • Rupture can lead to fetal exsanguination
uterine rupture
Uterine Rupture
  • Associated with Prior c/s
  • Rates of uterine rupture?
    • Spontaneous rupture (no c/s history): 1/2000 (0.05%)
    • Low Transverse: 0.5%-1%risk rupture, VBAC 80% success rate
    • Classical C/s: 10% risk rupture, schedule amnio/c/s ~37 weeks.
placental abruption
Placental Abruption
  • Premature separation of placenta
  • Painful third-trimester bleeding
  • Risk Factors
    • smoking, trauma, HTN cocaine, pprom, polyhydramnios, multiples
  • Trauma evaluation
    • bleeding, contractions, abdominal pain and NRFHT in 4hrs
  • U/s misses up to 50% of abruptions
  • Management: IV, T+X, Continuous monitoring, c/s vs. vag delivery
case cont d
Case Cont’d

U/s reveals active, vertex fetus. Placenta anterior and free of os. Pt having contractions q 2-3 minuters. Bleeding increases. BP drops from 110/60 to palpable systolic pressure of 70. FHT drops from 120 to 90 bpm.

What do you do???

post partum hemorrhage
Post Partum Hemorrhage

A 34yo G6P6 patient at term has just delivered a 4000gm infant after second stage of labor lasting 3 ½ hours. The placenta delivered spontaneously and the patient is bleeding briskly.

  • What is average EBL w/ SVD?
    • 500cc
  • What is average EBL w/ C/S?
    • 1000cc
classes of hemorrhage
Classes of Hemorrhage
  • Class 1
    • <900cc
    • Minimal symptoms
  • Class 2
    • 1200-1500cc
    • Tachycardia, tachypnea
  • Class 3
    • 1800-2100cc
    • Overt Hypotension, cold, clammy skin
  • Class 4
    • 2400cc
    • Shock, absent BP
management
Management
  • Fluids
    • Crystalloid, open wide/bolus
  • Labs
    • Cbc, coags, fibrinogen
  • Transfuse PRPC’s
  • FFP
    • Larger vol (250cc/unit, all coagulation factors)
  • Cryopercipitate
    • Smaller volume (20cc/unit, many coagulation factors)
differential diagnosis12
Differential Diagnosis
  • Atony
  • Uterine inversion
  • Laceration (cervical, vaginal)
  • Retained Placenta
uterine atony
Uterine Atony
  • Risk factors
    • multiparity, multiple gestation, macrosomia, abruption, retained POC’s, placenta previa, induction (prolonged pitocin)
  • Management
    • Bimanual exam/massage
    • IV acess/fluids
    • Oxytocin, methergine 0.2mg IM, Hemabate 250mcg IM, misoprostol 800 to 1000mcg rectally
  • Laparotomy
    • Uterine artery ligation
    • B Lynch
    • Hysterectomy
  • UAE
uterine inversion
Uterine Inversion
  • Inverted fundus extends beyond cervix (looks beefy red)
  • Stop pitocin if infusing
  • Replace uterus
  • Relaxants if necessary (terbutaline, MgSo4, Nitrogylcerin)
  • Anesthesia
  • Laparotomy