Hemorrhage in Pregnancy

PPH
 Over half a million women die during pregnancy and childbirth each year
 Hemorrhage is the most common cause of maternal death
 25% - 60% of maternal death is due to PPH
 PPH is the most common cause of hemorrhage related maternal deaths
 The incidence of PPH is approx. 3% - 5%

• Excessive bleeding affects approximately 5 to 15 percent of women after giving

birth.
• Hemorrhage that occurs within the first 24 hours postpartum is termed early
postpartum hemorrhage.
• While excessive bleeding after 24 hours is referred to as late postpartum
hemorrhage.
• In general, early PPH involves heavier bleeding and greater morbidity
Causes of maternal death
7% Haemorrhage
8% 25% Anaemia Malaria
other
Sepsis
12%
Abortion related

Hypertensive
disorders
13% Obstructed labour
20%
Other direct causes
15%
Definitions
1.Excessive bleeding after delivery of the fetus that makes the patient symptomatic
and/or results in signs of hypovolemia
OR
2.Blood loss > or = 500 ml in singleton, vaginal delivery
> or =1000 ml - in twin vaginal delivery
- in C/S delivery
OR
3.A 10% decline in postpartum hct

Two types

• Primary PPH - within the first 24 postpartum hours

• Secondary PPH - between 24 hours and 6 weeks postpartum

Etiology of PPH
• Uterine atony – commonest cause

• Uterine, cervical, and vaginal lacerations

• Retained placenta or Adherent placenta

• Coagulopathy

• Uterine inversion

• Uterine rupture
Risk factor

Over distention
(big baby, twin, poly hydraminos)
Grand multiparity
Tocolytic agents
History of APH and PPH
Placenta previa or abruption
Coagulation defects
Chorioamnionitis
NB. Only about 10% of women with any of the risk factors develop PPH
• Over two-thirds have no identifiable risk factors
• Every child birth carries risk
Prevention and early interventions are key to survival
 Atonic Uterus
• Atonic uterus is the most common cause of primary PPH( A hypotonic uterus)

• leads retention of the placenta and excessive bleeding. Active management of the third

• stage of labor (AMTSL) is recommended for all deliveries (see section on AMSTL).

 Retained placenta
 .The common cause of placental retention is poor uterine contraction.
 In retention of the placenta without bleeding, pathological adherence should be considered and
manual r

Tx.manual removal of the placenta has to be done in the OR with all the preparation for laparotomy
Time from onset of complications to death

• PPH >>>>>>>>-2 hr
• APH >>>>>>>> 12 hr
• Eclempsia >>>>>> 2 days
• Obstructed labor>>>> 3 days
• Sepsis >>>>>> 6 days
Dx. Approach of PPH
Hx.. vaginal bleeding that appears at any given time after delivery of the fetus
 P/E-GA—V/S --HEENT—ABD.Exam..GUS..
IX..CBC..U/S..OFT..COUAGULATION PROFILE…
 Sequential steps in managing PPH
• SHOUT FOR HELP !!!!!
• Fundal massage
• IV access For Crystalloids to prevent hypotension
• oxygen delivery
• Catheterize and measure urine output
• Blood transfusion
• Antibiotics
Cont…

• Uterotonic drugs
Oxytocin ( iv, im, intramyometrial )
Ergometrine ( 0.3mg IM, IV)
PGs ( misopristol
Inspect vagina and cervix for lacerations; repair as necessary
• Temponade(pack)
• Bimanual compression
• Laparatomy
Ligation of bleeding sites
Hysterectomy
 APH
• Defn. :- is the occurrence of vaginal bleeding (VB) after 28th wks of
gestation and before delivery of the fetus
Ethiology
I. Placental cause-----Abruptio placentae
-----Placenta previa
---Rare : vasa previa and other placental abnormalities

II. Uterine rupture

III. Local legions of the cervix, vagina and vulva
 I.Placenta previa
PP.is partial or complete localization( implantation) of the placenta in the LUS
Risk Factor for PP
. Grand multiparity)
Prior trauma to the endometrium (ex. C/S scar, curratage, etc)
Placental hypertrophy(ex. DM, Erythroblastosis, etc)
twin pregnancy
Smoking = hypoxemia →Placental hypertrophy
Maternal age >35yrs
Types

1.Low lying PP ----- -Type I----placenta in LUS but away from the internal-os

2.Marginal PP -- --- Type II---edge of the placenta reaches the internal-os

3.Partial PP--------- Type III--beyond the internal-os but does not covers the cervical os
4.Total PP------- -- Type IV--covers the whole of the internal-os and the fully dilated cervix
Clinical course and diagnosis
The mean GA at Dx. = 32.5 wks.

PAINLESS, CAUSELESS, profuse, BRIGHT RED Vag. Bleeding

Why bleeding?

- formation of the LUS → detachment of the placenta

- placentitis

- direct trauma → coital, PV exam., douching

Can also remain asymptomatic
Other clinical findings :-
Hypovolemia
Anemia
Soft uterus
Malpresentation
Floating presenting part
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Cont…..
IX---CBC……HGB/HCT….
 Ultrasound confirm the Dx…

- Abdominal Vs Vaginal
 Double set up examination

 Complication
A) Maternal
• Blood loss & shock
• Adherent placenta
• Transfusion risks
• Longer hospital stay
• Surgical morbidity
• Post partum hemorrhage
• Recurrence rate — 4 to 8 percent
B) Fetal / Neonatal

1.↑ed PNMR from prematurity

2.↑ed risk of fetal anomalies ( 5x)

3.↑ed IUGR (20% )

4.Birth trauma ( b/c of malpresentation)

5.Neonatal anemia
Management
• Principles :-
Admit or Refer all patients to a hospital
NEVER NEVER NEVER do PV- EXAM
Take Resuscitative measures
Secure IV – line ( 1 or 2 IV – lines)
Administer fluids depending upon the patient status
Take blood for BG & RH, HCT
X – match at least two units of blood
Transfuse if indicated (HCT < 30%)

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Plan further management
1.Expectant(conservative) management to prevent preterm
delivery.
- No active vaginal bleeding
- Preterm fetus
- Hemodynamicaly stable
- No anemia
 Follow maternal & fetal status with –BPP 2x/wk ,,V/S,, Serial HCT
Iron supplementation
Steroid therapy if GA <34 weeks

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2. Termination of pregnancy(definitive Tx.)
a. Term pregnancy
b. Labor
c. Torrential bleeding
d. IUFD
e. Lethal malformation
Mode of delivery:
1.Vaginal
- Type I(LLP) & type II anterior PP
2. Cesarean section(C/S) preferred mode of delivery

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II.Abruptio Placenta(AP)
• Def:- is a premature separation of the whole or part of a placenta implanted in
the upper segment of the uterus
- Also called accidental hemorrhage/ placental abruption
Approximately one third of all antepartum bleeding can be attributed to
placental abruption
Types
1. Revealed / external
2. Concealed: in most AP
- It might as well be:-
partial abruption
total abruption
marginal separation
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 Risk factors for AP:-
 Prior abruption = 4-5%
 Advanced age>35yrs and parity = 2.5%
 Preeclampsia = 5 fold
 Chronic hypertension = 5 fold
 Trauma,, Cocaine use
 PPROM = cause or result
 Multiple pregnancy = twin B, 3 fold
 Cigarette smoking = 2.5 fold
 Myoma
 Folate deficiencylow,,, socio-economic status
 polyhydramnious
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Complication of AP…
 hemorrhagic shock (acute renal failure,congestive heart
failure),
 DIC, and utero-placental insufficiency (UPI) that may
lead to
IUGR, fetal distress or IUFD
Coagulopathy
Anemia
Clinical presentation
mainly depends on the extent of placental
separation, rate of separation and flow of blood through the cervix
(concealed/ revealed)
Vaginal bleeding: menstrual-like dark red, painful (80%)
Severe Abdominal pain/ (uterine) tenderness—50%
Uterine hyper tonus ( focal or generalized)
Idiopathic preterm labor
Fetal distress / NRFHRP
epistaxis, echymosis, petichii
Bleeding with placental abruption is almost always maternal
Cont…

IX……>
U/S
Treatment
Resuscitative measures
Expectant Mx. If preterm
Termination of pregnancy (delivery)
Vaginal vs C/S….depend on the condition
Treatment of complication
III. Vasa previa
Vp.. refers to vessels that traverse the membranes in the lower uterine
segment in advance of the fetal head.
Rupture of these vessels can occur with or without rupture of the
membranes and result in fetal demesis
 Confirmation = Apt, Kleihauer-Betke tests
Management = immediate abdominal delivery.
2. Local Causes
3. Idiopathic
NB.The commonest cause of APH
Ectopic pregnancy
Def..is the implantation of the fertilized ovum outside of the endometrial cavity
The most common site for ectopic pregnancy is the fallopian tube.
It is the leading cause of maternal mortality during 1st trimester 10 –14 % of
maternal deaths.
Predisposing/risk factors
Previous ectopic pregnancy
PID – chronic salpingitis : 30%~50%, TB(risk of PID)
Infertility,,,Smoking
Previous tubal surgery
Developmental, functional tubal abnormality
Increased use of assisted reproductive technique
Endometriosis
 PATHOLOGY
95 %

70 % 12 % 2.4 %

3.2 %

1.3 %
11.1 %

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Clinical manifestation of ectopic pregnancy: Symptoms (Triad)

Amenorrhea 70-85%, 6-8 weeks

Lower abdominal /pelvic pain: commonest symptom
 - Tubal distention and peritoneal irritation by blood
Vaginal bleeding results from sloughing of the decidua
Syncope
GI symptoms
Relative infertility

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Signs

General condition

Abdominal examination
Abdominal tenderness
Abdominal mass
Pelvic examination
Adnexal, cervical motion tenderness
Adnexal mass
Slightly enlarged soft uterus

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IX& Imaging
• HCG test: 80-100% positive
Negative HCG test does not rule out ectopic pregnancy

• Ultrasound: transvaginal and abdominal

- Criteria for diagnosis
-Discriminatory zone at 5 and 6 weeks
-CBC &U/A

•Culdocenthesis
- Positive (non-clotting blood): ruptured ectopic pregnancy
- Negative culdocenthesis does not exclude ectopic

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Differential diagnosis
• Abortion
• Molar pregnancy
• PID
• Torsion of an ovarian cyst
• Ruptured corpus luteum
• Appendicitis

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Complication of Ectopic Px.
Bleeding(anaemia)
Shock
Sepsis
Peritonitis
Infertility
Surgical related complication

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 Management Approach


Depend on clinical presentation & complication

Medical for Unruptured

ABC of life Approach

Iv fluid(shock)

Treatment of Anaemia With blood transfusion

Antibiotics& Analgesics

Surgical( for ruptured)
laparotomy, If there is extensive damage to the tubes, perform salpingectomy(radical)
Conservative: salpingostomy
salpingoplasty
segmental resection and anastomosis