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Bleeding in Pregnancy: Antepartum & Postpartum Hemorrhage. OB & GY Dept. First Hospital, Xi’An Jiao Tong University. Learning Objectives. Definition of Post Partum Hemorrhage Management of PPH Risk Factors for PPH Differential Diagnosis of Third Trimester Bleeding

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bleeding in pregnancy antepartum postpartum hemorrhage
Bleeding in Pregnancy: Antepartum & Postpartum Hemorrhage

OB & GY Dept. First Hospital, Xi’An Jiao Tong University

learning objectives
Learning Objectives
  • Definition of Post Partum Hemorrhage
  • Management of PPH
  • Risk Factors for PPH
  • Differential Diagnosis of Third Trimester Bleeding
  • Management of Placenta Previa and Abruptio Placenta
worst case scenario
“Worst Case Scenario”
  • An insulin dependent diabetic was induced for suspect fetal macrosomia and delivered a 4300 gram male infant because of late decelerations. A low forceps delivery was done. An episiotomy was done. Thee was a Shoulder Dystocia. Immediately after delivery of the placenta the patient bled uncontrollably and the anesthesiologist yelled, “The patient is in shock.” There is a 4th degree perineal laceration and the uterus is “boggy” and there is a left side wall laceration as well.
definitions of postpartum hemorrhage
Definitions of Postpartum Hemorrhage
  • Estimated blood loss
  • a. > 500 mL with vaginal birth
  • b. > 1000 mL with cesarean delivery
  • c. > 1500 mL with cesarean hysterectomy
  • Decline from antepartum to postpartum hematocrit of > 10%
  • Postpartum hematocrit < 27%
  • Transfusion of red blood cells
postpartum hemorrhage
Postpartum Hemorrhage
  • An event, not a diagnosis.
  • Excessive blood loss
      • Atony
      • Abnormal Implantation Site
        • Placenta Accreta
        • Uterine Inversion
      • Genital Tract Injury
        • Cervical or Vaginal Lacerations
        • Pelvic Hematoma
postpartum hemorrhage vaginal birth antepartum postpartum 10 hct
Postpartum HemorrhageVaginal BirthAntepartum - postpartum > 10% (Hct)

Risk Factors

  • Prolonged 3rd stage of labor
  • Preeclampsia
  • Mediolateral episiotomy

Combs CA et al, obstet Gnecol. 1991:77:63

postpartum hemorrhage c s
Postpartum HemorrhageC/S

Risk Factors

  • General anesthesia
  • Amnionitis
  • Preeclampsia

Combs CA et al, obstet Gynecol 1991:77;77

postpartum hemorrhage vaginal birth postpartum hct 27 or blood transfusion
Postpartum HemorrhageVaginal BirthPostpartum Hct <27% or Blood Transfusion

Risk Factors

  • Estimated blood loss > 500 ml
  • Marginal previa
  • Placental abruption
  • Third stage of labor > 30 minutes
  • Chorioamnionitis

Nicol B et al obstet Gynecol 1997;90:514

postpartum hemorrhage antepartum postpartum 10 hct
Postpartum HemorrhageAntepartum - Postpartum > 10% (Hct)

Risk Factors

  • Preeclampsia
  • Disorders of active phase of labor
  • Native American ethnicity
  • Previous PPH
  • Maternal weight > 250 lbs
postpartum hemorrhage11
Postpartum Hemorrhage

Knowing the risk factors associated with postpartum hemorrhage means the obstetricians can effectively manage at-risk patients.

One can ancticipate those patients where there is a greater likelihood of a postpartum hemorrhage

postpartum hemorrhage12
Postpartum Hemorrhage
  • Medical Management

Atony - Bimanual compression

- 15 methyl PGF 2: 0.25 mg 15’

IM or intra-myometrium

- Methylergonovine : 0.2 mg 1M

No IV => severe hypertension

- Misoprostol (100 mg) rectally

postpartum hemorrhage13
Postpartum Hemorrhage

Prevention

Vaginal deliveries

  • Active Management of 3rd stage of labor
  • Uterotonic agents

Cesarean deliveries

  • Spontaneous delivery placenta
  • Repair uterine incision in situ
postpartum hemorrhage15
Postpartum Hemorrhage

Surgical Management

  • Uterine artery ligation
  • Hypogastic artery ligation
  • Ovarian vessels
  • B-Lynch technique
  • Selective arterial embolization
  • Hysterectomy
hematoma
Hematoma

Pelvic Hematoma

  • Vulvar
  • Vaginal
  • Retroperitoneal
risk factors
Risk Factors
  • Episiotomy
  • Primiparity
  • Preeclampsia
  • Multiple gestation
  • Vulvovaginal varicosities
  • Prolonged 2nd stage of labor
  • Clotting abnormalities
hematoma19
Hematoma

Vulvar hematoma

  • Laceration of vessels in the superficial fascia of pelvic triangle
  • Volume support
  • < 3 cm: observation
  • > 3 cm: surgical evacuation with suture closure and dressing compression
hematoma20
Hematoma
  • Vaginal hematoma
      • Accumulation of blood above the pelvic diaphragm
      • More associated with forceps deliveries
      • Incision and evacuation
      • Vaginal packing for 12 – 18 hours
hematoma21
Hematoma
  • Retroperitoneal hematomas
      • Sudden onset of hypotensive shock
      • Laceration of a branch of hypogastric artery
      • Inadequate hemostasis of the uterine arteries (C/S)
      • Rupture of low transverse scar
      • Surgical exploration and ligation of the hypogastric vessel
potential complications of puerperal hematomas
Potential Complications of Puerperal Hematomas
  • Transfusion
  • Coagulation Defects
  • Anemia
  • Fever
  • Reformation
  • Deep vein thrombosis
  • Scarring with resultant dyspareunia
  • Fistula Formation
  • Prolonged Hospitalization and Recuperation
placenta accreta increta percreta
Placenta Accreta/Increta/Percreta
  • Accreta: villi attatched to myometrium (85%)
  • Increta: villi invading the myometrium (15%)
  • Percreta: villi beneath or through the uterine serosa (5%)
placenta accreta increta percreta24
Placenta Accreta/Increta/Percreta

Risk factors

  • Early 30s
  • Parity (2 or 3 prior births)
  • Prior C/S
  • H/O of D& C
  • Prior manual placental removal
  • Prior retained placenta
  • Infection
postpartum accreta
Postpartum Accreta

Postpartum hemorrhage

  • 39 – 64%
  • 2600 ml (without previa)
  • 4700 ml (with previa)
placenta accreta increta percreta26
Placenta Accreta/Increta/Percreta

Postpartum hemorrhage

  • Conservative Management
  • Hysterectomy
placenta accreta percreta increta
Placenta Accreta/Percreta/Increta

Conservative management

  • Leaving the placenta in place
  • Localized resection and repair
  • Oversewing a defect (esp percreta)
  • Blunt disection/curretage
uterine inversion
Uterine Inversion
  • 1/2000  1/6400
  • Partial delivery of placenta
  • Rapid onset of maternal shock

Degree

    • 1st (Incomplete)

- Corpus does not pass through the cervix

    • 2nd (Complete)

- Corpus passes through the cervix

    • 3rd (Prolapse)

- Corpus extends through vaginal introitus

uterine inversion29
Uterine Inversion

Treatment

  • Fluid therapy
  • Restoration of uterus
  • Pushing the fundus with a fisted hand along the axis of vagina through cervix back into pelvis

If failed

  • Terbutaline
  • Mg SO4
  • General anesthesia
  • Laparotomy
uterine rupture
Uterine Rupture
  • 0.05% for all pregnancies
  • 0.8% after a previous low transverse c/s
  • 75% in prior classical c/s
  • 25% in prior uterine myomectomy
uterine rupture31
Uterine Rupture

Risk Factors

  • Surgical procedures of uterus
    • C/S, myomectomy, perforation, cornual resection, hysteroscopic or laparoscopic injuries, penetrating abdominal wounds

• Grand multiparity

    • Obstetric trauma
    • Fetal macrosomia
    • Malpresentation
    • Breech extraction
    • Instrumental vaginal deliveries
uterine rupture32
Uterine Rupture
  • Symptoms and signs
      • Ripping lower abdominal Pain
      • Referred Shoulder Pain
      • Vaginal Hemorrhage
      • Fetal Bradycardia
      • Loss of fetal presentation part
uterine rupture33
Uterine Rupture

Management

  • Hysterectomy
  • Repair  recurrent rupture: 19%
third trimester bleeding antepartum hemorrhage
Third Trimester Bleeding:Antepartum Hemorrhage
  • Placental Abruption
  • Placental Previa
real life situation
“Real Life Situation”
  • A patient calls you by telephone and tells you that she has some vaginal bleeding with some crampy lower abdominal pain at 32 weeks gestation. She is hypertensive and has used drugs in the past as well. She has had 2 previous CS and was transfused with the last one. She was told that she had a placenta previa earlier in her pregnancy with her ultrasound exam at 20 weeks.
placental abruption
Placental Abruption
  • External hemorrhage
  • Concealed hemorrhage
  • Total
  • Partial
  • 1/200 – 1/1550 deliveries
  • Perinatal mortality: 25%
  • Recurrence: 4 – 12.5%
placental abruption40
Placental Abruption

Risk Factors RR

  • Increased Maternal age and parity N/A
  • Preeclampsia 2.1 – 4.0
  • Chronic hypertension 1.8 – 3.0
  • PROM 2.4 – 3.0
  • Smoking 1.4 – 1.9
  • Cocaine N/A (13%)
  • Prior abruption 10 – 25
placental abruption42
Placental Abruption
  • Symptoms & Signs Frequency (%)
  • Vaginal bleeding 78
  • Uterine tenderness or back pain 66
  • Fetal distress 60
  • High frequency of contractions 17
  • Hypertonus 17
  • Idiopathic preterm labor 22
  • IUFD 15
placental abruption43
Placental Abruption
  • DIC
  • Acute renal failure
  • Couvelaire uterus
placental abruption44
Placental Abruption

Management

  • Gestational age
  • Maternal status
  • Fetal status
  • Correct maternal hypovolemia, anemia, hypoxia
  • ? Tocolysis
  • Vaginal vs. C/S
placenta previa
Placenta Previa
  • Incidence: 0.3- 0.7 %
  • Definitions:
    • Total
    • Partial
    • Marginal
    • Low-lying
placental previa
Placental Previa

Risk Factors

  • Increased maternal age
  • Increase parity
  • Smoking
  • Prior C/S

One: 2X – 3X (0.5-0.75%)

Two: 1.9%

Three: 4.1%

  • Diagnosis: U/S (TVU), MRI
placental previa52
Placental Previa

GA at U/S (wk) Previa or Bleeding at Delivery

  • < 20 2.3%
  • 20 – 25 3.2%
  • 25 – 30 5.2%
  • 30 – 35 24%
placental previa53
Placental Previa

Management

  • ? Preterm
  • ? Fetal lung maturity
  • ? Labor
  • ? Severe hemorrhage
  • Vaginal delivery vs. C/S