OBSTETRIC HEMORRHAGES

Prepared by N. BahniyPrepared by N. Bahniy

The main causes of hemorrhages in the first half of pregnancy

Spontaneous abortionEctopic pregnancyHytadidiform Mole

Abortion is the termination of a pregnancy before viability, typically defined as 22 weeks from the first day of the last normal menstrual period or a fetus weighing less than 500 g and its height is less than 28 cm.

Classification of abortions

Spontaneous Induced

According to clinical duration spontaneous abortion is divided:

Threatened Initial Inevitable Completed Incomplete Missed

Causes of spontaneous abortions

1. Maternal Infections – Listeria, Mycoplasma hominis, Ureaplasma

urealyticum, Toxoplasmosis,Rubella, Cytomegalovirus. Endocrine factors - luteal phase inadequacy,

HyperthyroidismDiabetes Mellitus Environmental factors Uterine abnormalities 2. Paternal - chromosomal abnormality in either parent.

3. Fetal - genetic abnormalities of the conceptus, approximately half of which are autosomal trisomies.

DIAGNOSIS AND TREATMENT OF DIFFERENT TYPES OF ABORTIONS

Threatened abortion

Signs – lover abdominal pain.

In bimanual examination – cervix is closed, enlargement of the uterus corresponds with gestational period

Management – conservative.

Initial abortion

Signs – lover abdominal pain, bloody vaginal discharge.

In bimanual examination – cervix is closed, enlargement of the uterus corresponds with gestational period

Management – conservative.

Inevitable abortion

Signs – cramp abdominal pain thanks to uterine contractions, bloody vaginal discharge till profuse hemorrhage.

In bimanual examination – cervix is dilated, products of conception are presented on cervical channel, enlargement of the uterus doesn’t correspond with gestational period – smaller

Management –surgical – uterine curettage.

Complete abortion – all products of conception are expelled out of uterus

Signs - lover abdominal pain, bloody vaginal discharge.

In bimanual examination – cervix is dilated or closed, enlargement of the uterus doesn’t correspond with gestational period – smaller.

Management –surgical – uterine curettage

Incomplete abortion – retention of some conceptus inside the uterus

Signs – lover abdominal pain, bloody vaginal discharge.

In bimanual examination – cervix is dilated, enlargement of the uterus doesn’t correspond with gestational period – smaller, some products of conception should be expelled out.

Management –surgical – uterine curettage

Missed AbortionIs the retention of a failed intrauterine

pregnancy for an extended period.These patients present with an absence of

uterine growth and may have lost some of the early symptoms of pregnancy, presented of dark bloody discharge

Although unusual, disseminated intravascular coagulopathy (DIG) can occur.

Management –surgical – uterine curettage

Importance of uterine curettage

Necessary to remove the products of conception and prevent further bleeding and infection.

Conservative treatment in the case of threatened and initial abortion

Bed rest Sedative drugs – Valeriannae,

Persen,Novopaside. Spasmolitics – No-Spani, Papaverini hydrochloride Analgetics – Analgin, Baralgin Progesterone – Utrogestan, Duphastone,

Progesterone Chorionic Gonadotropin Hormone Vitamines – vit. E

Stages of uterine curettageAnesthesia - paracervical block or general. Bimanual examination Disinfection of perineal region Speculum insertion Grasping the cervix for anterior lip with a toothed

tenaculum. Uterine probing- to identify the status of the

internal os and to confirm uterine size and position.

Dilation of the cervix by Hehar’s dilators Uterine curettage by sharp curette

Induced Abortion:

Elective (Voluntary) - is the interruption of pregnancy before 12 weeks of pregnancy (before viability) at the request of the woman but not for reasons of impaired maternal health or fetal disease.

Therapeutic - termination of pregnancy before 22 weeks of pregnancy ( before viability) for the purpose of safeguarding the health of the mother.

ECTOPIC PREGNANCY

Implantation outside of the uterine cavity is termed as ectopic pregnancy

! Ectopic pregnancy is the leading cause of maternal mortality in the first trimester

Etiology of ectopic pregnancy

1.Mechanical Factors - prevent or retard passage of the fertilized ovum into the uterine cavity include the following.

1. Salpingitis, 2. Peritubal adhesions subsequent to postabortal or puerperal infection 3. Developmental abnormalities of the tube, especially diverticula,

hypoplasia. 4. Previous ectopic pregnancy. 5. Previous operations on the tube, either to restore patency 6. Multiple previous induced abortions. 7. Tumors that distort the tube, such as uterine myomas, adnexal masses.2.Functional Factors - that delay passage of the fertilized ovum into the

uterine cavity. 1. External migration of the ovum 2. Menstrual reflux 3. Altered tubal motility 4. Cigarette smoking at the time of conception 3.Increased Receptivity of Tubal Mucosa to Fertilized Ovum. 4.Assisted Reproduction. 5.Failed Contraception.

Classification of ectopic pregnancy

According to localization: Tubal – isthmic, interstitial,ampullary Ovarian Abdominal Broad-Ligament pregnancy CervicalAccording to clinical duration: Progressive Ruptured - Tubal rupture, Tubal abortion

Clinical signs of Ectopic Pregnancy Presence of Presumptive (nausea, vomiting) and

Probable (amenorrhea) signs of pregnancy Irregular vaginal bleeding results from the

sloughing of the decidua from the endometrial lining. It is scanty, dark brown, and may be intermittent or continuous.

Pain – from light to severe Syncope Dizziness Urge to defecate Signs of internal hemorrhage - peritoneal

irritation, shock

Pelvic examination in ectopic pregnancy

Unilateral or bilateral exquisite tenderness especially on motion of the cervix

Adnexal massEnlarged uterus Tenderness and painful of the posterior

fornix

Signs of internal hemorrhages which provoke hypovolemic shock are the more prominent the more closely fertilized ovum localized near the uterus

Diagnostic procedures

Complete blood count Positive urinary test fir estimation of

chorionic gonadotropin (hCG) levels UltrasonographyCuldocentesisCurettage of the uterine cavity can also

rule out ectopic pregnancy

Culdocentesis – is the simplest technique for identifying hemoperitoneum

Bloody fluid that

does not clot result

of hemoperitoneum resulting from an ectopic pregnancy

Management of ectopic pregnancySurgical: linear salpingostomy segmentai resection Salpingectomy

Medical - Methotrexate, folinic acid antagonist: if the gestation is less than 6 weeks, the tubal mass is not more than 3.5 cm in diameter, and the fetus is not alive

Signs of cervical pregnancy uterine bleeding without

cramping after a period of amenorrhea

softened cervix disproportionally enlarged to a size equal to or larger than the corpus

complete confinement and firm attachment of the products of conception to the endocervix, snug internal cervical os.

MANAGEMENT CERVICAL PREGNANCY

HYSTERECTOMY EMBOLIZATION

of A. UTERINAE

Hydatidiform Mole

Is an abnormal conceptus with loss of villus vascularity and without an embryo or fetus.

Most of symptoms are presented thanks to markedly elevated hCG levels.

Signs of Hydatidiform Mole

Vaginal bleeding with molar elementsPreeclampsia In pelvic exam - uterus larger than

expected, Ovarian enlargement due to bilateral theca lutein cysts

Ultrasonography – “snow-storm” appearance

Treatment of Hydatidiform Mole

Vacuum aspirationDigital removal Curettage by sharp curette

The main causes of bleeding in the second half of pregnancy VulvaVaricose veinsTears or lacerations VaginaTears or lacerations CervixPolypGlandular tissue (normal)CervicitisCarcinoma Intrauterine Placenta previa Abruptio placentae Vasa previa

PLACENTA PREVIA

Definition: abnormal location of the placenta over, or in close proximity to, the internal cervical os.

Placenta previa can be categorized as: complete or total - if the entire cervical os is covered; partial - if the margin of the placenta extends across

part but not all of the internal os; marginal , if the edge of the placenta lies adjacent to the

internal os; low lying - if the placenta is located near but not directly

adjacent to the internal os till 6 cm.

PLACENTA PREVIA

Etiology of placenta previa is not understood, but abnormal vascularization has long been proposed.

Patients at risk:Increasing maternal ageIncreasing parityPrevious cesarean

Clinical findings and Diagnosis

Painless bleeding The bleeding is caused by separation of part of the

placenta from the lower uterine segment and cervix, possibly in response to mild uterine contractions. The patient often describes a sudden onset of bleeding without any apparent antecedent signs.

Ultrasonography has been of enormous benefit in localizing the placenta.

Careful vaginal examination – in labor.

Management of patients with placenta previa during pregnancy

Initial hospitalization with hemodynamic stabilization, followed by expectant management until fetal maturity has occurred.

Bed rest Vitamins – for increasing of vascular strenght:

Rutin, Ascorutin, Ca Bloodstoping agents – Vicasol, Dicinon,

Tranexam Smasmolytics in the case of pregnancy

interruption

Management of patients with placenta previa in labor

Complete – cesarean section;

Partial, marginal, low lying - artificial rupture of the membranes and oxytocin induction of labor.

If the hemorrhage exceeds 250-300ml – immediate cesarean section

PLACENTAL ABRUPTION - premature separation of the normally implanted placenta from the uterine wall.

Etiology: when there is hemorrhage into the decidua basalis, leading to premature placental separation and further bleeding. The cause for this bleeding is not known.

Patients at risk: Maternal hypertension Multiply pregnancy Polyhidramnios External trauma Preterm prematurely ruptured membranes Cigarette smoking Cocaine abuse Uterine leiomyoma,

Clinical findings and Diagnosis

External bleeding can be profuse or there may be no external bleeding (concealed hemorrhage)

Uterine tenderness Back pain Fetal distress Uterine hypertonus or high-frequently contractions Idiopathic preterm labor Dead fetus when placenta is totally shared. Coagulation disorders Ultrasonography can help in diagnosis

Management of Placental Abruption

When the fetus is mature - hemodynamic stabilization and delivery by cesarean section. In the second stage of labor – immediate delivery by forceps application, vacuum, total breech extraction.

When the fetus is immature and blood loss is < 250 ml – very close observation, coupled with facilities for immediate intervention, can be practiced.

Couvelaire uterus – Uteroplacental Apoplexy

Differential characteristics between placenta previa and abruptio placentaeCharacteristics Placenta previa Abruptio PlacentaMagnitude of blood loss Variable Variable

Duration Often ceases within 1-2 hours

Usually continues

Abdominal discomfort None Can be severe, pain

Fetal heart rate patternon electronic monitoring

Absent Tachycardia, then bradycardia; loss ofvariability; decelerations frequentlypresent; intrauterine demise not rare

Coagulation defects Rare Associated, but infrequent; DIG oftensevere when present Cocaine use

Associated history None Abdominal trauma;maternal hypertension;multiple gestation; polyhydramnios

VASA PREVIA In vasa previa, the umbilical cord inserts into the

membranes of the placenta and one such vessel lies below the presenting fetal part in the vicinity of the internal os.

If this vessel ruptures, fetal bleeding occurs. Because of the low blood volume of the fetus, seemingly insignificant amounts of blood may place the fetus in jeopardy.

A small amount of vaginal bleeding associated with fetal tachycardia may be the clinical presentation.

A test to distinguish fetal blood from maternal blood, such as the Kleihauer-Betke or the Apt test on the basis of the marked resistance to pH changes in fetal red cells compared with the friable nature of adult red cells in the presence of strong bases.

Immediate cesarean section is the only way to save the fetus in vasa previa.

HEMORRHAGE IN THE THIRD STAGE OF LABOR AND EARLY PUERPERAL PERIOD

Postpartum hemorrhage is defined as blood loss in excess of physiologic blood loss at the time of vaginal delivery – 0,5% from body weight.

Postpartum hemorrhage before delivery of the placenta is called third-stage hemorrhage.

Postpartum hemorrhage after delivery of placenta during the first two hours is called as hemorrhage in early puerperal stage.

Mechanisms of Hemorrhage stopping after placental

separation

uterine contractions – calibers of ruptured vessels decreases during uterine contractions;

formation of thrombs, especially in the region of placental site;

torsion of thin septs in which vessels are situated.

Causes of Postpartum Hemorrhage

uterine atonygenital tract trauma bleeding from the placental site (retained

placental tissue, low placental implantation, placental adherence, uterine inversion)

coagulation disorders

Predisposing factors for uterine atony

1. Overdistended uterus – multiple fetuses, Hydramnios, distention with clots.

2. Anesthesia or analgesia – halogenated agents, conducted analgesia with hypertension.

3. Exhausted myometrium – rapid labor, prolonged labor, oxytocin or prostaglandin stimulation.

4. Chorionamnionitis.4. Previous uterine atony.

Uterine atony - total absence of uterine contractions into the external irritation.

Uterine hypotony - inadequate uterine contractions on the external irritation. In the pauses between uterine contractions a uterus is soft.

But blood form clots in the case of uterine hypo- or atony. These clots are stored in the uterine cavity that’s why a uterus is enlarged in sizes.

CONTRICTILE DRUGS  

  OxytocinErgometrine/ Methyl-ergometrine

15-methyl Prostaglandin F2α

Dose and route IV: Infuse 20 units in 1 L IV fluids at 60 drops per minute  IM: 10 units

IM or IV (slowly): 0.2 mg

IM: 0.25 mg

Continuing dose  IV: Infuse 20 units in 1 L IV fluids at 40 drops per minute

Repeat 0.2 mg IM after 15 minutes If required, give 0.2 mg IM or IV (slowly) every 4 hours 

0.25 mg every 15 minutes

Maximum dose Not more than 3 L of IV fluids containing oxytocin

5 doses (Total 1.0 mg)

8 doses (Total 2 mg)

Precautions/Contrain-dications

Do not give as an IV bolus

Pre-eclampsia, hypertension, heart disease

Asthma

PABAL – I/V BOLUS

ОXYTOCIN ANALOG 1мл – 100 мкг

карбетоцину Діє через 3 хв 1 ін’єкція на 6 годин

MISOPROSTOL

Acts in 30min and last 4-6 hours

FIGO – 1000мкг

Hemorrhages prevention !!!!

Tranexamic acid

Antifibrinilytic

50 mg/ml

15-20 mg/kg

REMESTIP - VASOKONSTRICTOR

0,2 -1, 0 MG every 4-6 hours i/v bolus Effect - 5-10 min

Ligation of uterine arteries, ovarian arteries, a. iliaca interna

Hysterectomy

Antishock garment

Predisposing factors for Genital tract trauma

1. Complicated vaginal delivery.2. Cesarean section or hysterectomy, forceps or

vacuum.3. Uterine rupture; risk increased by: previously

scarred uterus, high parity, hyperstimulation, obstructed labor, intrauterine manipulation.

4. Large episiotomy, including extensions.5. Lacerations of the perineum, vagina or cervix.

Diagnosis and management of

Genital Tract Trauma

Diagnosis – speculum inspectionManagement - ligation and suturing of all

ruptures of the vagina, cervix and perineum. In the case of uterine rupture – hysterectomy should be performed

Bleeding from placental implantation cite

1. Retained placental tissue – avulsed cotyledon, succentuariate lobe

2. Abnormally adherent – accreta, increta, percreta.

Abnormal placenta adherent

any implantation of the placenta in which there is abnormally firm adherence to the uterine wall thanks to partial or total absence of the decidua basalis and imperfect development of the fibrinoid layer (Nitabush’s membrane):

the placental villi are attached into the basal layer - placenta adhaerens;

the placental villi are attached to the myometrium - placenta accreta;

extensive growth of placental tissue into the uterine muscle itself – placenta increta;

complete invasion through the sickness of the uterine muscle to the serosa or beyond – placenta percreta.

Classification of abnormal placental adherence

Complete or total placenta accreta will not cause bleeding because the placenta remains attached

Partial ( the abnormal adherence involves a few to several cotyledons)

Focal (the abnormal adherence involves a single cotyledon) type may cause profuse bleeding, as the normal part of the placenta separates and the myometrium cannot contract sufficiently to occlude the placental site vessels.

Clinical findings, Diagnosis, Management

1. Absence of the signs of placental separation during 30 minutes.

2. External bleeding – in the case of partial adherence, absence of the bleeding – in the case of total placenta accreta.

In the case of placental adherence bleeding stop, but in the case of placenta accreta, increta and percrata increase.

That’s why in these cases manual removal of the placenta should be stopped immediately and hysterectomy should be performed

Predisposing factors for Coagulation defects

1. Placental abruption.2. Prolonged retention of dead fetus.3. Amnionic fluid embolism.4. Saline-induced abortion.5. Sepsis with endotoxemia.6. Severe intravescular hemolysis.7. Massive transfusions.8. Severe preeclampsia or eclampsia.9. Congenital coagulopathies

DIC - syndrome

Prothrombin complex concentrate

Recombinant VII clotting factorRecombinant VII clotting factor

80-90 80-90 mgmg//kgkg Fresh frozen plasma

Proteolytic enzymes inhibitors – KONTRYCAL, GORDOX