Bleeding in Pregnancy: Antepartum & Postpartum Hemorrhage

OB & GY Dept. First Hospital, XiAn Jiao Tong University

Learning Objectives
Definition of Post Partum Hemorrhage Management of PPH Risk Factors for PPH Differential Diagnosis of Third Trimester Bleeding Management of Placenta Previa and Abruptio Placenta

Worst Case Scenario

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

Definitions 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: Results of Logistic Regression

Vaginal Birth (N=9.598) Cesarean Deliveries (N=3.052)

Anesthesia (general vs. epidural) Amnionitis Episiotomy (mediolateral vs. none/midline) Labor abnormalities Protracted active phase Arrest of descent (present vs. absent) Lacerations (cervical/vaginal/perineal vs. none) Multiple gestations (twins vs. singletons) Preeclampsia (present vs. absent) Prior postpartum hemorrhage (present vs. absent) Third stage (>30 minutes vs. <30 minutes)

-NS 4.67

2.94 2.69 --

-2.91 2.05 3.31 5.02 3.55 7.56

2.40 1.90 NS NS 2.18 NS --

Postpartum Hemorrhage
An event, not a diagnosis. Excessive blood loss Atony Abnormal Implantation Site Placenta Accreta Uterine Inversion Genital Tract Injury Cervical or Vaginal Lacerations Pelvic Hematoma

Postpartum Hemorrhage Vaginal Birth Antepartum - postpartum > 10% (Hct)

Risk Factors Prolonged 3rd stage of labor Preeclampsia Mediolateral episiotomy

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

Postpartum Hemorrhage C/S

Risk Factors General anesthesia Amnionitis Preeclampsia

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

Postpartum Hemorrhage Vaginal Birth Postpartum Hct <27% or Blood Transfusion

Risk Factors Estimated blood loss > 500 ml Marginal previa Placental abruption Third stage of labor > 30 minutes Chorioamnionitis

Nicol B et al obstet Gynecol 1997;90:514

Postpartum Hemorrhage Antepartum - Postpartum > 10% (Hct) Risk Factors Preeclampsia Disorders of active phase of labor Native American ethnicity Previous PPH Maternal weight > 250 lbs

Postpartum Hemorrhage
Knowing the risk factors associated with postpartum hemorrhage means the obstetricians can effectively manage at-risk atpatients. One can ancticipate those patients where there is a greater likelihood of a postpartum hemorrhage

Postpartum Hemorrhage
Medical Management Atony - Bimanual compression - 15 methyl PGF 2E: 0.25 mg 15 2E IM or intra-myometrium intra- Methylergonovine : 0.2 mg 1M No IV => severe hypertension - Misoprostol (100 mg) rectally

Postpartum Hemorrhage
Prevention Vaginal deliveries Active Management of 3rd stage of labor Uterotonic agents Cesarean deliveries Spontaneous delivery placenta Repair uterine incision in situ

Management of Postpartum Hemorrhage

Postpartum Hemorrhage Vital Signs/Help I.V. / Oxygen Foley Catheter Flow Sheet Atony Bimanual Compression Retained Placenta Abnormal Implantation Surgical Options Laceration or Rupture Surgical Repair

Prostaglandin or Methergine or Both Surgical Options

Ultrasound

Manual Exploration or Curettage

Postpartum Hemorrhage
Surgical Management Uterine artery ligation Hypogastic artery ligation Ovarian vessels B-Lynch technique Selective arterial embolization Hysterectomy

Figure

Hematoma
Pelvic Hematoma Vulvar Vaginal Retroperitoneal

Risk Factors
Episiotomy Primiparity Preeclampsia Multiple gestation Vulvovaginal varicosities nd stage of labor Prolonged 2 Clotting abnormalities

Hematoma
Vulvar hematoma Laceration of vessels in the superficial fascia of pelvic triangle Volume support < 3 cm: observation > 3 cm: surgical evacuation with suture closure and dressing compression

Hematoma
Vaginal hematoma Accumulation of blood above the pelvic diaphragm More associated with forceps deliveries Incision and evacuation Vaginal packing for 12 18 hours

Hematoma
Retroperitoneal hematomas Sudden onset of hypotensive shock Laceration of a branch of hypogastric artery Inadequate hemostasis of the uterine arteries (C/S) Rupture of low transverse scar Surgical exploration and ligation of the hypogastric vessel

Potential Complications of Puerperal Hematomas

Transfusion

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

Placenta Accreta/Increta/Percreta
Accreta: villi attatched to myometrium (85%) Increta: villi invading the myometrium (15%) Percreta: villi beneath or through the uterine serosa (5%)

Placenta Accreta/Increta/Percreta
Risk factors Early 30s Parity (2 or 3 prior births) Prior C/S H/O of D& C Prior manual placental removal Prior retained placenta Infection

Postpartum Accreta

Postpartum hemorrhage 39 64% 2600 ml (without previa) 4700 ml (with previa)

Placenta Accreta/Increta/Percreta
Postpartum hemorrhage Conservative Management Hysterectomy

Placenta Accreta/Percreta/Increta
Conservative management Leaving the placenta in place Localized resection and repair Oversewing a defect (esp percreta) Blunt disection/curretage

Uterine Inversion
1/2000 b 1/6400 Partial delivery of placenta Rapid onset of maternal shock Degree 1st (Incomplete) - Corpus does not pass through the cervix 2nd (Complete) - Corpus passes through the cervix 3rd (Prolapse) - Corpus extends through vaginal introitus

Uterine Inversion
Treatment Fluid therapy Restoration of uterus Pushing the fundus with a fisted hand along the axis of vagina through cervix back into pelvis If failed - Terbutaline - Mg SO4 - General anesthesia - Laparotomy

Uterine Rupture
1. 0.05% for all pregnancies 2. 0.8% after a previous low transverse c/s 3. 75% in prior classical c/s 4. 25% in prior uterine myomectomy

Uterine Rupture
Risk Factors Surgical procedures of uterus C/S, myomectomy, perforation, cornual resection, hysteroscopic or laparoscopic injuries, penetrating abdominal wounds Grand multiparity Obstetric trauma Fetal macrosomia Malpresentation Breech extraction Instrumental vaginal deliveries

Uterine Rupture
Symptoms and signs Ripping lower abdominal Pain Referred Shoulder Pain Vaginal Hemorrhage Fetal Bradycardia Loss of fetal presentation part

Uterine Rupture
Management Hysterectomy Repair recurrent rupture: 19%

Third Trimester Bleeding: Antepartum Hemorrhage

Placental Abruption Placental Previa

Real Life Situation

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

Placental Abruption
External hemorrhage Concealed hemorrhage Total Partial 1/200 1/1550 deliveries Perinatal mortality: 25% Recurrence: 4 12.5%

Placental Abruption
Risk Factors RR

Increased Maternal age and parity Preeclampsia Chronic hypertension PROM Smoking Cocaine Prior abruption

N/A 2.1 4.0 1.8 3.0 2.4 3.0 1.4 1.9 N/A (13%) 10 25

Placental Abruption
Symptoms & Signs Frequency (%) Vaginal bleeding Uterine tenderness or back pain Fetal distress High frequency of contractions Hypertonus Idiopathic preterm labor IUFD 78 66 60 17 17 22 15

Placental Abruption
DIC Acute renal failure Couvelaire uterus

Placental Abruption
Management
Gestational age Maternal status Fetal status Correct maternal hypovolemia, anemia, hypoxia ? Tocolysis Vaginal vs. C/S

Placenta Previa
Incidence: 0.3- 0.7 % Definitions: Total Partial Marginal Low-lying

Tubal Occlusion:

Placental 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 Previa
GA at U/S (wk) < 20 20 25 25 30 30 35 Previa or Bleeding at Delivery 2.3% 3.2% 5.2% 24%

Placental Previa
Management
?

Preterm

 ? Fetal lung maturity  ? Labor  ? Severe hemorrhage  Vaginal delivery vs. C/S