OBSTETRIC By CC Nadine D.

Bacalangco
HEMORRHAGE
OBJECTIVES
To understand the normal hemostatic response during obstetrical
hemorrhage.
To identify different pathologies causing obstetrical hemorrhage in
antepartum and postpartum periods.
To differentiate each pathologies based on the pathophysiology, the
clinical manifestations and physical findings
To identify the different diagnostics and expected findings
To understand the management of each pathology based on the
current guidelines and clinical trials
To identify the prognosis and
LOWER UTERINE SEGMENT :
Transformed from the
isthmus during eff acement

CERVIX: Bounded by internal

and external cervical os

NORMAL PLACENTA :
implants at the fundus
MECHANISMS OF NORMAL
HEMOSTASIS
• Antepartum Bleeding

• Postpartum Bleeding
 ANTEPARTUM
HEMORRHAGE
ANTEPARTUM HEMORRHAGE
“Vaginal bleeding that occurs from 22 weeks
age of gestation up to the time of delivery.”
- POGS, CPG

*ABORTION- bleeding that occurs before 22

weeks (20 weeks in Philippines)
>>
Bleeding is due to cervical effacement
and dilatation of the cervix resulting to
tears in small vessels
Indication for increased risk of an
adverse outcome even if bleeding has
stopped
Complicates: 2-5% of pregnancies
>>
Cardiac Output:
onon-pregnant : 1% is supplied to uterus
opregnant : 20% is supplied to uterus
The uterus has an extensive blood supply.
Any massive bleeding that occurs during
pregnancy can dramatically alter the
hemodynamic status of a patient.
PLACENTA PREVIA
PLACENTA ACCRETA
ABRUPTIO PLACENTA
PLACENTA PREVIA
PLACENTAL MIGRATION
A phenomenon associated with placenta
previa involving the leading edge of the
placenta moving away from the internal
cervical os because the LUS is starting to form
2nd Trimester: 45% of ultrasound
results show low lying
oit is not normal but it is expected
o12% persists as TPP at term
>>
When placenta previa detected by UTZ
at 24wk AOG, repeat UTZ around 34-
36wk AOG. And if still low lying, tell the
patient about her condition and advice to
limit activities
PLACENTA PREVIA
A placenta that is
implanted
somewhere in the
lower uterine
segment, either over
or very near the
internal cervical os.
Placenta goes before
(previa) the fetus into
oTotal/Complete Placenta Previa : placenta
completely covers internal cervical os.
oPartial Placenta Previa: placenta covers a
portion of the internal cervical os.
oMarginal Placenta Previa: edge of placenta
encroaches the margin of internal cervical os
(UTZ: 0.5-2 cm distance from cervical os)
oLow-lying Placenta Previa: does not cover
internal cervical os but still in the lower uterine
segment. (UTZ: 2.1-3.5 cm distance from
cervical os)
INCIDENCE
The relationships and definitions used for
classification in some cases of placenta previa
depend on cervical dilatation at the time of
assessment.
• 1:250 births or 0.4%
• Philippines- increased incidence
• 1985- 1:360 or 0.27%
• 1991- 1:93 or 1.07%
PREDISPOSING FACTOR
• Multiparity
• Multiple Induced Abortions
• Previous CS
• Puerperal Endometritis during previous pregnancy
• Advanced maternal age
• Large placenta
• Smoking
PATHOPHYSIOLOGY
Onset of Labor
↓
LUS retracted upward
↓
Dilatation of the cervical os
↓
Placental separation from the decidua
↓
Tearing into maternal blood sinuses in
the decidua
↓
HEMORRHAGE from spiral arteries
After delivery,
LUS unable to contract
↓
HEMORRHAGE
20
 SIGNS AND SYMPTOMS
• Painless Vaginal Bleeding in the 3rd trimester
• Usually does not appear until near the end of the second trimester or later,
but it can begin even before midpregnancy
• Bleeding is external, thus the amount of blood loss can be assessed better
• The earlier the bleeding episode, the more serious the type of placenta previa
• The amount of bleeding seen externally is equal to the amount of blood loss
internally this is important in differentiating between abruption and previa
• Uterus soft, non-tender, non contractile
• 35% would present in breech/shoulder
DIAGNOSIS
1. Transabdominal Ultrasound
• 93-97% accuracy

2. Transvaginal Ultrasound
• 100% sensitivity
• Safe in pregnant women with placenta previa
• Transvaginal is the GOLD STANDARD in diagnosis for PP
DIFFERENTIAL DIAGNOSIS
• Abruptio Placenta
• Lesions in the Vagina/Cervix
• Vasa Previa
MANAGEMENT
A. Pre-term, Not In Labor, mother and fetus stable
• Expectant management until end 37wk AOG
• Hospitalization, corticosteroids, transfusion, bed, stand-by
available blood (if patient is anemic or unstable)
• Patient may go home/need not be hospitalized if:
• Patient is intelligent and reliable
• Available/accessible transportation/communication
• Hematocrit >30% volume
MANAGEMENT
B. Term Pregnancy/Fetal Lung Maturity Achieved
(>37 weeks)
• MANAGEMENT IS CESARIAN SECTION
• no need to wait for spontaneous labor

C. Pre-term, In Labor, Minimal Bleeding, mother

and fetus stable
• Tocolytics
• for relaxing uterus with end goal of prolonging pregnancy and time for
fetus to mature
• increased birth weight

D. Severe Hemorrhage (Regardless of AOG)

 COMPLICATIONS
• Postpartum hemorrhage
• insufficient sphincteric tone of LUS to close blood vessels

• IUGR
• poor placental implant-poor exchage of gases

• Congenital Abnormalities
• Placenta Accreta (15%)
• abnormally attached placenta
• poor decidua formation
• little resistance to invading trophoblast
• Most dreaded
 ABNORMAL
PLACENTAL
ATTACHMENT
 DEGREES OF ABNORMAL
PLACENTAL ATTACHMENT
• Accreta
• abnormal attachment to the myometrium
• 80%

• Increta
• invasion of the myometrium
• 15%

• Percreta
• penetrates through the myometrium
• Traversed the full thickness of the myometrium and serosa
• 5%

28
 DIAGNOSIS
• Ultrasound: Suggestive
Findings
• absence of hypoechoic
myometrial zone
• multiple lakes-Swiss Cheese
appearance
• focal disruption of uterine
serosa & bladder wall
• Color Flow Doppler -
important in the diagnosis of
placenta percreta
29
MANAGEMENT
A. Pre-partum Hemorrhage
• Iron and folic acid
• Erythropoietin
• Autologous blood transfusuion

30
MANAGEMENT
B. Intra-partum/Post-partum
• Focused repair
• attempt to sew the bleeding areas only
• Bracketing the bleeding areas
• by suturing
• Argon Beam Coagulator
• ablation of vessels (cautery)
• Pelvic vessel embolization and catherization with
ballon tipped catheter
 MANAGEMENT
• What to do about the placenta?
• Placenta previa alone: deliver placenta
• Placenta previa + accrete: hysterectomy with placenta in situ

• Desires Fertility?
• Leave placenta behind and give methotrexate and antibiotic
• Methotrexate – chemotherapeutic drug found to markedly
decrease size of placenta
• appraise the patient regarding failure of treatment
 MORBIDITY
• ARDS
• Acute Tubular Necrosis
• Pulmonary Embolism
• if bleeding is inadequately managed

• Ureteral Injury
• during hysterectomy
ABRUPTIO PLACENTA
 ABRUPTIO PLACENTA
• Normal Pregnancy- placenta
separates during the 3rd stage of
labor, after the delivery of the
fetus.
• Abruptio placenta- premature
separation of normally implanted
placenta
• Retroplacental Hematoma-
indicates that central
separation is starting to occur, 35
 INCIDENCE
• 1:200-300 pregnancies – Philippines
 PREDISPOSING FACTORS
•Severe pre-eclampsia or CHVD(chronic hypertension
vascular disease)
• most common predisposing factor
•Cigarette Smoking
• predisposes to decidual necrosis and development of
hypertension
•PROM
• sudden decompression of uterus
• threefold risk of abruption with preterm rupture was further
increased with infection.
• inflammation and infection as well as preterm delivery may be
the primary causes leading to abruption
•Chorioamnionitis
• Inflammation
 PREDISPOSING FACTORS
• Severe IUGR
• Advance Maternal Age and Parity (> 40yo, P5)
• Unmarried Status
• Male Fetus
• History of Abruptio (2 previous occurences-25% risk)
• Short Umbilical Cord

• Sudden decompression of the Uterus

• delivery of first of twin

• Retroplacental myomas
• placenta could not attach properly 38
 CLASSIFICATION (AS TO
ONSET)
• Acute
• Shearing forces from trauma
• sudden uterine decompression

• Chronic
• chronic pathologic lesions
• lack of trophoblastic invasion
• begin early in pregnancy women may have abnormally
• elevated serum levels of alpha-fetoprotein
 CLASSIFICATION (AS TO
TYPE)
• Concealed Bleeding
• bleeding observed not
appropriate with signs and
symptoms presented (px
pale, shocky, hypovolemic
but with minimal bleeding)
• because edges of placenta
remains attached, the blood
in between placenta and
endometrium remain inside
• only a small percentage of px
with abruption placenta
present with this
• poor prognosis due to under
management of the
physicians.
 CLASSIFICATION (AS TO
TYPE)
• Revealed (External)
Bleeding
• bleeding is visible as the
edge of placenta has been
separated allowing
retroplacental hematoma to
egress out of vagina
• Better prognosis

41
 PATHOLOGY
• Placental abruption is initiated by haemorrhage into the
decidua basalis. The decidua then splits, leaving a thin
layer adhered to the myometrium. Consequently, the
process in its earlier stages consist of the development
of the decidual hematoma that leads to separation,
compression and ultimate destruction of the placenta
adjacent to it.
 SIGNS AND SYMPTOMS
• Mild
• evidence of abruption with NO fetal compromise
• minimal pain and bleeding

• Moderate
• evidence of abruption with fetal compromise

• Severe
• evidence of abruption with fetal demise
• fetal death in utero, shock, profuse vaginal bleeding

43
 SIGNS AND SYMPTOMS
• Vaginal bleeding
• painful secondary to uterine contractions brought about by the presence of thrombin
which is a potent of uterotonic agent found in hematoma
• high frequency, hypertonic uterine contractions
• Uterine tenderness
• Fetal distress
• High frequency contractions
• Preterm labor
• Dead Fetus
• Crampy, continous pain
• brought about by increased uterine contractions (hypertonus)
• Bloody Amniotic Fluid (Portwine AF)
• secondary to concealed type of abruption placenta

44
 DIAGNOSIS
• Severe cases- signs and symptoms
• Milder cases-diagnosis is made by exclusion, clinical
inspection and UTZ exam
• Amniocentesis - Portwine amniotic fluid
• supportive but not confirmatory
• uses long gauge needle, UTZ guided, aspirate fluid: pink/red
• very invasive procedure
 DIAGNOSIS
• Retroplacental Clot Formation
• Volume of clot is 40% of actual blood loss mild form

• Ultrasound
• to rule out placenta previa
• may show retroplacental clot
• if negative, does not exclude abruption placenta
• UTZ finding: fluid or dark area behind the placenta
• Color Doppler Imaging
• useful for patient with pregnancy induced hypertension and for
possible abruption, seen as notching
46
 DIFFERENTIAL DIAGNOSIS
• Placenta Previa
• Uterine rupture
• Abdominal pregnancy
• Ruptured hematongioma
• Hepatic rupture
MANAGEMENT
A. Maternal Status
• Monitor BP, CR, RR, Fluid Intake, Urine Output
• Crossmatch blood
• Correct hypovolemia, anemia, hypoxia
• Blood studies – CBC, platelet count, plasma fibrinogen and
fibrin degradation products, PTT (prone to develop DIC)

B. Fetal Status
• Fetal Monitor
• Fetal Distress – immediate delivery
MANAGEMENT
C. Gestational Age
Term pregnancy w/o fetal distress Preterm pregnancy without fetal
+ diagnosis uncertain, Mother distress
stable
↓
↓
Delay delivery
Close observation
↓
↓
If with fetal distress
Immediate intervention if with fetal
distress or if diagnosis of AP is ↓
certain Immediate delivery

49
MODE OF DELIVERY
Cesarean Section
Live fetus with:
Failed induction
Fetal Distress
OB Indications: e.g.
cephalopelvic disproportion,
preeclampsia
No labor w/in 4 hours from
the time she is admitted after
dx of abruption placenta
Vaginal Delivery
Fetal death- if fetus is dead
already, no need to hurry, you
can correct anemia first
Imminent delivery
Minimal bleeding w/o signs of
fetal distress
Oxytocin may be used- for
contractions to be regular
Amniotomy - for quick delivery
 COMPLICATIONS
• Couvelaire Uterus (Uterine Appolexy)
• Uterus transformed to a blue organ
• extravasation of blood up to serosal layer

• Acute Renal Failure

• Seen in severe forms
• Incomplete treatment of hypovolemia and anemia

• Consumptive Coagulopathy/DIC
• Dread complication
• Seen in 30% of cases
• Hypofibrinogenemia of <150mg/dl
 PROGNOSIS
• Directly related to the length of time between onset of
abruptio and delivery
• Depends on the adequacy of fluid and blood
replacement
 POSTPARTUM
HEMORRHAGE
POSTPARTUM BLEEDING
Postpartum – any bleeding that
results in signs and symptoms of
hemodynamic instability if untreated
after delivery
ESTIMATED BLOOD LOSS
•500 cc for vaginal birth
•1000 cc for cesarean section
•1500 cc for cesarean/ hysterectomy
•10% decline in antepartum to postpartum hematocrit
 POSTPARTUM HEMORRHAGE
• Early – Blood loss is greater than 500ml in the first 24
hours after a vaginal delivery or greater than 1000ml
after a caesarean birth
• Late – Hemorrhage that occurs between 24 hours and 6
weeks
Hemorrhage Classfollowing delivery
Estimated Blood (e.g. RETAINED
Loss Blood Volume ClinicalPLACENTAL
Signs & Symptoms
TISSUE)
0 (normal loss) <500 <10 None
1 500-1000 15 Minimal
2 1200-1500 20-25 Oliguria, tachycardia, tachypnea, postural hypotension
3 1800-2100 30-35 Hypotension, tachycardia, cold clammy
4 >2400 >40 Profound shock

WHO Classification of Postpartum

Hemorrhage
 CAUSES: 4 T’S
• Tone – uterine atony
• Trauma – uterine, cervical, vaginal injury
• Tissue – retained placenta or clots
• Thrombin – pre-existing or acquired coagulopathy

57
1. UTERINE ATONY
• failure of the uterus to contract properly following
delivery
• Mismanagement of the 3rd stage of labor ( from delivery
of the baby to delivery of the placenta) – 3rd stage
haemorrhage
• After the delivery, some would tend to stimulate the
fundus, impedes normal separation. Leads to incomplete
separation of placenta

58
 UTERINE ATONY
• failure of the uterus to contract properly following
delivery
• Mismanagement of the 3rd stage of labor ( from delivery
of the baby to delivery of the placenta) – 3rd stage
haemorrhage
• After the delivery, some would tend to stimulate the
fundus, impedes normal separation. Leads to incomplete
separation of placenta

59
 RISK FACTORS
• overdistended uterus – twin, macrosomia,
polyhydramnios
• Uterine muscle fatigue/relaxation – labor induction,
prolonged labor
• chorioamnionitis
• uterine distortion
• uterine relaxing drugs
 ACTIVE MANAGEMENT
1. Oxytocin within 2 minutes of birth 10 units IM
2. Early cord gutting/clamping
3. Controlled cord traction
 DIAGNOSIS
• soft, more uterus
• open cervix
• With profuse bleeding
MANAGEMENT
1.) Fundal massage
2.) Uterotonics
• oxytocin
• methylergonovine
• Prostaglandin
• Prostaglandin F2a .25mg IM
• Carboprost 0.25 mg IM (may repeat every 15-90 minutes to maximum
of 8 doses
• Prostaglandin E1 (Misoprostol)
• Carbetocin – 100mcg IM/IV

3.) Bimanual uterine compression 63

3.) Bimanual uterine
compression
-Abdominal hand will compress
the posterior part of the uterus
creating a tamponade. Once
vaginal hand is removed,
bleeding will ensue.
>>
4) Brace Suturing – this is done if bimanual
compression could not work and if patient
wants to have more children
 SURGICAL MANAGEMENT
• ligation of the uterine arteries
• ligation of the internal iliac arteries
• hysterectomy
ALTERNATIVE MANAGEMENT:
PERSISTENT ATONY
1. Angiographic arterial
embolization
2. Uterine tamponade
 Uterine packing
 Balloon tamponade
 Condom tamponade

Bakri tamponade balloon catheter

2. GENITAL TRACT
LACERATION
- 2nd most common
Lower Genital Tract Laceration
Hematomas
Uterine Rupture

- Postpartum bleeding despite firm contracted uterus

LOWER GENITAL TRACT
LACERATION
1. Lacerations of the perineum
2. Injuries to the cervix
DEGREE:
 1st degree
laceration- vaginal
mucosal membrane,
perineal skin and
fourchette

 2nd degree
laceration- involves
the muscle of the
perineal body

 3rd degree
laceration- involves
the anal sphincter
CERVICAL LACERATION
•Consequence of vaginal delivery
•Also involves the descending part of the uterine
cavity
•Place anchoring suture just above 1 cm of the
laceration at 3 and 9 o’ clock.
3. PUERPERAL HEMATOMAS
Types of hematomas
1. Vulvar
•involves the pudendal artery
•Branches include inferior rectal, transverse perineal and posterior labial arteries.
2. Vulvovaginal/Paravaginal
•Associated with forceps delivery
•Complain of rectal pressure
•Involves the descending branch of uterine artery/vein (blood accumulates
above the
pelvic diaphragm)
3. Supravaginal/Subperitoneal/Retroperitoneal
•Least common but most dangerous
•Asymptomatic until hypotension
•Involved vessel from the hypogastric artery
•This may results from uterine rupture, placental abruption and
extension of vaginal
hematomas.
DIAGNOSIS
1.) Symptoms:
excruciating pain, often mistaken as pain of episiorrhaphy
Can’t void (urinate)
2.) Physical Exam:
tense, fluctuant tender mass with discoloration of the skin on
examination
Vulvar hematoma is easy [sic] to identify.
It is a violaceous fluctuant mass.
TREATMENT
1. Expectant management: Ice pack and observation
2. Incision and evacuation: severe pain, rapidly enlarging
3. Ligation of bleeding points: obliteration of potential space
4. Compression 12-24 hours
<3 cm – treated conservatively (e.g. ice packs)
>3 cm and rapidly expanding – primary evacuation
closurecompression
5. Arterial Embolization. The advent of interventional radiology has
made possible the imaging of vessels of the pelvis and introduction of
pellets to occlude the blood supply to the uterus. (This can be used if
unresponsive to surgical management.)
4. UTERINE RUPTURE
•Most serious, not high in our center
•Classical (vertical) uterine incision is seldom done but there
is still an increase incidence of rupture.
•Incidence of classical rupture: 40-120/1000
•Incidence of low transverse rupture: 2-15/1000
•If patients want go into trial of labor, there should be no
oxytocin.
•Trial of labor only if the indication of 1st Cesarian delivery
was NOT dystocia, could be breech or severe preeclampsia.
 RISK FACTORS
(UNSCARRED UTERUS)
1. Grand multiparity – more than 5
2. Neglected labor
• Bandl’s ring is an indication for CS.
• Assess bladder if full.
3. Malpresentation – transverse lie
4. Breech extraction
5. Uterine instrumentation
6. Congenital uterine instrumentation
RISK FACTORS (SCARRED
UTERUS)
1.Oxytocin induction/augmentation
2.Cervical ripening
3.Shorter inter-delivery interval
4.One layer closure
5.Lower uterine wall thickness <3-3.5mm
CLASSIFICATION
1. Complete Rupture – direct
communication between the uterine and
peritoneal cavity
2. Incomplete Rupture – 2 cavities are
separated by the uterine serosa or the broad
ligament
1.) Hysterectomy
- intractable bleeding
- multiple uterine rupture sites
2.) Wound repair
- Conservative management
- If small wound, bleeding minimal, 1-time CS, transverse
rupture, no coagulopathy, has not completed family size
5. INVERSION OF UTERUS
• Displacement of fundus during the 3rd stage of
labor
• Most commonly caused by strong traction on the
umbilical cord
• Causes life threatening hemorrhage
• Rare complication
• Seen in 1/2100 to 1/6400 (0.5%) deliveries
CONTRIBUTING FACTORS
• Fundal implantation of placenta
• Vigorous fundal pressure
• Excessive traction to cord with a relaxed
uterus
DIAGNOSIS
• Abdominal palpation of a crater life
depression
• Vaginal palpation of the fundal wall
 Reduction of uterine inversion
The protruding fundus is grasped with
fingers directed toward the posterior
fornix.
The uterus is returned to position by
pushing it through the pelvis and into
the abdomen with steady pressure
towards the umbilicus.

Other treatment:
• Oxytocin/bimanual compression
- Once uterus returns to normal, stop
tocolytics
and give oxytocin.
•
6. RETAINED PLACENTA
• retention of the placenta in utero for
more than 30 minutes
• May result from partial separation of the
placenta or entrapment of the partially
or fully separated placenta
6. COAGULOPATHIES
• When bleeding continues with no identifiable source, an acquired
coagulopathy must be considered
• Coagulation status must be assessed quickly and continuously
BLOOD PRODUCTS COMMONLY TRANSFUSED IN OBSTETRICAL HAEMORRHAGE