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Antepartum

Obstetrical Hemorrhage
Hemorrhage
International

Obstetrical Hemorrhage

Antepartum
ObstetricalHemorrhage
Hemorrhage
International

Principles

Prompt diagnosis
Recognize reserve and ability to compensate
Resuscitate vigorously
Identify underlying cause
Treat underlying cause

Antepartum Hemorrhage
International

Antepartum Hemorrhage

Antepartum 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

Antepartum 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% - % of pregnancies
- lower genital tract lesion 5%
- other

Antepartum 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

Antepartum 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

Antepartum Hemorrhage
International

Laboratory
CBC, blood type, Rh, Coombs
coagulation status
INR, PTT, fibrinogen or TCT
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

Antepartum Hemorrhage
International

Vaginal Bleeding
Risk Factors Tests (No vaginal exam)
Fetal / Maternal Assessment
Mother or fetus unstable

Mother and fetus stable

Hemodynamic Resuscitation

Labs / Fetal Monitoring


U/S vaginal exam

Mother or fetus unstable


Delivery

Expectant
consider ongoing loss, etiology,
gestation

Antepartum 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!

Antepartum 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

Antepartum 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

Antepartum 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

Antepartum Hemorrhage
International

Risk Factors for Abruption


hypertension: gestational and preexisting
abdominal trauma
cocaine or crack abuse
previous abruption
overdistended uterus
multiple gestation, polyhydramnios
smoking, especially >1 pack/day

Antepartum 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

Antepartum Hemorrhage
International

ABRUPTION
Live Fetus

Dead Fetus
coagulopathy
Delivery
(watch for DIC)
Assess Maturity

Maturity
Vaginal delivery or C/S

Immaturity
Steroids plus expectancy
Transfusion? Transfer?

Antepartum Hemorrhage
International

Placenta Previa - Definition


placenta covers or lies near the cervix

Placenta Previa - Classification


total
partial
marginal

- entirely covers the os


- partially covers the os
- close enough to the os to increase risk
of bleeding as cervical effacement and
dilatation occur

Antepartum 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

Antepartum 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

Antepartum Hemorrhage
International

PREVIA
Assess maturity

Maturity

Delivery by C/S (consider accreta)


May try vaginal if marginal

Immaturity

Steroids plus expectancy


Transfusion? Transfer?

Antepartum 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%

Antepartum 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

Antepartum 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 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 test
Calculate 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

Antepartum Hemorrhage
International

Modified Apt Test

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

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Postpartum Hemorrhage

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Objectives
Definition

Etiology
Risk Factors
Prevention
Management

Antepartum
PostpartumHemorrhage
Hemorrhage
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

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Etiology of Postpartum Hemorrhage


Tone

- uterine atony

Tissue

- retained tissue/clots

Trauma

- laceration, rupture, inversion

Thrombin

- coagulopathy

Antepartum
PostpartumHemorrhage
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)

Antepartum
PostpartumHemorrhage
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)

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Risk Factors for PPH - Postpartum


lacerations or episiotomy
retained placenta/placental
abnormalities

uterine rupture
uterine inversion

acquired coagulopathy (e.g. DIC)

Antepartum
PostpartumHemorrhage
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

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Active v.s Expectant Third Stage Management


Outcome

(subjects)

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
Cochrane Library
Issue 1, 2000

1
Odds Ratio (95% Confidence Interval)

10

Antepartum
PostpartumHemorrhage
Hemorrhage
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

Antepartum
PostpartumHemorrhage
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

Antepartum
PostpartumHemorrhage
Hemorrhage
International

A = airway
B = breathing
C = circulation

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Management - ABC s
talk to and observe patient

large bore IV access (


gauge)
crystalloid - lots!
CBC

cross-match and type


get HELP!

16

Antepartum
PostpartumHemorrhage
Hemorrhage
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

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Management - Bimanual Massage

Antepartum
PostpartumHemorrhage
Hemorrhage
International

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

Antepartum
PostpartumHemorrhage
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

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Replacement of Inverted Uterus

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Replacement of Inverted Uterus

Antepartum
PostpartumHemorrhage
Hemorrhage
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

Antepartum
PostpartumHemorrhage
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

Antepartum
PostpartumHemorrhage
Hemorrhage
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

Antepartum
PostpartumHemorrhage
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

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Conclusions

be prepared
practice prevention
assess the loss
assess maternal status
resuscitate vigorously and
appropriately
diagnose the cause
treat the cause

Antepartum
PostpartumHemorrhage
Hemorrhage
International

Management - Evolution
Panic
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness

Antepartum
Postpartum Hemorrhage
International

Keep your bloody fingers off


the cervix!