Management of Obstetrical Hemorrhage

1. Management of Obstetrical Hemorrhage Jeffrey Stern, M.D.

2. 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

3. Etiology of Obstetrical Hemorrhage: Antepartum • Placenta previa • Abruption • Coagulopathy: ITP/pre-eclampsia, FDIU

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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)

10. Retained Products of Conception: Etiology • Succentiurate lobe • Placenta accreta, increta, percreta • Previous C-section; hysterotomy • Previous puerperal curettage • Previous placenta previa • High parity

11. Management of Retained Products of Conception • Examine placenta carefully • Manual exploration of uterus • Careful curettage-Banjo curret

12. Placenta Accreta, Increta, Percreta: Risk Factors • High Parity • Previous placenta previa • Previous C-section • GTN • Advanced maternal age • Previous uterine abnormal placentation

13. 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

14. 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

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

16. Genital Tract Laceration and Hematomas: Etiology • Macrosomia • Forceps • Episiotomy • Precipitous delivery • C-section incision extension • Uterine rupture

17. Therapy of Genital Tract Lacerations • Superficial lacerations and small hematomas: expectant • Large laceration • Repair in layers • Consider a drain

18. 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

19. 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

20. 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

22. Evaluate for Ovarian Collaterals May need to embolize

23. Mid-Embolization “Pruned Tree Vessels”

24. Post Embolization

25. Post Embolization Pre Embo Post Embo

26. 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

27. 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

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

29. Classic Symptoms of Uterine Rupture • Fetal distress • Vaginal bleeding • Cessation of labor • Shock • Easily palpable fetal parts • Loss of uterine catheter pressure

30. 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

31. Management of Uterine Rupture • Laparotomy • Debride and repair in 2-3 layers of Maxon/PDS • Subtotal Hysterectomy • Total Hysterectomy

32. 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)

33. 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