4. Obstetrical Hemorrhage.pdf

LEVEL III Obstetrical Hemorrhage MODULE 9 Fatmah B. Mangondato-Lucman, MD OBSTETRICS 06 SEPTEMBER 2023 OUTLINE...

LEVEL III Obstetrical Hemorrhage MODULE 9 Fatmah B. Mangondato-Lucman, MD OBSTETRICS 06 SEPTEMBER 2023 OUTLINE ⚫ Whenever the postpartum hematocrit is lower than the one OBSTETRICAL HEMORRHAGE............................................. 1 obtained on admission for delivery, blood loss can be GENERAL CONSIDERATIONS........................................... 1 estimated as the sum of the calculated pregnancy. POST PARTUM HEMORRHAGE............................................ 2  Added volume plus 500 ml for each 3-volume percent UTERINE ATONY................................................................ 2 decline of the hematocrit RETAINED PLACENTA....................................................... 2 UTERINE INVERSION......................................................... 3 INJURIES TO THE BIRTH CANAL...................................... 3 UTERINE RUPTURE........................................................... 4 ANTEPARTUM HEMORRHAGE............................................. 4 PLACENTAL ABRUPTION................................................... 4 PLACENTA PREVIA............................................................ 5 MORBIDLY ADHERENT PLACENTA.................................. 6 VASA PREVIA...................................................................... 7 OBSTETRICAL COAGULOPATHIES..................................... 7 PREGNANCY-INDUCED COAGULATION CHANGES........ 8 MANAGEMENT OF HEMORRHAGE................................... 8 OBSTETRICAL HEMORRHAGE ⚫ Cause of obstetrical antepartum and postpartum Figure 2. Blood volume loss estimation hemorrhage are the 4 Ts:  Tone RISK FACTORS  Tissue  Trauma  Thrombin Figure 1. Four Ts GENERAL CONSIDERATIONS MECHANISM OF NORMAL HEMOSTASIS ⚫ Near term an incredible amount of blood flows through the intervillous space  At least 600mL/min ⚫ Intact coagulation system is not necessary for postpartum hemostasis unless there are lacerations in the uterus, birth canal or perineum. ⚫ With placental separation, these vessels at the implantation site are avulsed and hemostasis is achieved first by myometrial contraction, which compresses this formidable number of large vessels. Figure 3. Obstetrical hemorrhage risk factors ⚫ Compression is followed by clotting and obliteration of vessels lumens. TIMING ANTEPARTUM HEMORRHAGE DEFINITION AND INCIDENCE Vaginal bleeding from the genital tract during 24th week of POSTPARTUM HEMORRHAGE pregnancy and prior to childbirth Cumulative blood loss of more than 1000ml accompanied Remains at higher risk for an adverse outcome even though by signs and symptoms of hypovolemia. bleeding has stopped and placenta previa has been excluded sonographically. Hypovolemia – characterized by hypotension, tachycardia, and Includes: decreased urine output o Placenta previa o Placenta abruptio ESTIMATED BLOOD LOSS o Vasa previa ⚫ Approximately half of the actual loss 1 of 8  OBSTETRICS Obstetrical Hemorrhage POSTPARTUM HEMORRHAGE  Carboprost tromethamine Cumulative blood loss of more than 1000 mL accompanied  Dinoprostone by signs and symptoms of hypovolemia.  Misoprostol Includes: ⚫ Tranexamic Acid o Uterine atony  Used to help stop the bleeding o Genital tract lacerations EVALUATION AND MANAGEMENT LATE POSTPARTUM HEMORRHAGE ⚫ Bleeding unresponsive to uterotonic agents: Bleeding after 24 hours  Bimanual uterine compression If there are no lower genital tract laceration and the uterus  Whole blood and pRBC – transfuse if with persistent is contracted, yet supracervical bleeding persists, then hemorrhage manual exploration of the uterus is done to exclude a  Anesthesia uterine tear.  Two large bore IV catheters o This also is completed routinely after internal podalic  Volume resuscitation version, breech extraction or successful vaginal birth  Manually explore thoroughly inspect cervix and vagina after cesarean. ⚫ Surgical procedures BLOOD LOSS ESTIMATION ⚫ A treacherous feature of postpartum hemorrhage is the failure of the pulse and blood pressure to undergo more than moderate alterations until large amounts of blood have been lost. POST PARTUM HEMORRHAGE UTERINE ATONY ⚫ Most frequent cause of obstetrical hemorrhage ⚫ Active management of third-stage labor ⚫ If heavy bleeding persists after delivery of the newborn and while the placenta remains partially or totally attached, then manual placental removal is indicated. Figure 5. Bimanual compression for uterine atony  Give antibiotics: ampicillin and cefazolin.  Simultaneously, 20 U of oxytocin in 1000 mL of RETAINED PLACENTA crystalloid solution will be often effective given intravenously at 10 ml/min for a dose of 200 mU/min. ⚫ Failure to deliver the placenta within 30 minutes after the ⚫ Oxytocin is never given as an undiluted bolus dose because delivery of the infant. serious hypotension or cardiac arrythmia can develop. RISK FACTORS Active Management of Third Stage of Labor ⚫ Previous history 1. Giving of oxytocin 10 units IM right after the delivery of the 1st ⚫ Preterm baby after making sure that there is no twin. ⚫ Use of ergometrine 2. Cord control/cord traction with counter traction in the lower uterine segment of the uterus. ⚫ Uterine abnormalities 3. Uterine massage. ⚫ Preeclampsia ⚫ Stillbirth ⚫ SGA ⚫ Velamentous cord insertion ⚫ Maternal age, ≥30 years old MANAGEMENT ⚫ Uterotonics ⚫ Manual removal of placenta ⚫ Antibiotics ⚫ Blood transfusion Figure 4. Manual removal of placenta RISK FACTORS ⚫ Primiparity ⚫ High parity ⚫ Overdistended uterus ⚫ Labor abnormalities ⚫ Labor induction and augmentation ⚫ Prior postpartum hemorrhage EVALUATION ⚫ Uterotonic agents  Oxytocin  Methergine 2 of 8  OBSTETRICS Obstetrical Hemorrhage UTERINE INVERSION Figure 8. L: Huntington procedure; R: Haultain procedure INJURIES TO THE BIRTH CANAL ⚫ Vulvovaginal laceration ⚫ Cervical laceration ⚫ Puerperal hematoma VULVOVAGINAL LACERATION Figure 6. Different degrees of uterine inversion ⚫ Often sustained during operative vaginal delivery ⚫ Deeper underlying tissue and thus usually cause significant 1st degree – inverted fundus extends to the cervix but not beyond. hemorrhage. 2nd degree – body of the uterus protrudes through the cervix into ⚫ Lacerations involving the middle third or upper third of the the vagina. vaginal vault usually are comorbid with injuries of the 3rd degree – prolapse of inverted uterus outside the vulva. perineum or cervix. 4th degree – prolapse of inverted uterus to vagina. CLASSIFICATION ACCORDING TO TIME OF ONSET ⚫ Acute – within 24hours after birth ⚫ Subacute – between 24 hours and 4 weeks after birth ⚫ Chronic – any time after 4 weeks of birth or in non-pregnant RECOGNITION AND MANAGEMENT ⚫ Immediate assistance:  Blood  General anesthesia and large-bore IV infusions ⚫ If the placenta is separated, uterus may be replaced back. ⚫ If the placenta is still attached, adequate tocolytic may be used to relax the uterus and reposition. ⚫ If failed repositioning, placenta is peeled off and steady pressure with fist, palms, or fingers. ⚫ Once the uterus is restored to normal configuration, adequate uterotonics is given. Figure 9. Classification of perineal lacerations 1st degree – fourchette, perineal skin, vaginal mucous membrane 2nd degree – first degree structures plus fascia and muscles of the perineal body (bulbospongiosus and transverse perineal muscles) 3rd degree – second-degree structures plus external anal sphincter o 3a – 50% of EAS is torn o 3c – EAS and IAS are torn 4th degree – extends completely through the rectal mucosa to expose its lumen CERVICAL LACERATION ⚫ Colporrhexis – entirely or partially avulsed from the vagina Figure 7. Repositioning of incomplete uterine inversion in the anterior, posterior, and lateral fornices. ⚫ Annular or circular detachment – the entire vaginal SURGICAL INTERVENTION portion of the cervix is avulsed. ⚫ 1-2 cm lacerations are not repaired unless bleeding. ⚫ Huntington procedure – clamps at round ligament. ⚫ Superficial lacerations of the cervix can be seen on close ⚫ Haultain procedure – sagittal cut posteriorly through the inspection in more than half of all vaginal deliveries, most muscular ring to release it. measuring 20 weeks AOG. ⚫ Major Findings:  Vaginal bleeding  Abdominal pain  Hypertonic uterine contractions  Uterine tenderness  NRFHR pattern Figure 10. Repair of cervical laceration PATHOGENESIS AND PATHOPHYSIOLOGY ⚫ Rupture of maternal vessels in the decidua basalis PUERPERAL HEMATOMA ⚫ Accumulating blood splits the decidua, separating a thin ⚫ Classifications: layer of decidua with its placental attachment from the  Supralevator hematoma uterus.  Anterior perineal triangle hematoma ⚫ Detached portion is unable to exchange gases and  Posterior perineal triangle and ischioanal fossa nutrients. hematoma  Remaining fetoplacental unit: unable to compensate ⚫ Risks: → fetus becomes compromised  Vaginal and perineal laceration ⚫ In some cases, it may be due toan acute process  Episiotomy resulting from one of the following:  Operative delivery 1. Shearing forces resulting from trauma. ⚫ Diagnosis: 2. Sudden uterine decompression resulting from  Rapidly and causes excruciating pain membrane rupture with hydramnios.  Tense and tender swelling, ecchymotic 3. Cocaine usage leading to acute vasoconstriction. ⚫ Management:  Incision is made at the point of maximal distension CLINICAL CLASSIFICATION  Evacuated hematoma cavity is surgically closed and the vagina is packed for 12-14 hours SEVERE ABRUPTIO PLACENTA ⚫ Mother is unstable.  Significant coagulopathy UTERINE RUPTURE  Hypotension ⚫ Predisposing Factors:  Ongoing major blood loss  Primary – intact and unscarred uterus ⚫ FHR tracing is nonreassuring.  Secondary – preexisting incision, injury, or anomaly  Persistent fetal bradycardia of the myomentrium  Late decelerations  Loss of variability  Sinusoidal FHR pattern NONSEVERE ABRUPTIO PLACENTA ⚫ FHR pattern is reassuring ⚫ Maternal VS is normal ⚫ Lab test normal or mildly abnormal ⚫ Mild to moderate bleeding MINOR ABRUPTIO PLACENTA ⚫ Mother is stable ⚫ Fetal status is reassuring ⚫ Lab tests are normal ⚫ Active bleeding has stopped Figure 11. Some causes of uterine rupture PREDISPOSING FACTORS ⚫ Pathogenesis: ⚫ Demographic  Most often involves the thinned out lower uterine  Advanced maternal segment.  High parity  When the rent is in the immediate vicinity of the cervix,  Race and familial association it frequently extends transversely or obliquely. ⚫ Pregnancy Associated Hypertension  When the rent forms in the portion of the uterus  Chronic hypertension with superimposed preeclampsia adjacent to the broad ligaments, the tear is usually or with fetal growth restriction longitudinal. ⚫ Preterm Prematurely Ruptured Membranes ⚫ Management:  20 to 36 weeks age of gestation  Hysterectomy  Inflammation and infection  Maternal obesity comorbid with uterine rupture is ⚫ Prior Abruption associated with increased rates of adverse neonatal ⚫ Others: outcomes.  Cigarette smoking 4 of 8  OBSTETRICS Obstetrical Hemorrhage  Cocaine abuse  Mode of delivery should be chosen to minimize the risk  Uterine leiomyoma of maternal morbidity or mortality.  Isolated single umbilical artery  Generally preferable  Subclinical hypothyroidism ⚫ Expectant Management with Preterm Fetuses  For non-severe and minor abruptio placenta CLINICAL FINDINGS  95% and keep patient warm.  ART ⚫ Estimate extent of blood loss by collection of volumetric containers and/ or by weighing pads/ towels used to absorb CLINICAL FEATURES vaginal bleeding. ⚫ Painless bleeding – sentinel bleed ⚫ Draw blood for CBC, Blood type, and RH coagulation ⚫ Uterine body remodels to form lower uterine segment studies. Internal os dilates and implanted placenta separates ⚫ crude clotting test- bedside by placing 5 ml of patient’s Bleeding ensues by the inherent inability of myometrial blood in a tube with no anticoagulant for 10 minutes. fibers to contract. ⚫ Pregnancies at 34 - 36 weeks ⚫ Bleeding from the lower uterine segment continues until  Deliver with non-severe placental abruption. delivery. ⚫ Morbidly adherent placenta DELIVERY  Frequent and serious complication ⚫ Cesarean Delivery  Poorly developed decidua that lines the lower uterine  Expeditious delivery is recommended for pregnancies segment at any gestational age complicated by severe placental abruption ⚫ Vaginal Delivery  Fetal demise 5 of 8  OBSTETRICS Obstetrical Hemorrhage DIAGNOSIS ⚫ TVS is the most accurate method of assessment, safe even with bleeding ⚫ Placenta previa at 18-22 weeks  With prior CS – evaluated again at 28 weeks  Without prior CS – evaluated again at 32 weeks ⚫ At 32 weeks, placental edge 40 years old ETIOPATHOGENESIS ⚫ Parity >5 ⚫ Occurs when a defect of the decidua basalis and Nitabuch’s layer allows the trophoblasts, which have tissue-invasive SCREENING characteristics, to break the barrier and invade the myometrium ⚫ Combination of clinical risk factors evaluated on the first prenatal visit and grayscale imaging at 20 to 24 weeks ⚫ Placental evaluation in the 11-14 weeks scan among high CLASSIFICATION risk women ACCORDING TO THE DEPTH OF INVASION ⚫ Placenta Accreta Vera (75%) – chorionic villi are attached CLINICAL PRESENTATION to the myometrium but do not invade the muscle. ⚫ Placenta Increta (15%) – chorionic villi invade deeper into ⚫ Usually asymptomatic the myometrium but not the serosa. ⚫ Unless with placenta previa with bleeding ⚫ Placenta Percreta (5%) – chorionic villi penetrate through the entire uterine wall or beyond the serosa and extend to DIAGNOSIS adjacent structures like the bladder or the bowels. ⚫ Grayscale ultrasound combined with Color or 3D power doppler ⚫ Complemented by MRI in equivocal cases ⚫ TVS, TAB, and TPS are complementary techniques and should be used as necessary GRAY SCALE SONOGRAPHIC SIGNS ⚫ Loss of normally visible retroplacental “clear space” or hypoechoic zone ⚫ Progressive thinning of the retroplacental hypoechoic zone to