Antepartum

Obstetrical
International Hemorrhage
Hemorrhage

Obstetrical Hemorrhage
 Obstetrical
Antepartum
Hemorrhage
International Hemorrhage

Principles
• Prompt diagnosis
• Recognize reserve and ability to compensate
• Resuscitate vigorously
• Identify underlying cause
• Treat underlying cause
 Antepartum
International Hemorrhage

Antepartum Hemorrhage
 Antepartum
International Hemorrhage

Objectives
• Definitions and Incidence
• Etiology and Risk Factors
• Diagnosis
• Management
- maternal and fetal assessment
- appropriate resuscitation
- no vaginal exam prior to determining
placental location
• Individual Causes
 Antepartum
International Hemorrhage

Definition
• vaginal bleeding between 20 weeks and delivery
Incidence
• 2% to 5% of all pregnancies
• various causes of antepartum haemorrhage
- abruptio placenta 40% - 1% of pregnancies
- unclassified 35%
- placenta previa 20% - ½% of pregnancies
- lower genital tract lesion 5%
- other
 Antepartum
International Hemorrhage

Etiology of APH
• Cervical
– contact bleeding (e.g. intercourse, pap, neoplasia, examination)
– inflammation (e.g. infection)
– effacement and dilatation (e.g. labour, cervical incompetence)
• Placental
– abruptio
– previa
– marginal sinus rupture
• Vasa previa
• Other - abnormal coagulation
 Antepartum
International Hemorrhage

Diagnostic Procedures
• History and physical - No digital pelvic exam
• Ultrasound
– definitive test for previa
– less useful in abruptio
• Electronic Fetal Monitoring
– for fetal compromise and uterine tone
• Speculum
– do ultrasound first if possible
– No digital pelvic exam
 Antepartum
International Hemorrhage

Laboratory
• CBC, blood type, Rh, Coombs
• coagulation status
– INR, PTT, fibrinogen or TCT
• 2 - 4 units of PRBC cross matched as appropriate
• bedside clot test
• Kleihauer-Betke or Neirhaus test
– vaginal and/or maternal blood
• fetal lung maturity indices if appropriate
 Antepartum
International Hemorrhage

Vaginal Bleeding
Risk Factors Tests (No vaginal exam)

Fetal / Maternal Assessment

Mother or fetus unstable Mother and fetus stable

Hemodynamic Resuscitation Labs / Fetal Monitoring

U/S ± vaginal exam

Mother or fetus unstable

Expectant
consider ongoing loss, etiology, gestation
Delivery
 Antepartum
International Hemorrhage

Management - ABC ’s
• talk to and observe mother and fetus
• large bore IV access
• crystalloid (N/S)
• CBC and coagulation status
• cross-match and type
• get HELP!
 Antepartum
International Hemorrhage

Hemodynamic Resuscitation
• early aggressive resuscitation to protect fetus and
maternal organs from hypoperfusion and to prevent DIC
• stabilize vital signs
• large bore IV crystalloid infusion, plasma expanders
• follow hemoglobin and coagulation status
• oxygen consumption is up 20% in pregnancy
 Antepartum
International Hemorrhage

Fetal Considerations
• lateral position increases cardiac output up to 30%
• consider amniocentesis for lung indices
• external fetal and labor monitoring
• Kleihauer-Betke if suspected abruption
• post-trauma monitor at least 4 hours for evidence of
fetal insult, abruptio, fetal maternal transfusion
 Antepartum
International Hemorrhage

Abruptio Placenta - Definition

• premature separation of normally implanted placenta

Abruptio Placenta - Classification

• Total - fetal death
• Partial - fetus may tolerate up to 30-50% abruption
 Antepartum
International Hemorrhage

Risk Factors for Abruption

• hypertension: gestational and pre-existing
• abdominal trauma
• cocaine or crack abuse
• previous abruption
• overdistended uterus
– multiple gestation, polyhydramnios
• smoking, especially >1 pack/day
 Antepartum
International Hemorrhage

Clinical Presentation of Abruption

• vaginal bleeding usually painful, unremitting
• presence of risk factor
• hemodynamic status may not correlate with
amount of vaginal blood loss - concealed abruptio
• may be evidence of fetal compromise
• uterus - tender, irritable, contracting or tetanic
• ultrasound rules out previa and may show clot
 Antepartum
International Hemorrhage

ABRUPTION

Live Fetus Dead Fetus

± coagulopathy

Delivery
(watch for DIC)

Assess Maturity

Maturity Immaturity

Vaginal delivery or C/S Steroids plus

expectancy
Transfusion? Transfer?
 Antepartum
International Hemorrhage

Placenta Previa - Definition

• placenta covers or lies near the cervix

Placenta Previa - Classification

• total - entirely covers the os
• partial - partially covers the os
• marginal - close enough to the os to increase risk
of bleeding as cervical effacement and
dilatation occur
 Antepartum
International Hemorrhage

Risk Factors for Previa

• previous placenta previa
• previous caesarian section or uterine surgery
• multiparity (5% in grand multiparous patients)
• advanced maternal age
• multiple gestation
• smoking
 Antepartum
International Hemorrhage

Clinical Presentation of Previa

• vaginal bleeding usually painless (unless in labour)
• maternal hemodynamic status corresponds to
amount of vaginal blood loss
• well tolerated by fetus unless maternal instability
• uterus - non-tender, not irritable, soft
• may have abnormal lie
• ultrasound shows previa
 Antepartum
International Hemorrhage

PREVIA

Assess maturity

Maturity Immaturity

Delivery by C/S (consider accreta) Steroids plus expectancy

May try vaginal if marginal Transfusion? Transfer?
 Antepartum
International Hemorrhage

Vasa Previa - Definition

• blood vessels in the membranes run across the cervix
• requires a vellamentous insertion or succenturiate lobe
Complication
• ex-sanguination following amniotomy or ROM
Diagnosis
• Apt test or Kleihauer test on vaginal blood
• terminal fetal bradycardia ± initial tachycardia or sinusoidal FH
Prognosis
• fetal mortality as high as 50-70%
 Antepartum
International Hemorrhage

Conclusions
• assess maternal status and stability
• assess fetal well-being
• resuscitate appropriately
• assess cause of bleeding - avoid vaginal exam
• expectant management if appropriate
• deliver if indicated based on maternal or fetal status
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Postpartum
Hemorrhage
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Objectives
• Definition
• Etiology
• Risk Factors
• Prevention
• Management
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Traditional Definition
• blood loss of > 500 mL following vaginal delivery
• blood loss of > 1000 mL following cesarean delivery

Functional Definition
• any blood loss that has the potential to produce or
produces hemodynamic instability
Incidence
• about 5% of all deliveries
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Etiology of Postpartum
Hemorrhage
Tone - uterine atony
Tissue - retained tissue/clots
Trauma - laceration, rupture, inversion
Thrombin - coagulopathy
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Risk Factors for PPH - Antepartum

• previous PPH or manual removal
• placental abruption, especially if concealed
• intrauterine fetal demise
• placenta previa
• gestational hypertension with proteinuria
• overdistended uterus (e.g. twins, polyhydramnios)
• pre-existing maternal bleeding disorder (e.g. ITP)
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Risk Factors for PPH - Intrapartum

• operative delivery - cesarean or assisted vaginal
• prolonged labour
• rapid labour
• induction or augmentation
• chorioamnionitis
• shoulder dystocia
• internal podalic version and extraction of second twin
• acquired coagulopathy (e.g. HELLP, DIC)
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Risk Factors for PPH -

Postpartum
• lacerations or episiotomy
• retained placenta/placental abnormalities
• uterine rupture
• uterine inversion
• acquired coagulopathy (e.g. DIC)
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Prevention
• be prepared
• active management of the third stage
- prophylactic oxytocin with delivery or with delivery
of anterior shoulder
– 10 U IM or 5 U IV bolus
– 20 U/L N/S IV run rapidly
- early cord clamping and cutting
- gentle cord traction with suprapubic countertraction
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Antepartum
Hemorrhage
International Hemorrhage

Active v.s Expectant Third Stage

Outcome
Management
(subjects)
PPH > 500 mL (n=4636)
PPH > 1000 mL (n=4636)
Maternal Hb < 91 (n=4256)
Blood transfusion (n=4829)
Therapeutic oxytocin (n=4829)
Nausea (n=3407)
Manual removal (n=4829)
0.1 1 10
Cochrane Library
Issue 1, 2000 Odds Ratio (95% Confidence Interval)
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Diagnosis - Is this a PPH?

• consider risk factors
• observe vaginal loss
• express blood from vagina following C/S
• REMEMBER
- blood loss is consistently underestimated
- ongoing trickling can lead to significant blood loss
- blood loss is generally well tolerated to a point
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Diagnosis - What is the cause?

• assess the fundus
• inspect the lower genital tract
• explore the uterus
- retained placental fragments
- uterine rupture
- uterine inversion
• assess coagulation
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

A B C
A = airway
B = breathing
C = circulation
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Management - ABC ’s
• talk to and observe patient
• large bore IV access (16 gauge)
• crystalloid - lots!
• CBC
• cross-match and type
• get HELP!
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Management - Assess the fundus

• simultaneous with ABC ’s
• atony is the leading cause of PPH
• if boggy  bimanual massage
- rules out uterine inversion
- may feel lower tract injury
- evacuate clot from vagina and/or cervix
- may consider manual exploration at this time
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Management - Bimanual Massage

 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Management - Oxytocin
• 5 units IV bolus
• 20 units per L N/S IV wide open
• 10 units intramyometrial given transabdominally
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Management - Manual Exploration

• if no response to bimanual massage and oxytocin
then proceed to exploration
• manual exploration will:
- rule out uterine inversion
- palpate cervical injury
- remove retained placenta or clot from uterus
- rule out uterine rupture or dehiscence
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Replacement of Inverted Uterus

 Postpartum
Antepartum
Hemorrhage
International Hemorrhage
Replacement of Inverted Uterus
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Management - Additional Uterotonics

• ergotamine - caution in hypertension
- 0.25 mg IM or 0.125 mg IV
- maximum dose 1.25 mg
• Hemabate (carboprost) - asthma is relative contraindication
- 15 methyl-prostaglandin F2
- 0.25 mg IM or intramyometrial
- Maximum dose 2 mg
• Cytotec (misoprostil) - caution in asthma
- 400 mg pr or po
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Management - Bleeding with firm

uterus
• explore the lower genital tract
• requirements - appropriate analgesia
- good exposure and lighting
• appropriate surgical repair
- may temporize with packing
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Management - Continued uterine

bleeding
• possible coagulopathy - INR, PTT, TCT, fibrinogen
• if coagulation is abnormal:
- correct with clotting factors, platelets
• if coagulation is normal:
- prepare for O.R. (may consider embolization)
- rule out uterine rupture, inadequate incision repair
- consider uterine/hypogastric ligation, hysterectomy
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Management - ABC ’s

ENSURE that you are always

ahead with your resuscitation!!!!
• consider need for Foley catheter, CVP, arterial line, etc
• consider need for more expert help
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Conclusions
• be prepared
• practice prevention
• assess the loss
• assess maternal status
• resuscitate vigorously and appropriately
• diagnose the cause
• treat the cause
 Postpartum
Antepartum
Hemorrhage
International Hemorrhage

Management - Evolution

Panic
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness
 Antepartum
Postpartum
International Hemorrhage

Keep your bloody fingers

off the cervix!