Bleeding in Pregnancy: Bleeding in Pregnancy: Antepartum & Postpartum Antepartum & Postpartum

HemorrhageHemorrhage

OB & GY Dept. First Hospital, Xi’An Jiao Tong University

Learning ObjectivesLearning Objectives

Definition of Post Partum HemorrhageDefinition of Post Partum Hemorrhage

Management of PPHManagement of PPH

Risk Factors for PPHRisk Factors for PPH

Differential Diagnosis of Third Trimester Differential Diagnosis of Third Trimester BleedingBleeding

Management of Placenta Previa and Abruptio Management of Placenta Previa and Abruptio Placenta Placenta

““Worst Case Scenario”Worst Case Scenario”

An insulin dependent diabetic was induced for An insulin dependent diabetic was induced for suspect fetal macrosomia and delivered a 4300 suspect fetal macrosomia and delivered a 4300 gram male infant because of late decelerations. gram male infant because of late decelerations. A low forceps delivery was done. An episiotomy A low forceps delivery was done. An episiotomy was done. Thee was a Shoulder Dystocia. was done. Thee was a Shoulder Dystocia. Immediately after delivery of the placenta the Immediately after delivery of the placenta the patient bled uncontrollably and the patient bled uncontrollably and the anesthesiologist yelled, “The patient is in anesthesiologist yelled, “The patient is in shock.” There is a 4shock.” There is a 4thth degree perineal laceration degree perineal laceration and the uterus is “boggy” and there is a left side and the uterus is “boggy” and there is a left side wall laceration as well. wall laceration as well.

Definitions of Postpartum HemorrhageDefinitions of Postpartum Hemorrhage

1. Estimated blood loss

a. > 500 mL with vaginal birth

b. > 1000 mL with cesarean delivery

c. > 1500 mL with cesarean hysterectomy

Decline from antepartum to postpartum hematocrit of > 10%

2. Postpartum hematocrit < 27%

3. Transfusion of red blood cells

Risk Factors of Postpartum Hemorrhage: Risk Factors of Postpartum Hemorrhage: Results of Logistic RegressionResults of Logistic Regression

Vaginal BirthVaginal Birth

(N=9.598)(N=9.598)

Cesarean DeliveriesCesarean Deliveries

(N=3.052)(N=3.052)

Anesthesia (general vs. epidural)Anesthesia (general vs. epidural) ---- 2.942.94

AmnionitisAmnionitis NSNS 2.692.69

Episiotomy (mediolateral vs. none/midline)Episiotomy (mediolateral vs. none/midline) 4.674.67 ----

Labor abnormalitiesLabor abnormalities

Protracted active phaseProtracted active phase

Arrest of descent (present vs. absent)Arrest of descent (present vs. absent)

----

2.912.91

2.402.40

1.901.90

Lacerations (cervical/vaginal/perineal vs. none)Lacerations (cervical/vaginal/perineal vs. none) 2.052.05 NSNS

Multiple gestations (twins vs. singletons)Multiple gestations (twins vs. singletons) 3.313.31 NSNS

Preeclampsia (present vs. absent)Preeclampsia (present vs. absent) 5.025.02 2.182.18

Prior postpartum hemorrhage (present vs. absent)Prior postpartum hemorrhage (present vs. absent) 3.553.55 NSNS

Third stage (>30 minutes vs. <30 minutes)Third stage (>30 minutes vs. <30 minutes) 7.567.56 ----

Postpartum HemorrhagePostpartum Hemorrhage

An event, not a diagnosis.An event, not a diagnosis.

Excessive blood lossExcessive blood loss

AtonyAtony

Abnormal Implantation SiteAbnormal Implantation Site– Placenta AccretaPlacenta Accreta– Uterine InversionUterine Inversion

Genital Tract InjuryGenital Tract Injury– Cervical or Vaginal LacerationsCervical or Vaginal Lacerations– Pelvic HematomaPelvic Hematoma

Postpartum HemorrhagePostpartum HemorrhageVaginal BirthVaginal Birth

Antepartum - postpartum Antepartum - postpartum >> 10% (Hct) 10% (Hct)Risk FactorsRisk Factors

Prolonged 3Prolonged 3rdrd stage of labor stage of labor

Preeclampsia Preeclampsia

Mediolateral episiotomy Mediolateral episiotomy

Combs CA et al, obstet Gnecol. 1991:77:63Combs CA et al, obstet Gnecol. 1991:77:63

Postpartum HemorrhagePostpartum HemorrhageC/SC/S

Risk FactorsRisk Factors

General anesthesiaGeneral anesthesia

AmnionitisAmnionitis

PreeclampsiaPreeclampsia

Combs CA et al, obstet Gynecol 1991:77;77Combs CA et al, obstet Gynecol 1991:77;77

Postpartum HemorrhagePostpartum HemorrhageVaginal BirthVaginal Birth

Postpartum Hct <27% or Blood Postpartum Hct <27% or Blood TransfusionTransfusion

Risk FactorsRisk FactorsEstimated blood loss Estimated blood loss >> 500 ml 500 mlMarginal previaMarginal previaPlacental abruptionPlacental abruptionThird stage of labor Third stage of labor >> 30 minutes 30 minutesChorioamnionitis Chorioamnionitis

Nicol B et al obstet Gynecol 1997;90:514Nicol B et al obstet Gynecol 1997;90:514

Postpartum HemorrhagePostpartum HemorrhageAntepartum - Postpartum Antepartum - Postpartum >> 10% (Hct) 10% (Hct)

Risk FactorsRisk Factors

PreeclampsiaPreeclampsia

Disorders of active phase of laborDisorders of active phase of labor

Native American ethnicityNative American ethnicity

Previous PPHPrevious PPH

Maternal weight Maternal weight >> 250 lbs 250 lbs

Postpartum HemorrhagePostpartum Hemorrhage

Knowing the risk factors associated with Knowing the risk factors associated with postpartum hemorrhage means the postpartum hemorrhage means the obstetricians can effectively manage at-risk obstetricians can effectively manage at-risk patients.patients.

One can ancticipate those patients where there One can ancticipate those patients where there is a greater likelihood of a postpartum is a greater likelihood of a postpartum hemorrhagehemorrhage

Postpartum HemorrhagePostpartum Hemorrhage

Medical ManagementMedical ManagementAtony - Bimanual compression Atony - Bimanual compression

- 15 methyl PGF 2- 15 methyl PGF 2: 0.25 mg 15’: 0.25 mg 15’ IM or intra-myometriumIM or intra-myometrium - Methylergonovine : 0.2 mg 1M- Methylergonovine : 0.2 mg 1M

No IV => severe hypertensionNo IV => severe hypertension - Misoprostol (100 mg) rectally - Misoprostol (100 mg) rectally

Postpartum HemorrhagePostpartum Hemorrhage

PreventionPrevention

Vaginal deliveriesVaginal deliveries

Active Management of 3Active Management of 3rdrd stage of labor stage of labor

Uterotonic agentsUterotonic agents

Cesarean deliveriesCesarean deliveries

Spontaneous delivery placentaSpontaneous delivery placenta

Repair uterine incision in situRepair uterine incision in situ

Management of Postpartum HemorrhageManagement of Postpartum Hemorrhage

Surgical Options

Prostaglandin or M ethergineor Both

Bimanual Compression

Atony

M anualExplorationor Curettage

Ultrasound

Retained

SurgicalOptions

AbnormalImplantation

Placenta

SurgicalRepair

Laceration or Rupture

Vital Signs/HelpI.V. / Oxygen

Foley CatheterFlow Sheet

Postpartum Hemorrhage

Postpartum HemorrhagePostpartum Hemorrhage

Surgical ManagementSurgical ManagementUterine artery ligationUterine artery ligationHypogastic artery ligationHypogastic artery ligationOvarian vesselsOvarian vesselsB-Lynch techniqueB-Lynch techniqueSelective arterial embolizationSelective arterial embolizationHysterectomyHysterectomy

FigureFigure

HematomaHematoma

Pelvic HematomaPelvic Hematoma

VulvarVulvar

VaginalVaginal

RetroperitonealRetroperitoneal

Risk FactorsRisk Factors

EpisiotomyEpisiotomy

PrimiparityPrimiparity

PreeclampsiaPreeclampsia

Multiple gestationMultiple gestation

Vulvovaginal varicosities Vulvovaginal varicosities

Prolonged 2Prolonged 2ndnd stage of labor stage of labor

Clotting abnormalitiesClotting abnormalities

HematomaHematoma

Vulvar hematomaVulvar hematoma

Laceration of vessels in the superficial fascia Laceration of vessels in the superficial fascia of pelvic triangleof pelvic triangle

Volume supportVolume support

< 3 cm: observation< 3 cm: observation

>> 3 cm: surgical evacuation with suture 3 cm: surgical evacuation with suture closure and dressing compressionclosure and dressing compression

HematomaHematoma

– Vaginal hematomaVaginal hematoma

–Accumulation of blood above the pelvic Accumulation of blood above the pelvic diaphragmdiaphragm

–More associated with forceps deliveriesMore associated with forceps deliveries

–Incision and evacuationIncision and evacuation

–Vaginal packing for 12 – 18 hoursVaginal packing for 12 – 18 hours

HematomaHematoma

Retroperitoneal hematomasRetroperitoneal hematomas

Sudden onset of hypotensive shockSudden onset of hypotensive shock

Laceration of a branch of hypogastric arteryLaceration of a branch of hypogastric artery

Inadequate hemostasis of the uterine arteries (C/S)Inadequate hemostasis of the uterine arteries (C/S)

Rupture of low transverse scarRupture of low transverse scar

Surgical exploration and ligation of the Surgical exploration and ligation of the hypogastric vesselhypogastric vessel

Potential Complications of Potential Complications of Puerperal HematomasPuerperal Hematomas

• Transfusion• Coagulation Defects• Anemia• Fever• Reformation• Deep vein thrombosis• Scarring with resultant dyspareunia• Fistula Formation• Prolonged Hospitalization and Recuperation

Placenta Accreta/Increta/PercretaPlacenta Accreta/Increta/Percreta

Accreta: villi attatched to myometrium Accreta: villi attatched to myometrium (85%)(85%)

Increta: villi invading the myometrium Increta: villi invading the myometrium (15%)(15%)

Percreta: villi beneath or through the uterine Percreta: villi beneath or through the uterine serosa (5%)serosa (5%)

Placenta Accreta/Increta/PercretaPlacenta Accreta/Increta/Percreta

Risk factorsRisk factors

Early 30sEarly 30s

Parity (2 or 3 prior births)Parity (2 or 3 prior births)

Prior C/SPrior C/S

H/O of D& CH/O of D& C

Prior manual placental removalPrior manual placental removal

Prior retained placentaPrior retained placenta

InfectionInfection

Postpartum AccretaPostpartum Accreta

Postpartum hemorrhagePostpartum hemorrhage

39 – 64%39 – 64%

2600 ml (without previa)2600 ml (without previa)

4700 ml (with previa)4700 ml (with previa)

Placenta Accreta/Increta/PercretaPlacenta Accreta/Increta/Percreta

Postpartum hemorrhagePostpartum hemorrhage

Conservative ManagementConservative Management

HysterectomyHysterectomy

Placenta Accreta/Percreta/IncretaPlacenta Accreta/Percreta/Increta

Conservative managementConservative management

Leaving the placenta in placeLeaving the placenta in place

Localized resection and repairLocalized resection and repair

Oversewing a defect (esp percreta)Oversewing a defect (esp percreta)

Blunt disection/curretageBlunt disection/curretage

Uterine InversionUterine Inversion

1/2000 1/2000 1/6400 1/6400

Partial delivery of placentaPartial delivery of placenta

Rapid onset of maternal shockRapid onset of maternal shock

DegreeDegree– 1st (Incomplete)1st (Incomplete)

- Corpus does not pass through the cervix- Corpus does not pass through the cervix– 22ndnd (Complete) (Complete)

- Corpus passes through the cervix- Corpus passes through the cervix– 33rdrd (Prolapse) (Prolapse)

- Corpus extends through vaginal introitus- Corpus extends through vaginal introitus

Uterine InversionUterine InversionTreatmentTreatment

– Fluid therapyFluid therapy– Restoration of uterusRestoration of uterus– Pushing the fundus with a fisted hand along the Pushing the fundus with a fisted hand along the

axis of vagina through cervix back into pelvisaxis of vagina through cervix back into pelvis

If failedIf failed- TerbutalineTerbutaline- Mg SO4Mg SO4- General anesthesiaGeneral anesthesia- Laparotomy Laparotomy

Uterine RuptureUterine Rupture

1.1. 0.05% for all pregnancies0.05% for all pregnancies

2.2. 0.8% after a previous low transverse c/s0.8% after a previous low transverse c/s

3.3. 75% in prior classical c/s75% in prior classical c/s

4.4. 25% in prior uterine myomectomy25% in prior uterine myomectomy

Uterine RuptureUterine RuptureRisk FactorsRisk Factors

– Surgical procedures of uterusSurgical procedures of uterus

C/S, myomectomy, perforation, cornual C/S, myomectomy, perforation, cornual resection, hysteroscopic or laparoscopic resection, hysteroscopic or laparoscopic injuries, penetrating abdominal woundsinjuries, penetrating abdominal wounds

• • Grand multiparity Grand multiparity

Obstetric traumaObstetric trauma

Fetal macrosomiaFetal macrosomia

MalpresentationMalpresentation

Breech extractionBreech extraction

Instrumental vaginal deliveriesInstrumental vaginal deliveries

Uterine RuptureUterine Rupture

Symptoms and signsSymptoms and signs

Ripping lower abdominal PainRipping lower abdominal Pain

Referred Shoulder PainReferred Shoulder Pain

Vaginal HemorrhageVaginal Hemorrhage

Fetal BradycardiaFetal Bradycardia

Loss of fetal presentation partLoss of fetal presentation part

Uterine RuptureUterine Rupture

ManagementManagement

HysterectomyHysterectomy

Repair Repair recurrent rupture: 19% recurrent rupture: 19%

Third Trimester Bleeding:Third Trimester Bleeding:Antepartum HemorrhageAntepartum Hemorrhage

Placental AbruptionPlacental Abruption

Placental PreviaPlacental Previa

““Real Life Situation”Real Life Situation”A patient calls you by telephone and tells you A patient calls you by telephone and tells you that she has some vaginal bleeding with some that she has some vaginal bleeding with some crampy lower abdominal pain at 32 weeks crampy lower abdominal pain at 32 weeks gestation. She is hypertensive and has used gestation. She is hypertensive and has used drugs in the past as well. She has had 2 drugs in the past as well. She has had 2 previous CS and was transfused with the last previous CS and was transfused with the last one. She was told that she had a placenta one. She was told that she had a placenta previa earlier in her pregnancy with her previa earlier in her pregnancy with her ultrasound exam at 20 weeks.ultrasound exam at 20 weeks.

Placental AbruptionPlacental Abruption

External hemorrhage

Concealed hemorrhage

Total

Partial

1/200 – 1/1550 deliveries

Perinatal mortality: 25%

Recurrence: 4 – 12.5%

Placental AbruptionPlacental Abruption

Risk Factors RR

•Increased Maternal age and parity N/A

•Preeclampsia 2.1 – 4.0

•Chronic hypertension 1.8 – 3.0

•PROM 2.4 – 3.0

•Smoking 1.4 – 1.9

•Cocaine N/A (13%)

•Prior abruption 10 – 25

Placental AbruptionPlacental Abruption

Symptoms & Signs Frequency (%)

•Vaginal bleeding 78

•Uterine tenderness or back pain 66

•Fetal distress 60

•High frequency of contractions 17

•Hypertonus 17

•Idiopathic preterm labor 22

•IUFD 15

Placental AbruptionPlacental Abruption

DIC

Acute renal failure

Couvelaire uterus

Placental AbruptionPlacental Abruption

Gestational age

Maternal status

Fetal status

Correct maternal hypovolemia, anemia, hypoxia

? Tocolysis

Vaginal vs. C/S

Management

Placenta PreviaPlacenta Previa

Incidence: 0.3- 0.7 %

Definitions:

Total

Partial

Marginal

Low-lying

Tubal Occlusion:

Placental PreviaPlacental Previa

Risk Factors

•Increased maternal age

•Increase parity

•Smoking

•Prior C/S

One: 2X – 3X (0.5-0.75%)

Two: 1.9%

Three: 4.1%

•Diagnosis: U/S (TVU), MRI

Placental PreviaPlacental Previa

GA at U/S (wk) Previa or Bleeding at Delivery

• < 20 2.3%

• 20 – 25 3.2%

• 25 – 30 5.2%

• 30 – 35 24%

Placental PreviaPlacental Previa

? Preterm

? Fetal lung maturity

? Labor

? Severe hemorrhage

Vaginal delivery vs. C/S

Management