Hemorrhages in Pregnancy

Coe S. Tolosa MD
FLUID AND BLOOD REPLACEMENT
• Guided by manifestations based on amount of
blood volume loss
– <15%% (≤750cc)
• no measurable change in BP, PR or RR
– 15-25% (750-1500cc)
• PR >100/min, BP normal, with orthostatic change, RR,
urine output 20-30ml/hr, anxious  VOLUME
REPLACEMENT
– 30-40% (1500- 2000cc)
• PR>120/min, hypotension, tachypnea, urin eoutput 5-
15h/hr, confused
– >40% (>2000cc)
• PR >140/min, hypotension, marked tachypnea, anuria,
lethargic, obtunded  BLOOD TRANSFUSION
 Unique features considered in
Pregnancy
• Because of  blood volume  may lose up to
20% of her blood before clinical signs are
apparent
• In volume-contracted cases, patient is more
vulnerable
• Bec of  blood flow to gravid uterus, large
amount of blood may be lost rapidly
– > CAN GO TO SUDDEN DECOMPENSATION
AND EXSANGUINATE
Flexibility should be exercised in the application
of guideline and blood transfusion may be
initated prior deterioration of vital signs when
blood loss remains unabated
 Management: GENERAL

• Rapid initial assessment

• PE to detect hypoperfusion
• Request for CBC, BT+Crossmatching of packed
RBC, Platelet count, baseline serum
electrolytes, BUN, Creatinine
• Insert 2 IV infusion lines
• Determine CAUSE of hemorrhage
and treat aggressively
Management: FLUID Resuscitation

• CRYSTALLOID is first line

– 1L in 15-20 mins… at least 2L in first hour
• Consider comorbids
• Aim to replace 3 times the estimated fluid loss
to restore circulating blood volume
• Use of colloids is an option
– One is to one
• Insert IFC and monitor UO
 Management: GENERAL

• If patient responds + bleeding controlled 

adjust to 1L x 6 hours and as necessary
• If unresponsive, consider blood transfusion
• May insert CVP line
 Management: Blood Transfusion

• Properly crossmatched packed RBCs are

primary transfusion product
• If not available  type specific blood
• In extreme and blood type not known  O(-)
blood may be administered but inform risks
• Blood must be available ASAP
• 1 unit pRBCS = 1g Hgb and hematocrit 3%
 Management: Blood Transfusion

• Blood product CANT be mixed with Ringer’s

Lactacte  can cause calcium to precipitate
with citrate (preservative)
• Monitor bleeding parameters (Platelet, PT,
PTT)
• Consider transfusin 1 unit FFP for every 4 units
pRBC
• Platelet transfusion for PC<50,000
 Precautions in MASSIVE
TRANSFUSION (>10units)
• May develop dilutional coagulopathy
– Diluting platelets and clotting factors
– Managed as DIC

• Blood warmers should be used

– Hypothermia can impair coagulation and decrease
tissue perfusion
 Precautions in MASSIVE
TRANSFUSION (>10units)
• Consider 10cc of 10% Calcium Gluconate Slow
IV for every ≥6units blood infused
– Citrate toxicity may develop  cardiac depression

• Hyperkalemia may also develop because of

passive diffusion of potassium out of RBC
during storage
INCOMPLETE ABORTION
 INCOMPLETE ABORTION

• A product of conception is expelled with

retention of the rest in the uterine cavity
before 20th weeks AOG
 Risk Factors

• Fetal Factors • Maternal Factors

– Abnormal zygote – Increased parity and age
development – Infections
– Aneuploidy – Chronic debilitating
• Environmental and Drug disease
Use – Malnutrition
• Immunological – Endocrine abnormalities
– Uterine defects
– Incomptetent cervix
 Clinical Manifestations

• SYMPTOMS
– Vaginal Bleeding
– Hypogastric pains
– Passage of meaty tissues
• SIGNS
– Cervix dilated
– Placental tissues at os
– Uterine size incompatible
 Diagnosis

• CLINICAL
• History of amenorrhea, bleeding with
expulsion of meaty tissues
• Laboratory Tests
• CBC
• Blood Typing
• If unsure on retention and no
evidence of tissue at os  TVS
 Management
• IV Fluid
– D5LRS 1L + 10 u Oxytocin at 25-30 gtts/min
• Evacuate the tissues at os
• Sedate or analgesia or anesthesia instituted
• Curettage
• Optional broad spectrum antibiotics on high risk
patients
• Optional Oxytocin Tablet for the first
24 hours
 Complete Clinical Assesment
Review History: Length of amenorrhea/LMP, duration and amount of bleeding, duration and severity of
Presentation cramping, abdominal pain, shoulder pain, drug allergies
Cleaned pad, not soaked after 5 Physical Exam: Vital signs, heart, lung, abdomen, Extremities
mins
Indication of systemic problem (shock, sepsis etc)
Fresh blood, no clots
Pelvic Exam: Uterine size, stage of abortion, uterine position
Mixed with mucus
Other: Remove any visible products of conception in the os
Determine ABO type

THREATENED INCOMPLETE AND COMPLETE MISSED ABORTION

ABORTION INEVITABLE ABORTION ABORTION Cervix Closed
Cervix Closed Cervix Open Cervix Open or Closed Little or no bleeding
Light to Moderate Light/Moderate/Heavy Light to Moderate Uterine size less or
bleeding bleeding bleeding equal to AOG
Uterine size equal to Uterine size less or equal to Uterine size less or
AOG AOG equal to AOG

Restrict to bedrest
Reevaluate after 2
weeks or sooner if
bleeding increases FIRST TRIMESTER SECOND TRIMESTER
Antibiotics if with signs of infection Antibiotics if with signs of infection
Pain control as needed Pain control as needed
Vacuum aspiration or D&C Uterotonic or Instrumental Curettage
 Complete Clinical Assesment
Review History: Length of amenorrhea/LMP, duration and amount of bleeding, duration and severity of
Presentation cramping, abdominal pain, shoulder pain, drug allergies
Cleaned pad, not soaked after 5 Physical Exam: Vital signs, heart, lung, abdomen, Extremities
mins
Indication of systemic problem (shock, sepsis etc)
Fresh blood, no clots
Pelvic Exam: Uterine size, stage of abortion, uterine position
Mixed with mucus
Other: Remove any visible products of conception in the os
Determine ABO type

THREATENED INCOMPLETE AND COMPLETE MISSED ABORTION

ABORTION INEVITABLE ABORTION ABORTION Cervix Closed
Cervix Closed Cervix Open Cervix Open or Closed Little or no bleeding
Light to Moderate Light/Moderate/Heavy Light to Moderate Uterine size less or
bleeding bleeding bleeding equal to AOG
Uterine size equal to Uterine size less or equal to Uterine size less or
AOG AOG equal to AOG

Restrict to bedrest
Reevaluate after 2
weeks or sooner if
bleeding increases FIRST TRIMESTER SECOND TRIMESTER
Antibiotics if with signs of infection Antibiotics if with signs of infection
Pain control as needed Pain control as needed
Vacuum aspiration or D&C Uterotonic or Instrumental Curettage
 FIRST TRIMESTER SECOND TRIMESTER
Antibiotics if with signs of infection Antibiotics if with signs of infection
Pain control as needed
Pain control as needed
Vacuum aspiration or D&C
Uterotonic or Instrumental Curettage

If there are signs of uterine: If there are NO signs of uterine:

perforation perforation
Instruments extend beyond uterus Examine specimen
Fat or bowel in specimen Family Planning
Discharge

If evacuation is complete: If evacuation is NOT complete:

Begin Antibiotics Begin Antibiotics
Oxytocin Evacuate uterus (direct vision)
Observe (2 hours) Oxytocin
Observe ( 2 hours
If laparotomy not available, refer

If bleeding stops: If bleeding continues:

Give Ergometrine Laparotomy, refer if not
Observe available
If stable: If NOT stable:
Give Ergometrine Give Ergometrine
Observer overnight Refer to Tertiary Hospital

If bleeding stops: If bleeding continues:

Observe overnight Refer
SEPTIC ABORTION
• Infection of NON-viable products of
conception less than 20weeks AOG
• PREVALENCE (POGS): 3 to 7 in 1000 deliveries
• STEP 1: Assessment of severity must be done
based on the following scoring system

• STEP 2: Administer loading dose of

recommended antibiotic therapy

• STEP 3: Evacuate focus of infection

• Grading Pattern:
– None 0
– Mild 1
– Moderate 2
– Severe 3
• Scoring System:

• Mild </= 8
• Moderate 9-19
• Severe >/= 20
• The infection should be considered severe in
the presence of the ff regardless of the score
unless secondary to blood loss:

• a. hypotension + tachycardia
• b. tachypnea RR >24
• MILD
– Pen G 4 million IV q6
• MODERATE
– Pen G 4 million IV q6 + Aminoglycoside
• SEVERE
– Pen G 4 million IV q6
– Aminoglycoside
– Metronidazole 500 mg TID IV or PO
Other antimicrobials
- Doxycycline 200mgIV q12hours x 3 days, then
100mg q12hrs x 11days
- Piperacillin 4g IV every 6 hours
- Meropenem 500mg IV every 8 hrs
- Ertapenem 1g IV once a day
- Cefoxitin 2g IV every 6 hours
- Cefotetan 2g IV every 12 hours
- Or Monotherapy w/Moxifloxacin 400mg IV OD
• Additional Regimens
- ATS 3000 IU IM ANST + TT 1cc IM

• Consider STEROIDS in Severe Forms

- Dexamethasone 6mg/kg slow IV
- Methylprednisone 30mg/kg slow IV

If sexually promiscuous, consider Doxycycline or

Tetracycline as oral therapy
• CURETTAGE
- within 6 hours from admission
- IVFs
- Correction of electrolyte and metabolic
abnormalities
- Transfusion of blood products
- Oxygenation
• PELVIC CLEANUP is an option in:
- severe cases, especially in multigravidas
- patients with no response to curettage and antibiotics

In cases wherein CIRCUMSTANCES ARE

UNDETERMINED, treat as MILD unless with:
a. hypotension + tachycardia
b. tachypnea
 SEPTIC ABORTION

Assess Severity
Mild </= 8
Moderate 9-19
Severe >/= 20

I. SUPPORTIVE II. MEDICATION III. SURGERY

• IVFs A. Antibiotic • Curettage
• Correction of electrolyte •MILD - Pen G
and metabolic •MODERATE - Pen G +
abnormalities Aminoglycoside • Pelvic Cleanup
• Transfusion of blood •SEVERE - Pen G +
products Aminoglycoside +
• Oxygenation Metronidazole

B. Vaccination – ATS + TT

C. Consider steroids in
severe form
ECTOPIC PREGNANCY
• Pregnancy that develops after implantation of
the blastocyst anywhere else other than the
endometrial lining of the uterine activity
•
• Majority in the fallopian tube (mainly in the
ampulla)
• RISK FACTORS:
- Tubal Pathology •Salpingitis
•Salpingitis Isthmica Nodosa
- Contraception Failure •Previous
•PostAbdominal Surgery not
Tubal Sterilization
•Usethe
involving of fallopian
Copper Ttube
380 IUD
- Hormonal Alterations •Previous
•Progestin
Tubal levels
•Increase Surgery
only contraceptives
of Estrogen and
•Previous
•Progesterone
Ectopic Pregnancy
Progesteron releasing
interfere IUDtubal
with
- Previous abortion •Exposure to DES in utero
motility
•IVF and embryo transfer
- Cigarette smoking
- Abnormal embryonic development
- Increasing maternal age
 Clinical Manifestations
• Symptoms • Signs
– Abdominal pain – Adnexal tenderness
– Amenorrhea
– Abdominal tenderness
– Vaginal Bleeding
– Dizziness, fainting – Adnexal mass
– Shoulder tip pain – Uterine enlargement
– Urge to defecate – Orthostatic changes
– Pregnancy symptoms – Fever
– Passage of Tissue
 Diagnosis

• Clinical
• Laboratory Test/Procedures
• Diagnostic Procedures
 Diagnosis

• Clinical
• Laboratory Test/Procedures
• Diagnostic Procedures
• Clinical
– TRIAD: Pain + Amenorrhea + Vaginal Bleeding
– May present with
• Nausea, breast fullness, fatigue, low abdominal pain,
heavy cramping, shoulder pain, recent dyspareunia
– Physical findings
• Pelvic tenderness, enlarged uterus, adnexal mass and
tenderness
 Diagnosis

• Clinical
• Laboratory Test/Procedures
• Diagnostic Procedures
• Laboratory Test/Procedures
– B-HCG
• Positive pregnancy test
– Serial serum levels DO NOT double every two days
– Levels lower than 3000 mIU/ml
– Hematocrit less than 30% in ruptured ectopic
– Leukocyt count normal to mild elevation
– Progesterone
• Level of 5-25ng/ml may indicate nonviable pregnancy
– Under research
• Serume estradiol, inhibin, pregnancy associated plasma protein
A,pregnanediol glucoride, placental
proteins, creatinine kinase, quadruple screen
• Laboratory Test/Procedures
– Ultrasonography
• Complex and cystic adnexal mass or visualization of
an embryo or placenta
• TVS shows absence of intrauterine gestational sac
when gestation is known to be >38 days or B-HCG
is above 1500-2500mIU/ml
• Abdominal ultrasound shows absence of
intrauterine gestation sac when B –HCG is above
6000-6500mIU/ml
• Color doppler flow – demonstrates a 20%
difference in degree of tubal flow between the
adnexae as compared to less than 8% difference in
intrauterine pregnancies
 Diagnosis

• Clinical
• Laboratory Test/Procedures
• Diagnostic Procedures
• Diagnostic Procedures
– Culdocentesis
• Inserting a needle through the posterior fornix of the
vagina into the cul de sac and aspirating nonclotting
blood
– Laparoscopy
• Direct assessment
• Provides the option to treat once diagnosis is
established
– Dilatation and Curettage
• No chorionic villi obtained should raised
suspicion of a possible ectopic pregnancy
 Management

• Criteria
• Approach
• Procedures
• Criteria
– Woman NOT hemodynamically stable
– Does NOT fulfill criteria for medical management
• Approach
– LAPAROSCOPIC
• Hemodynamically stbale
• Less blood loss, shorter hospital stay, lower analgesic
requirements
• Shorter operation times in skilled surgeons
• Similar intrauterine pregnancy rates
– LAPAROTOMY
• NOT hemodynamically stable
• When laparoscopy is difficult  dense adhesions,
massive hemoperitoneum
• Surgeon lacking skills
• PROCEDURES
– RADICAL
• SALPINGECTOMY
– Resection of tubal segment containing gestation
– Performed if:
» Tube is severely damaged
» There is uncontrolled bleeding
» Recurrent ectopic pregnancy in same tube
» Large tubal pregnancy >5cm
» Woman has completed pregnancy
• CORNUAL RESECTION of an interstitial pregnancy
• HYSTERECTOMY for interstitial pregnancy
• PROCEDURES
– CONSERVATIVE
• Preserve tubal function in women desiring future fertility
• SALPINGOTOMY  tubal incision closed primarily
• SALPINGOSTOMY  tubal incision allowed to closed by
secondary intention
• FIMBRIAL EVACUATION
– Blunt curettage or digital expression (milking)
– Associated with high rate of recurrent ectopic pregnancies,
bleeding and tube damage
– May not remove entire tubal gestation
• SEGMENT RESECTION of tubal segment
– May be candidates for delayed microsurgical
reanastomosis
 Abdominal pain
Algorithm I: Vaginal Bleeding
Missed Period

Diagnosis Positive Pregnancy Test

TVS

Intrauterine Pregnancy Ectopic Pregnancy Abnormal Intratuterine Nondiagnostic

viable Pregnancy

Prenatal care TREAT (Algorithm II) D&C Quantitative HCG

< Discriminatory zone

> Discriminatory zone 1500 – 2500 mIU/ml
1500 – 2500 mIU/ml
Serial B-HCG
D&C

Normal rise Abnormal rise or fall Normal fall

(-) chorionic villi (+) chorionic villi
D&C
Repeat UTZ when B-HCG
Treat as ectopic
> discriminatory zone
(Algorithm II Nondiagnostic

Intrauterine Pregnancy Ectopic Pregnancy Abnormal Intratuterine

viable Pregnancy
(-) chorionic villi
(+) chorionic villi

Prenatal care TREAT (Algorithm II) D&C

Treat as ectopic
(Algorithm II
 Algorithm I:
Management
Ectopic Pregnancy

Hemodynamically stable Hemodynamically unstable

Fulfills criteria for medical treatment Does not fulfill criteria for medical treatment

MEDICAL
SURGICAL
Methotrexate
Single/Multiple dose regimen
Unstable Stable
Monitor B-HCG Dense Adhesions

Day 4 and 7 Massive Hemoperitoneum laparoscopy

Increase laparotomy

Plateau Decrease by at least 15%

Evaluate damage to oviduct
Fail to decrease
Desire for fertility

Repeat Methotrexate (Surgery Continue monitoring until

<5 mIU/ml
Radical Conservative

Salpingectomy
Hysterectomy
Algorithm I:
Management Conservative

Day 7 B-HCG >1000ml mIU/ml or >15% level of initial level Monitor B-HCG weekly
Day 9 B-HCG >10% of initial
Day 0 serum progesterone >1.5ng/ml
Decrease by at least 15%

Persistent Ectopic
Pregnancy Continue monitoring until
<5 mIU/ml

Salpingectomy
Salpingostomy
Methotrexate
Expectant
ABRUPTIO PLACENTA
 ABRUPTIO PLACENTA

• Denotes separation of a normally implanted

placenta before birth of the fetus
• Commonly made in the 3rd trimester
• 2-3 per 1000 pregnancies
• 5-10% of direct obstetric deaths, 2-4% of
overall maternal deaths
 ABRUPTIO PLACENTA

• Unifying etiologic concept still UNKNOWN

• Underlying disease of the deciduas and
uterine blood vessels best explain the diversity
of associated factors
 ABRUPTIO PLACENTA:
Classic Symptoms
• Vaginal bleeding  Hallmark sign
• 10% of cases present with concealed
hemorrhage
• Abdominal pain
• Less constant presenting symptom
• Intermittent and difficult to distinguis from
labor pain
• Severe cases: SHARP, SUDDEN SEVERE
 ABRUPTIO PLACENTA:
Classic Symptoms
• Uterine Contractions
• High frequency and low amplitude
• Baseline uterine tonus is elevated
• Uterine Tenderness
• Generalized
• Localized  point of maximum tenderness
is the site of placental development
 ABRUPTIO PLACENTA: Diagnosis

• Diagnosis is based on CLINICAL SIGNS and

SYMPTOMS
• Ultrasonography
• Exclude placenta previa
• Acute hemorrhage is characteristicslly a
hyperechoic or isoechoic area beneath the
placenta
ABRUPTIO PLACENTA: Diagnosis
 ABRUPTIO PLACENTA: Management
• Will depend on Gestational Age, Maternal Status and
Fetal Status
• General Measures
• Immediate hospitalization
• Rapid evaluation of mother’s condition
• Frequent checking of vital signs
• Continuous fetal heart tone monitoring
• Ultrasound (once stable)
• Large bore IV line
• Crystalloid infusion (once with evidence of maternal hypovolemia)
• Blood samples for laboratory studies
• Indwelling Foley Catheter
• Secure blood for transfusion
• Method and Timing of Delivery
• Expectant Management
• If fetus is immature with mild abruption,
fetal heart tracing is reassuring and
mother is stable
• Correct maternal hypovolemia, anemia
and hypoxia
• Observe for 24-48 hrs
• Continuous fetal and uterine monitoring
• Tocolysis
• If fetus is immature, mild abruptio, no
fetal distress or maternal
complication
• Clinically evident placenta abruptio is
considered a CONTRAINDICATION
• Cesarean Delivery
• If delivery is not imminent, fetus has
reasonable chance of survival and
exhibits persistent evidence of
distress
• Maternal Indications: uncontrollable
hemorrhage from a contracted uterus
with concealed hemorrhage
• Decision time and speed of response
are important factors in neonatal
outcome
• Vaginal Delivery
• If the fetus is mature and fetal heart
rate tracing is reassuring
• If the fetus is dead, with severe
abruptio and coagulation defects
• Maternal outcome depends on
diligence with adequate fluid and
blood replacement therapy and not
on time interval to delivery
 Painful vaginal bleeding
Vaginal bleeding with hypertonic contractions

Hook to Fetal Monitor

+ FHT - FHT

Reassuring Nonreassuing Fetal status Stable maternal condition Unstable maternal condition
Term Fetus Unstable maternal Normal Bleeding Abnormal Bleeding
condition Parameters Parameters
Stable maternal condition

VAGINAL DELIVERY Correct Anemia and

Continuous Fetal CESAREAN DELIVERY Hypovolemia
Monitoring

VAGINAL DELIVERY

No evidence of fetal Evidence of fetal distress

distress

Favorable Cervix Unfavorable Cervix

VAGINAL DELIVERY VAGINAL DELIVERY

PLACENTA PREVIA
 PLACENTA PREVIA
• Placenta is implanted or very near the
internal os
• Total Placenta Previa
• Cervical os is covered completely
• Marginal Placenta Previa
• Cervical is partially covered
• Low-lying Placenta Previa
• Placenta is implanted in the
lower uterine segment
 PLACENTA PREVIA

• Risk Factors
• Advancing age (>35)
• Multiparity
• Prior Cesarean Section
• Multiple Gestation
• Recurrent abortions
• History of dilatation and curettage
• Smoking
 Clinical Manifestation

• PAINLESS VAGINAL BLEEDING (Classic

Presentation)
• 2/3 present before 36 wks
• Bleeding rarely profuse
• Usually stops spontaneously
• Recurs with labor
 Diagnosis

• Transabdominal Sonography, accuracy of

93-97%
• TVs improved the accuracy to 100%
• Both should complement each other
 PLACENTA PREVIA in PRETERM

NO active bleeding Minimal Bleeding and uterine Profuse bleeding

contractions

Expectant Tocolysis and Corticosteroids Cesarean Section

Management

MANNER OF DELIVERY

Previa Totalis Placental edge >/= 2cm from Placental edge <2cm
the os from the os

Cesarean Section Trial of Labor Associated with CS rate

PLACENTA ACCRETA
 PLACENTA ACCRETA
• Occurs when a defect of the decidua basalis results in
an ABNORMALLY INVASIVE PLACENTAL IMPLANTATION
• PARTIAL
• Diffuse penetration in to the myometrium
• INCRETA
• Myometrium is deeply invaded
• PERCRETA
• Invasion beyond the uterian wall,
peritoneum or adjacent structures
 PLACENTA ACCRETA

• Risk Factors
• Previous Cesarean Section
• Placenta Previa
• Advanced Maternal Age
 Diagnosis

• Colour Flow Doppler Ultrasound in those with

previa who have delivered by Cesarean
previously (due to increased risk)

• Antenatal imaging allows for preparation for

definitive surgery to avoid inappropriate
treatment in placenta previa-accreta
No Antenatal
Diagnosis of Undelivered Placenta > 30 minutes
Placenta
Accreta Check cervix; if (-) trapped placenta

Manual Evaluation & Extraction of the

Placenta under anesthesia

Absence of Cleavage plane

(+) Hemorrhage

•Hysterectomy
•Conservative Surgery if Feritlity preservation desired
 PRESENCE OF RISK FACTORS
PLACENTA •Previous Cesarean Section
•Placenta Previa
ACCRETA •Advance Maternal Age

with Targetted Ultrasound/Color Flow Doppler

Antepartal (25-40 weeks)

Diagnosis Antenatal Diagnosis

Placental Accretta

•Build up Hemoglobin & prepare cross-matched blood

•Delivery in a Tertiary Care Center
•Intrapartal Prophylactic Antibiotic
•Active Management of 3rd Stage Labor

Difficult Placental Delivery

•Hysterectomy
•Conservative Surgery if Feritlity preservation desired
 Complications

• Intrapartum/Postpartum Hemorrhage
• SHOCK (with or without Panhypopituitarism)
• Severe Anemia
• Puerperal Sepsis
• Hysterectomy
RETAINED PLACENTA
 RETAINED PLACENTA

• Failure of the delivery of the placenta within

30 minutes of the birth of fetus
• Occurs in approx 1% of vaginal deliveries
• After 2 CS for placenta prebia, risk to 40% of
placenta accreta
• 3 phases involved in NORMAL PLACENTAL
Expulsion
1. Separation through the spongy layer of
the decidua
2. Descent into the lower segment and
vagina
3. Expulsion outside
• Interference in any  Retained Placenta
1. Atonic uterus: Placenta completely
separated but retained
2. Simple, adherent placenta
3. Placenta incarcerated: due to cosnstriction
or contraction ring
4. Morbid adherent placenta:
partial or complete placenta accreta
RETAINED Undelivered Placenta > 30 minutes

PLACENTA
w/ Bleeding w/o bleeding
•Contraction Ring •Complete Placenta Accreta
•Atonic Uterus
•Partial Placenta Accreta

Attempt gentle cord traction while counter

traction of “rubbing” up the uterus

With lengthening of the cord Without lengthening of the cord

Atonic Uterus Placenta Accreta
Cntraction Ring

•Oxytocin IM
•Push Placenta towards the vagina Placenta NOT detached, Manual Removal under
Anesthesia
•Deliver Placenta by twisting while pulling
constantly

Cleavage Found No cleavage line formed

Extract Placenta (Accreta confirmed)

Hysterectomy
 Diagnosis

• CLINICAL
• LABORATORY TEST
 Diagnosis

• CLINICAL
1. Presence of Contraction ring if
• Sudden gush of blood
• Fundus moves higher and becomes globular
• Increase in cord length at the vulva
• Raising of the fundus does not cause
shortening of the cord
2. Absence of the above may indicate presence of
PLACENTA ACCRETA
 Diagnosis

2. Absence signs of contraction ring may indicate

presence of PLACENTA ACCRETA
• Do not attempt vigorous traction

3. Hour-glass contraction or nature of the adherent

placenta can only be diagnosed during manual
removal
 Diagnosis

• LABORATORY TEST
• Ultrasonography can identify placenta
accreta
 Management

• Bladder is Emptied
• IF PLACENTA HAS SEPARATED
• Deliver placenta by “rubbing up” uterus or
give Oxytocin
• Push placenta toward the vagina to help
with expulsion
• Placenta is held and twisted whilst pulling
constantly
 Management

• IF PLACENTA HAS NOT DETACHED

• Needs manual removal under anesthesia
• Insert gloved hand into the uterus with other
hand on fundus
• Follow umbilical cord until the lower edge of the
placenta
• Push the hand between placenta and body of
uterus and ease placenta away with a
sawing action
• Suspect ACCRETA if
• Failure to locate cleavage between placenta and
uterine cavity
• Placenta does not detach easily

USE OF EXCESS FORCE CAN RESULT TO LIFE

THREATENING HEMORRHAGE
RETAINED Undelivered Placenta > 30 minutes

PLACENTA
w/ Bleeding w/o bleeding
•Contraction Ring •Complete Placenta Accreta
•Atonic Uterus
•Partial Placenta Accreta

Attempt gentle cord traction while counter

traction of “rubbing” up the uterus

With lengthening of the cord Without lengthening of the cord

Atonic Uterus Placenta Accreta
Cntraction Ring

•Oxytocin IM
•Push Placenta towards the vagina Placenta NOT detached, Manual Removal under
Anesthesia
•Deliver Placenta by twisting while pulling
constantly

Cleavage Found No cleavage line formed

Extract Placenta (Accreta confirmed)

Hysterectomy
• When placenta is fully detached  explore uterine cavity for
damage and other pieces

• Massage fundus with once hand whilst extracting placenta

and membrances with hand in uterine cavity

• Look carefully at placenta

• Administer Ergometring IV and IM

• ALTERNATIVE MANAGEMENT
• Inject saline 20ml + 10 u Oxytocin into
the Umbilical vein
• If due to Hour-Glass Contraction ring
• Deepen anesthesia (HALOTHANE useful,
subcutaneous injection of 0.5ml in 1000
Adrenaline HCL or Inhalation of 2 amyl
nitrate capsule
• If ring Is too tight, proceed to manual
exploration and manual extraction

• If placenta accreta is suspected, managed as

such
UTERINE ATONY
 UTERINE ATONY

• Failure of the uterus to contract and retract

effectively after placental delivery

SIGNIFICANT BLEEDING ON THE IMPLANTATION

SITE
 UTERINE ATONY

• WHO estimates 130,000 bleed to death while

giving birth… Uterine atony is reponsible for
about 80% of cases of PPH

• POGS: 2-3/1000 deliveries…5-19% of all

antecedent cause of direct maternal mortality
 Risk Factors

• Overdistended uterus (large fetus, hydramnios

• Prolonged labor
• Very rapid labor
• Placenta previa
• Uterine Fibroid
• Induced/Augmented Labor
• Chorioamnionitis
• Halogenated anesthetics
 Clinical Manifestations

• Heavy to moderate vaginal bleeding that

persists
• Uterus is soft, boggy, distended and lacks tone
• Uterus has repeated periods of contractions
and relaxations
• With steady bleeding that persists
• Woman shows signs of hypovolemia
• In diagnosing, consider three other causes:
• Trauma
• Tissue
• Thrombin
 Management

• Timely recognition + Appropriate intervention

• Principles in Management
1. Call for Help
2. Keep the uterus contracted to stop
bleeding
3. Stabilize or resuscitate the woman and
prevent further bleeding
 Management

1. Call for Help

• Ask assistance
• Insert large bore IV line
• Crystalloid solution fast drip
• Blood typing, crossmatching and Hgb
determination
• Empty woman’s bladder, IFC and
monitor I & O
1. Call for Help
2. Keep the uterus contracted to stop bleeding
• Massage uterus firmly to expel clots
• Keep uterus contracted
• 1L IVF + 20u Oxytocin x 60 drops/min
• Secondary line if first is running to treat shock
• Methylergometrine 0.2mg IM
• Misoprostol 200mcg to 1000mcg
• Check that placenta and membranes are
complete
• Examine vagina, cervix and perineum
• Estimate amount of blood loss
1. Call for Help
2. Keep the uterus contracted to stop bleeding
3. Stabilize or resuscitate the woman and
prevent further bleeding
• Assess PR, BP, Color and Consciousness
 UTERINE ATONY
IV line (large bore)
(PLACENTA ALREADY DELIVERED)
IVF Fluid
Hct, Hgb, BT/RH typing,
Massage Uterus crossmatching
20 u Oxytocin to 1L IVF (start 2nd line)
Methylergometrine 0.2 mg IM
Misoprostol (200-1000mcg rectal)
Explore Uterus

Bleeding Persists Bleeding Persists

Bleeding Controlled

Bleeding Controlled
Bimanual/Aortic Compression

•Uterine exploration if with Intrauterine Balloon tamponade

uterine lacerations and retained
secundines Angiographic arterial embolization

Laparotomy Reproductive
Preservation desired
Bleeding
Bleeding Controlled Controlled Uterine/Ovarian ligations Uterine Compression
Sutures

Bleeding Persists

Bleeding Persists
Bleeding Hysterectomy
Controlled
Hysterectomy
Bleeding
•Close surveillance and Oxytocin for 24 hours Controlled
•In case of massive blood loss  GIVE BLOOD
TRANSFUSION

•For any indication of infection  start broad-spectrum

antibiotics

•Keep accurate records

UTERINE RUPTURE
 UTERINE RUPTURE

• Complete Uterine Rupture

• Full-thickness separation of uterine wall
and overlying serosa
• Occult or Incomplete Rupture
• Often referred as uterine dehiscence
• Separation of preexisting scar but the
visceral peritoneum stays intact
 Risk Factors
• Uterine status •Unscarred
•Scarred
•Previous CS
• Uterine configuration •Normal
•Previous Myomectomy
•Congenital•Transabdominal
Uterine Anomaly
•Grandmultiparity
• Pregnancy considerations •Materngal •Laparoscopic
Age
•Placentation
• Previous Pregnancy and •Cornual pregnancy
•Overdistention
Delivery History •Previous
•Dystocia succesful vaginal
delivery
•Trophoblastic
•Not in labor invasion of the
• Labor Status •No previous vaginal delivery
myometrium
•Spontaneous Labor
•Interdelivery interval
•Induced Labor
• Obstetrical Management •Augmentation of labor
•Duration of Labor
Considerations •Instrumentation (rotational
•Obstruction of labor
forceps)
• Uterine Trauma •Intrauterine manipulatoin
•Direct
•Fundaluterine trauma
pressure
•Violence
 Signs and Symptoms
• Depend on TIMING, SITE and EXTENT of
Uterine defect
• Fetal Distress
• Diminished baseline uterine pressure
• Loss of uterine contractility
• Abdominal pain
• Recession of presenting part
• Hemorrhage
• Shock
 Complications
Fetal and Neonatal
Consequences
• Fetal hypoxia or anoxia
• Fetal acidosis
• Neonatal intensive care unit
admission
• Fetal or neonatal death
Maternal Consequences
• Maternal bladder injury
• Severe maternal blood loss
or anemia
• Hypovolemic shock
• Need for hysterectomy
• Maternal death
 Management
• Initial management  URGENT SURGICAL DELIVERY
• Response time is CRITICAL
• Thorough examination of uterus and birth canal
required
• In most cases, hysterectomy is preferred
• Ligation of ipsilateral hypogastric artery to stop
bleeding
• In cases of lateral rupture involving lower
uterine segment and uterine artery
• Can attempt uterine repair
 Prognosis
• 4.2% maternal mortality
• 46% Perinatal Mortality and Morbidity
UTERINE INVERSION
 UTERINE INVERSION

• Acute inversion: immediately in the 3rd stage

of labor
• Life threatening  hemorrhage, shock and
possible maternal death
• Chronic inversion: minimun of 30 days after
childbirth
• Subacute inversion: period in between
 UTERINE INVERSION
• 1st degree
• Inverted wall extends but not through the
cervix
• 2nd degree
• Inverted wall protrudes through the cervix
but remains within the vagina
• 3rd degree
• Inverted fundus extends outside
the vulva
 Causes
• Mismanagement of 3rd stage of Labor
• Strong cord traction
• Excessive fundal pressure before placental
separation
• Other factors
• Manual removal of placenta before complete
placental separation
• Sudden increase in abdominal pressure
• Short umbilical cord
• Abnormally adherent placenta
• Antepartum use of MgSO4 or Oxytocin
• Primiparity and rapid emptying of uterus after
prolonged distention
• Congenital weakness or anomalies of the
uterus
 Clinical Manifestations
• Sudden massive vaginal bleeding
• Hypotension, tachycardia
• Shock out of proportion to blood loss
• Absence of uterine fundus or an obvious
defect of fundus on abdominal examination
• Palpation of inverted fundus at cervical os or
vaginal introitus
• Apprearance of a large fleshy mass
at the introitus
 Diagnosis
• Essentially CLINICAL

• Sonography mas show a hyperechoic mass in

the vagina
 Management
• Blood Typing, cross matching, Hemogram and
DIC screen
• Immediate treatment of Shock
• IV LR solution and blood replacement
 Acute Postpartum Uterine Inversion

UTERINE
Early Clinical Diagnosis
INVERSION Rule out a Ruptured Uterus

Immediate manipulative Resuscitative Measures started

repositioning simultaneously

Manual repositioning in OR •PlacentaPushing

not removed until IV
up the fundus with
under general anesthesia
(JOHNSON’S METHOD)
fluids and anesthesia are given
palm of the hand and fingers
in the direction of long axis of
Hydrostatic Repositioning
•Hand maintained in position
the vagina upward through
(O’Sullivan’s Technique) Uses the pressure
after reposition and of 3-5 liters
the cervix
of warm fluid infusedare
Oxytocins/Prostaglandins into the
EXLAP for uterine repositioning by: vagina to acieve reposition of
given
•Mechanical pulling up of the fundus from the constrictive ring the uterus
(HUNTINGTON’S TECHNIQUE
•Division of the constrictive ring posteriorly followed by repositioning
(HAULTAIN’s TECHNIQUE)
•Relax cervix with General
anesthesia
Hysterectomy

Postoperative management with

resuscitation, antibiotics and
prostaglanding (if uterus intact)
• Drugs for tocolysis
• MgSO4 4gm IV
• Nitroglycerine 100mcg IV
• Terbutaline 0.25 mg
• Ritodrine
 Acute Postpartum Uterine Inversion

UTERINE
Early Clinical Diagnosis
INVERSION Rule out a Ruptured Uterus

Immediate manipulative Resuscitative Measures started

repositioning simultaneously

Manual repositioning in OR
under general anesthesia
•1L of LR + 20u Oxytocin or
(JOHNSON’S METHOD) Methylergometrine IM

Hydrostatic Repositioning
(O’Sullivan’s Technique)
•Single dose of prophylactic
Antibiotics
EXLAP for uterine repositioning by: •Ampicillin 2g IV +
HUNTINGTON’S
•Mechanical pulling up of the fundus from the constrictive ring Metronidazole 500mg IV
(HUNTINGTON’S TECHNIQUE •Two Allis forceps applied on either
•Division of the constrictive ring posteriorly followed by repositioning
•Cefazolin
side of uterus1g
2cmIV below
+ the ring
(HAULTAIN’s TECHNIQUE)
HAULTAIN’S
Metronidazole
and steadyring
•Cervical traction500mg IV
applied.
is incised posteriorly
•Repeated until direction
in the vertical uterus is replaced
until
Hysterectomy
•Acervical
well place traction suture
constriction in the
is removed
fundus will help done.
and reposition
Postoperative management with •Cervical incision sutured
resuscitation, antibiotics and
prostaglanding (if uterus intact)
TRAUMA TO THE GENITAL TRACT
 TRAUMA TO THE GENITAL TRACT

• Anatomic disruption

• May involve the perineum, vagina, cervix and

levator ani muscle
 Risk Factors
• Forceps delivery
• Nulliparity
• Improper use of uterotonics
• Precipitate Labor
• Prolonged labor
• Fetal Macrosomia
• Untimely episotomy
• Midline episiotome
• Shoulder dystocia
• Epidural anesthesia
 Clinical Manifestations

• Excessive bleeding with or without hematoma

formation in a well contracted uterus
• Falling blood pressure
• Rising cardiac/pulse rate
 Diagnosis

• Direct visual inspection

 Management

• Complete Blood Count • Insert Foley Catheter

• Adequate • Tight pack from a raw
cervicovaginal surface area
inspection • Antimicrobials
• Bimanual examinaition • Stool Softeners
if apex of laceration is • NSAIDs
beyond sulcus
• Adequate blood
• Apply forcepts at 3 and replacement
9 o’clock position
• Vasopressors if needed
 BRISK BLEEDING Blood los >500ml
BP FAILING
PULSE RATE RISING

Soft “ boggy uterus
Recommendation:
TONE
2 large bore IV needle
Oxygen by mask
Monitor BP, PR, UO Bimanual Uterine
Team approach, call for help massage
20 IU L Normal Saline
infused up to 500ml
over 30 minutes
Genital Tract Tear Placenta Retained Blood not clotting
Inversion of Uterus TISSUE THROMBIN
TRAUMA
Inspect Placenta Observe Clotting
Explore Lower Genital Consider CBC, type
Tract and Crossmatch,
Coagulation Screed
Consider Exploring the
Uterus

LACERATION HEMATOMA

Small/Non Increaseing: OBSERVE

Cervical Vaginal Perineal

Large/Increasing:
Suture Repair: Suture repair by Evacuation of blood/clots
Layer Ligate bleeders
Anterograde (apex to base)
Antimicrobial Leave drain
Retrograde (base to apex)
Stool Softeners Suture defect compression suture
Antimicrobial
NSAIDS Antimicrobial
NSAIDS

NOTE: Blood loss ≥ 1000ml: Transfuse RBCs, platelets and/or clotting factors and support
blood pressure with vasopressors
 CERVICAL LACERATIONS

• Etiology
• Forceps, ventouse or breech extraction
before full dilatation
• Difficult forceps rotaton
• Manual dilatation of the cervix
• Improper use of oxytocins
• Precipitate labor
 CERVICAL LACERATIONS

• Predisposing factors
• Cervical rigidity
• Scarring of the cervix
• Edema as in prolonged labor
• Placenta previa due to increased vascularity
 CERVICAL LACERATIONS

• Types
• Unilateral: more common in LEFT due to
• Dextrorotation of the uterus
• Left occipitoanterior position is
commonest
• Bilateral
• Stellate: multiple tears
• Annular or circular detachment
 CERVICAL LACERATIONS

• Diagnosis
• Excessive hemorrhage inspite of well
contracted uterus
• Vaginal exam: tear can be felt
• Speculum exam for adequate exposure
• RIGBY or GELPI self-retaining retractor + 2
ring forceps
 CERVICAL LACERATIONS

• Complications
• Postpartum Hemorrhage
• Rupture due to upward extension
• Infection: Cervicitis and Parametritis
• Cervical incompetence
• Ureteric injury
 CERVICAL LACERATIONS

• Management
• Up to 2 cm are inevitable  heal rapidly as
long as not bleeding
• Immediate repair
• Assistant applies downwar pressure on
uterus
• Vaginal walls held with retractors
• Interrupted or running sutures from apex
 VAGINAL LACERATIONS
• Causes
• Primary Lacerations (less common)
• Forceps application
• Destructive operations
• Vaccum extraction if cup sucks vaginal wall

• Secondary Lacerations (more common)

• Extension from perineal or cervical
tears
 VAGINAL LACERATIONS
• Management
• Immediate repair
• Continuous locked absorbable suttres from
apex
• Can suture in retrograde fashion if apex is
inaccessible
 PERINEAL LACERATIONS

• Etiology
• Lack of perineal elasticity •Elderly Primigravida
•Excessive scarring
•Allowing due
headtoextension
• Marked perineal stretch •Friability
before crowing
edema
perineal

•Macrosomic baby
• Rapid Perineal Stretch •Face to pubis
•Precipitate delivery
labor
•Forceps delivery
•Rapid delivery of the
•Narrow suprapubic
aftercoming head in angle
breech
pushing heal backward
 PERINEAL LACERATIONS
• Complications
• Postpartum hemorrhage
• Puerperal infection
• Incontinence of stool and flatus
• Residual recto-vaginal fistula
• Future genital prolapse
• Dyspareunia due to tender vaginal scar
 BRISK BLEEDING Blood los >500ml
BP FAILING
PULSE RATE RISING

Soft “ boggy uterus
Recommendation:
TONE
2 large bore IV needle
Oxygen by mask
Monitor BP, PR, UO Bimanual Uterine
Team approach, call for help massage
20 IU L Normal Saline
infused up to 500ml
over 30 minutes
Genital Tract Tear Placenta Retained Blood not clotting
Inversion of Uterus TISSUE THROMBIN
TRAUMA
Inspect Placenta Observe Clotting
Explore Lower Genital Consider CBC, type
Tract and Crossmatch,
Coagulation Screed
Consider Exploring the
Uterus

LACERATION HEMATOMA

Small/Non Increaseing: OBSERVE

Cervical Vaginal Perineal

Large/Increasing:
Suture Repair: Suture repair by Evacuation of blood/clots
Layer Ligate bleeders
Anterograde (apex to base)
Antimicrobial Leave drain
Retrograde (base to apex)
Stool Softeners Suture defect compression suture
Antimicrobial
NSAIDS Antimicrobial
NSAIDS

NOTE: Blood loss ≥ 1000ml: Transfuse RBCs, platelets and/or clotting factors and support
blood pressure with vasopressors
 PUERPERAL VULVAR/VAGINAL
HEMATOMA
• Complications

VULVAR HEMATOMA VAGINAL HEMATOMA

• Traumatic • Forceps application
– Incomplete hemostatsis • Destructive operations
during repair or tear
• Vacuum extraction if
• Spontaneous the cup sucks vaginal
– Due to rupture of a wall
varicose vein
• Extension from perineal
or cervial tears
 PUERPERAL VULVAR/VAGINAL
HEMATOMA
• CLINICAL MANIFESTATIONS
• Severe perineal pain
• Rapid appearance of a tense, fluctuant and sensitive mass
• Symptoms of pressure IF NOT pain or inability to void
• Hematoma appears 12-28 hours after delivery
• Collection of blood limited by the levator ani above..
• May extend to the ischiorectal fossa
when >500ml
• Progressive enlarge, painful, tender, tense,
bluish swelling at the vulva
DISSEMINATED INTRAVASCULAR
COAGULATION IN OBSTETRICS
 DISSEMINATED INTRAVASCULAR
COAGULATION in OBSTETRICS
• Syndrome characterized by widespread
activation of coagulation leading to
thrombotic obstruction of small and midsized
vessels  tissue ischemia  bleeding from
consumption of platelets and coagulation
factors and the anticoagulant effect of
products of secondary fibrinolysis

• INTERMEDIATE disease
 DISSEMINATED INTRAVASCULAR
COAGULATION in OBSTETRICS
• Pregnancy predisposes patients to DIC for the
following reasons:
• Pregnancy produces a hypercoagulable state
• Pregnancy is associated with reduced fibrinolytic
activity
• Pregnancy is associated with decline in plasma
level of protein S
 Obstetric conditions associated with
DIC
1. Abruptio Placenta •Most common obstetric cause
•Mechanism: Activation of
2. Preeclampsia/Eclampsia EXTRINSIC •Majority
coagulation
will havecascade
subclinical
pathway by TISSUEcoagulopathy
consumptive
3. IUFD •Develops in 25% of dead •Mechanism:
THROMBOPLASTIN
fetus if release from
diminished
retained for >1 monthplacenta
PROSTACYCLIN leads to
4. Septic Abortion
•Mechanism: Activation ofabnormal
•Reported PLATELET
to occur
AGGREGATION
in 31% of pxs
whichreleased
can
EXTRINSIC coagulation•Mechanism:
pathway by ENDOTOXIN
•Occur in 45% of cases who
5. Amniotic FluidTISSUE
embolism
THROMBOPLASTIN initiate
activateds DIC extrinsic
BOTH
survive
released by necrotic fetus into the
clotting
cardivascular insult
mechanism (thru release of tissue
•Mechanism:
maternal circulation factor expression on the surface of
THROMBOPLASTIN from
activated monocytes and
amniotic fluid trigger the
endothelial cells) and intrinsic
EXTRINSIC coagulation
pathway (by activation of factor X.
pathway
 Clinical Manifestation

• Bleeding from multiple sites

• Skin: purpura, bleeding from injury sites,
hemorrhagic bulae, focal necrosis
• Cardiovascular: shock, acidosis, MI,
Cerebrovascular event, thromboembolism in
all vessels
• Renal: Acute renal insufficiency, oliguria,
hematuria, renal cortical necrosis
 Clinical Manifestation
• Liver: Hepatic failure, jaundice
• Lungs: ARDS, hypoxemia, edema and
hemorrhage
• GIT: bleeding, mucosal necrosis and
ulceration, intestinal ischemia
• Central Nervous: Coma, convulsions, focal
lesions, bleeding
• Adrenals: Adrenal insufficiency
(hemorrhagic necrosis)
 Establishing
STEP 1: RISK ASSESSMENT
DIC Diagnosis Does the patient have an underlying disorder known to be associated with
DIC

NO YES

STOP STEP 2: Check Coagulation Test, Platelet count, PT, Fibrinogen,

Soluble Fibrin Monomers, FDPs

STEP 3: Score Global Coagulation Test Results

•Platelet Count (x109: >100=0, <100=1, <50=2
•PT (sec): <3 = 0; >3 but <6 = 1. >6 = 2
•Fibrinogen (g/L: >1 = 0, <1 = 1
•Fibrine-related markers: no increase = 0, mod increase = 2, strong increase = 3

STEP 4: Calculate Score

STEP 5 if ≥ 5 Step 5 if ≤ 5

Compatible with DIC Suggest non overt DIC

Repeat scoring daily Repeat after 1-2 days


DIC
Management
Suggestive evidence of DIC
Wait for successof treatment but
be alert for deterioration
DIAGNOSIS OF DIC
Vigorous Treatment of Underlying Disease
Unequivocal evidence of DIC
Consider waiting for Consider replacement therapy &/or Consider replacement
success of treatment continuous heparin infusion in the ff: therapy only in the ff:
if patient’s condition •Abruptio placenta
•AF embolism
is stable
•Septic abortion •Severe Bleeding
•Fetal deasth in utero
Reevaluate clinical and laboratory parameters
If improved, continue If bleeding is a major problem: If thromboembolism is the
treatment until major problem, consider
Giver Replacement therapy q8 hrs;
recovery continuous heparin infusion
if it fails, consider adding heparin
infusion; if concomitant primary
fibrinolysis is evident, consider
adding an antifibrinolytic agent with
heparin
Thank you. 