10 Obstetric Haemorage

7/23/2019 10 Obstetric Haemorage

1/50

ntepartum Hemorrhage

International

Obstetrical Hemorrhage



2/50


International

Principles Prompt diagnosis

Recognize reserve and ability to compensate

Resuscitate vigorously Identify underlying cause

Treat underlying cause



3/50


International

Antepartum Hemorrhage


4/50


International

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


5/50


International

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% - % of pregnancies

- lower genital tract lesion 5%- other


6/50


International

Etiology of APH

Cervicalcontact 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


7/50


International

Diagnostic Procedures

History and physical - No digital pelvicexam

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


8/50


9/50


International

Hemodynamic Resuscitation

Risk Factors Tests (No vaginal exam)

Fetal / Maternal Assessment

Mother or fetus unstable Mother and fetus stable

Labs / Fetal Monitoring

U/S vaginal exam

Delivery

Vaginal Bleeding

Mother or fetus unstableExpectant

consider ongoing loss, etiology,

gestation


10/50


International

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!


11/50


International

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


12/50


International

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 evidenceof fetal insult, abruptio, fetal maternal transfusion


13/50


International

Abruptio Placenta - Definition

premature separation of normally implanted

placenta

Abruptio Placenta - Classification

Total - fetal death

Partial - fetus may tolerate up to 30-50%abruption


14/50


International

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


15/50


International

Clinical Presentation of Abruption

vaginal bleeding usually painful, unremitting

presence of risk factor

hemodynamic status may not correlate withamount 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


16/50


International

ABRUPTION

Live Fetus Dead Fetus

coagulopathy

Delivery

(watch for DIC)

Assess Maturity

Maturity Immaturity

Vaginal delivery or C/S Steroids plus expectancyTransfusion? Transfer?


17/50


International

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


18/50


International

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


19/50


International

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


20/50


International

PREVIA

Assess maturity

Maturity Immaturity

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

May try vaginal if marginal Transfusion? Transfer?


21/50


International

Vasa Previa - Definition

blood vessels in the membranes run across the cerv 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%


22/50


International

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


23/50


International

Kleihauer-Betke

Indications

Measures fetal cells in maternal circulation

Used in assessing for Rh Sensitization

Maternal blood Rh negative

Large antepartum bleed

Mechanism

Blood Film stained with acid elution

Fetal Hgb more acid resistant

Fetal RBC darkly stained, Maternal RBC "ghosts"Technique

Count Fetal cells per 50 low power fields

Five cells per 50 (lpf) = 0.5 ml bleed

Interpretation

Calculate Maternal Blood Volume (ml) =

(Pre-pregnant weight in kg) x 70 ml/kg x (1.0 + (0.5 x weeks gestation/36)) -

Estimated Blood loss (ml) at time of testCalculate Fetal Whole Blood (ml) =

(Fetal Cell Count/Maternal Cell Count) x Maternal Blood Volume

Rh Immune Globulin (RhoGAM) Dose

Give 300 ug per 30 ml fetal whole blood or 15 ml pRBC
http://www.fpnotebook.com/OB58.htmhttp://www.fpnotebook.com/HEM108.htmhttp://www.fpnotebook.com/HEM108.htmhttp://www.fpnotebook.com/OB125.htmhttp://www.fpnotebook.com/OB125.htmhttp://www.fpnotebook.com/HEM108.htmhttp://www.fpnotebook.com/OB58.htm


24/50


International

Indications

Assess for Vasa Previa in Late Pregnancy Bleeding

Mechanism

Differentiates Fetal from Maternal Blood

Technique

Collect bloody vaginal fluid

Add a small amount of tap water (Hemolyzes blood)Centrifuge sample

Add 5 cc pink supernatant to 1 cc Sodium Hydroxide 1%

Read in 2 minutes (may be difficult)

Pink sample indicates fetal Hemoglobin

Yellow-Brown sample indicates adult Hemoglobin

Modified Apt Test
http://www.fpnotebook.com/OB14.htmhttp://www.fpnotebook.com/OB11.htmhttp://www.fpnotebook.com/HEM79.htmhttp://www.fpnotebook.com/HEM79.htmhttp://www.fpnotebook.com/HEM79.htmhttp://www.fpnotebook.com/HEM79.htmhttp://www.fpnotebook.com/OB11.htmhttp://www.fpnotebook.com/OB14.htm


25/50


26/50


International

Objectives Definition

Etiology

Risk Factors

Prevention

Management

Postpartum Hemorrhage


27/50


International

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



28/50


International

Etiology of Postpartum Hemorrhage

Tone - uterine atony

Tissue - retained tissue/clots

Trauma - laceration, rupture, inversion

Thrombin - coagulopathy



29/50


International

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)



30/50


International

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 tw

acquired coagulopathy (e.g. HELLP, DIC)



31/50


International

Risk Factors for PPH - Postpartum lacerations or episiotomy

retained placenta/placental

abnormalities uterine rupture

uterine inversion

acquired coagulopathy (e.g. DIC)



32/50


International

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



33/50


International

Active v.s Expectant Third Stage Management

Cochrane Library

Issue 1, 2000

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

Odds Ratio (95% Confidence Interval)

Outcome (subjects)



34/50


International

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



35/50


International

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



36/50


International

A = airway

B = breathingC = circulation



37/50


International

Management - ABCs

talk to and observe patient

large bore IV access ( 16

gauge)

crystalloid - lots!

CBC

cross-match and type get HELP!



38/50


International

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


P t t H h


39/50


International

Management - Bimanual Massage



40/50

P t t H h


41/50


International

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




42/50


International

Replacement of Inverted Uterus




43/50


International

Replacement of Inverted Uterus




44/50


International

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




45/50


International

Management - Bleeding with firm uterus

explore the lower genital tract

requirements - appropriate analgesia

- good exposure and lighting

appropriate surgical repair

- may temporize with packing




46/50


International

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




47/50


International

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




48/50


International

Conclusions

be prepared

practice prevention

assess the loss

assess maternal status

resuscitate vigorously and

appropriately

diagnose the cause treat the cause


ntepartum HemorrhagePostpartum Hemorrhage


49/50

International

Management - Evolution

Panic

PanicHysterectomy

Pitocin

Prostaglandins

Happiness

p g

ntepartum HemorrhagePostpartum Hemorrhage


50/50

International

Keep your bloody fingers offthe cervix!

Documents

10 Obstetric Haemorage