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Obstetrical Hemorrhage International Obstetrical Hemorrhage Obstetrical Hemorrhage International Obstetrical Hemorrhage

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

Obstetrical Hemorrhage International A 25 year- old G 3 woman presents to the maternity Obstetrical Hemorrhage International A 25 year- old G 3 woman presents to the maternity unit with vaginal bleeding. Fetal heart rate is 140/mnt and her BP is 110/60 mm. Hg and her HR 85/mnt. Fundal height is 28 cm. She has been given nothing. What are the possible diagnosis ? -------------------------------How would you distinguish between the diagnosis ? -----------------------

Obstetrical Hemorrhage International Obstetrical Hemorrhage International

Obstetrical Hemorrhage International Antepartum Hemorrhage Obstetrical Hemorrhage International Antepartum Hemorrhage

Obstetrical Hemorrhage International Objectives • Definitions and Incidence • Etiology and Risk Factors • Obstetrical Hemorrhage 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

Obstetrical Hemorrhage International Definition • vaginal bleeding between 20 weeks and delivery Incidence • Obstetrical Hemorrhage 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% - ½% of pregnancies - lower genital tract lesion 5% - other

Obstetrical Hemorrhage International Etiology of APH • Cervical – contact bleeding (e. g. intercourse, Obstetrical Hemorrhage International 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

Obstetrical Hemorrhage International Diagnostic Procedures • History and physical - No digital pelvic exam Obstetrical Hemorrhage International 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

Obstetrical Hemorrhage International Laboratory • CBC, blood type, Rh, Coombs • coagulation status – Obstetrical Hemorrhage International Laboratory • CBC, blood type, Rh, Coombs • coagulation status – INR, PTT, fibrinogen • 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

Obstetrical Hemorrhage International Vaginal Bleeding Risk Factors Tests (No vaginal exam) Fetal / Maternal Obstetrical Hemorrhage International Vaginal Bleeding Risk Factors Tests (No vaginal exam) Fetal / Maternal Assessment Mother or fetus unstable Hemodynamic Resuscitation Mother or fetus unstable Delivery Mother and fetus stable Labs / Fetal Monitoring U/S ± vaginal exam Expectant consider ongoing loss, etiology, gestation

Obstetrical Hemorrhage International Management - ABC ’s • talk to and observe mother and Obstetrical Hemorrhage 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!

Obstetrical Hemorrhage International Hemodynamic Resuscitation • early aggressive resuscitation to protect fetus and maternal Obstetrical Hemorrhage 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

Obstetrical Hemorrhage International Fetal Considerations • lateral position increases cardiac output up to 30% Obstetrical Hemorrhage 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 evidence of fetal insult, abruptio, fetal maternal transfusion

Obstetrical Hemorrhage International Abruptio Placenta - Definition • premature separation of normally implanted placenta Obstetrical Hemorrhage 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

Obstetrical Hemorrhage International Risk Factors for Abruption • • • hypertension: gestational and pre-existing Obstetrical Hemorrhage 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

Obstetrical Hemorrhage International Clinical Presentation of Abruption • vaginal bleeding usually painful, unremitting • Obstetrical Hemorrhage International 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

Obstetrical Hemorrhage International ABRUPTION Live Fetus Dead Fetus ± coagulopathy Delivery (watch for DIC) Obstetrical Hemorrhage International ABRUPTION Live Fetus Dead Fetus ± coagulopathy Delivery (watch for DIC) Assess Maturity Vaginal delivery or C/S Immaturity Steroids plus expectancy Transfusion? Transfer?

Obstetrical Hemorrhage International Placenta Previa - Definition • placenta covers or lies near the Obstetrical Hemorrhage 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

Obstetrical Hemorrhage International Risk Factors for Previa • previous placenta previa • previous caesarian Obstetrical Hemorrhage 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

Obstetrical Hemorrhage International Clinical Presentation of Previa • vaginal bleeding usually painless (unless in Obstetrical Hemorrhage 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 !

Obstetrical Hemorrhage International PREVIA Assess maturity Maturity Immaturity Delivery by C/S (consider accreta) May Obstetrical Hemorrhage International PREVIA Assess maturity Maturity Immaturity Delivery by C/S (consider accreta) May try vaginal if marginal Steroids plus expectancy Transfusion? Transfer?

Obstetrical Hemorrhage International Vasa Previa - Definition • blood vessels in the membranes run Obstetrical Hemorrhage International 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%

Obstetrical Hemorrhage International Conclusions • • • assess maternal status and stability assess fetal Obstetrical Hemorrhage 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

Obstetrical Hemorrhage International Postpartum Hemorrhage Obstetrical Hemorrhage International Postpartum Hemorrhage

Obstetrical Hemorrhage International You have just delivered a 37 week twin pregnancy per vagina. Obstetrical Hemorrhage International You have just delivered a 37 week twin pregnancy per vagina. The third stage is complicated by post partum hemorrhage unresponsive to uterine message and the use of oxytocin. What would your next management steps be ----------------- ?

Obstetrical Hemorrhage International Objectives • Definition • Etiology • Risk Factors • Prevention • Obstetrical Hemorrhage International Objectives • Definition • Etiology • Risk Factors • Prevention • Management

Obstetrical Hemorrhage International Traditional Definition • blood loss of > 500 m. L following Obstetrical Hemorrhage International Traditional Definition • blood loss of > 500 m. L following vaginal delivery • blood loss of > 1000 m. L following cesarean delivery Functional Definition • any blood loss that has the potential to produce or produces hemodynamic instability Incidence • about 5% of all deliveries

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

Obstetrical Hemorrhage International Risk Factors for PPH - Antepartum • previous PPH or manual Obstetrical Hemorrhage 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)

Obstetrical Hemorrhage International • • Risk Factors for PPH - Intrapartum Operative delivery - Obstetrical Hemorrhage 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 twin • Acquired coagulopathy (e. G. Hellp, dic)

Obstetrical Hemorrhage International Risk Factors for PPH - Postpartum • Lacerations or episiotomy • Obstetrical Hemorrhage International Risk Factors for PPH - Postpartum • Lacerations or episiotomy • Retained placenta/placental abnormalities • Uterine rupture • Uterine inversion • Acquired coagulopathy (e. G. Dic)

Obstetrical Hemorrhage International Prevention • be prepared • active management of the third stage Obstetrical Hemorrhage 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

Obstetrical Hemorrhage International Active v. s Expectant Third Stage Management Cochrane Library Issue 1, Obstetrical Hemorrhage International Active v. s Expectant Third Stage Management Cochrane Library Issue 1, 2000

Obstetrical Hemorrhage International Postpartum Hemorrhage Diagnosis - Is this a PPH? • consider risk Obstetrical Hemorrhage International Postpartum 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

Obstetrical Hemorrhage International Diagnosis - What is the cause? • Assess the fundus • Obstetrical Hemorrhage 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

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

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

Obstetrical Hemorrhage International Postpartum Hemorrhage Management - Assess the fundus • simultaneous with ABC Obstetrical Hemorrhage International Postpartum 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

Obstetrical Hemorrhage International Postpartum Hemorrhage Management - Bimanual Massage Obstetrical Hemorrhage International Postpartum Hemorrhage Management - Bimanual Massage

Obstetrical Hemorrhage International Postpartum Hemorrhage Management - Oxytocin • 5 units IV bolus • Obstetrical Hemorrhage International Postpartum Hemorrhage Management - Oxytocin • 5 units IV bolus • 20 units per L N/S IV wide open • 10 units directly into the uterus if no I. V access

Obstetrical Hemorrhage International Management - Manual Exploration • if no response to bimanual massage Obstetrical Hemorrhage 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

Obstetrical Hemorrhage International Replacement of Inverted Uterus Obstetrical Hemorrhage International Replacement of Inverted Uterus

Obstetrical Hemorrhage International Replacement of Inverted Uterus Obstetrical Hemorrhage International Replacement of Inverted Uterus

Obstetrical Hemorrhage International Management - Additional Uterotonics • ergotamine - caution in hypertension - Obstetrical Hemorrhage International Management - Additional Uterotonics • ergotamine - caution in hypertension - 0, 2 mg IM / IV, interval 15’ - maximum dose 1 mg • Hemabate (carboprost) - asthma is relative contraindication - 15 methyl-prostaglandin F 2 - 0, 25 mg IM or intramyometrial - Maximum dose 2 mg • Cytotec (misoprostol) - caution in asthma - 400 µg pr or po

Obstetrical Hemorrhage International Management - Bleeding with firm uterus • explore the lower genital Obstetrical Hemorrhage 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

Obstetrical Hemorrhage International Postpartum Hemorrhage Management - Continued uterine bleeding • possible coagulopathy - Obstetrical Hemorrhage International Postpartum 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

Obstetrical Hemorrhage International Management - ABC ’s ENSURE that you are always ahead with Obstetrical Hemorrhage 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

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

Obstetrical Hemorrhage International Postpartum Hemorrhage Management - Evolution Panic Hysterectomy Pitocin Prostaglandins Happiness Obstetrical Hemorrhage International Postpartum Hemorrhage Management - Evolution Panic Hysterectomy Pitocin Prostaglandins Happiness

Obstetrical Hemorrhage International Obstetrical Hemorrhage International

Obstetrical Hemorrhage International Kleihauer-Betke Indications • Measures fetal cells in maternal circulation • Used Obstetrical Hemorrhage 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 Hb. F 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

Obstetrical Hemorrhage International Interpretation • Calculate Maternal Blood Volume (ml) = (Pre-pregnant weight in Obstetrical Hemorrhage International 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 test • Calculate Fetal Whole Blood (ml) = (Fetal Cell Count/Maternal Cell Count) x Maternal Blood Volume • Rh Immune Globulin (Rho. GAM) Dose Give 300 μg per 30 m. L fetal whole blood or 15 m. L PRBC

Obstetrical Hemorrhage International B-Lynch methode Obstetrical Hemorrhage International B-Lynch methode

Obstetrical Hemorrhage International Obstetrical Hemorrhage International

Obstetrical Hemorrhage International Medical Anti Schock Trouser & Penekan Infus Obstetrical Hemorrhage International Medical Anti Schock Trouser & Penekan Infus

Obstetrical Hemorrhage International Postpartum Hemorrhage Keep your bloody fingers off the cervix! Obstetrical Hemorrhage International Postpartum Hemorrhage Keep your bloody fingers off the cervix!