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Obstetric Hemorrhage

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Upon further questioning she does admit to having had some light bleeding on 1 ... at term by a Classical Cesarean Section for footling breech presentation. ... – PowerPoint PPT presentation

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Title: Obstetric Hemorrhage


1
Obstetric Hemorrhage
  • Abike James MD
  • Assistant Clinical Prof. Obstetrics and
    Gynecology
  • University of Pennsylvania

2
Third Trimester Bleeding
  • A 32 yo G2P1 presents at 36 weeks complaining
    of bright red vaginal bleeding. Upon further
    questioning she does admit to having had some
    light bleeding on 1 to 2 occasions last week. Her
    previous pregnancy was delivered at term by a
    Classical Cesarean Section for footling breech
    presentation.

3
Differential Diagnosis?
  • Placenta Previa
  • Uterine Rupture
  • Placental Abruption
  • Vasa Previa
  • Laceration
  • Vaginal mass

4
Placenta Previa
  • Painless third-trimester bleeding
  • Complicates 4-6 pregnancies between 10 and 20
    wks, 0.5 pregnancies gt20 weeks
  • Risk factors
  • Increasing parity, maternal age, prior c/s,
    curettages for sabs/tabs
  • Placental tissue overlying the internal os.
    Types?
  • Complete previa (20-30)
  • Partial previa (does not completely cover)
  • Marginal (proximate to os)
  • Management pelvic rest, u/s, IV, TS, C/S

5
Associated Conditions
  • Placenta accreta, increta, percreta
  • Risk inc w/ inc no. of prior c/s (50 risk in pt
    w/ previa and 2 prior c/s)
  • Vasa Previa
  • Vessels traverse the membranes in the lower
    uterine segment in advance of the fetal head.
  • Rupture can lead to fetal exsanguination

6
Uterine Rupture
  • Associated with Prior c/s
  • Rates of uterine rupture?
  • Spontaneous rupture (no c/s history) 1/2000
    (0.05)
  • Low Transverse 0.5-1risk rupture, VBAC 80
    success rate
  • Classical C/s 10 risk rupture, schedule
    amnio/c/s 37 weeks.

7
Placental Abruption
  • Premature separation of placenta
  • Painful third-trimester bleeding
  • Risk Factors
  • smoking, trauma, HTN cocaine, pprom,
    polyhydramnios, multiples
  • Trauma evaluation
  • bleeding, contractions, abdominal pain and NRFHT
    in 4hrs
  • U/s misses up to 50 of abruptions
  • Management IV, TX, Continuous monitoring, c/s
    vs. vag delivery

8
Case Contd
  • U/s reveals active, vertex fetus. Placenta
    anterior and free of os. Pt having contractions q
    2-3 minuters. Bleeding increases. BP drops from
    110/60 to palpable systolic pressure of 70. FHT
    drops from 120 to 90 bpm.
  • What do you do???

9
Post Partum Hemorrhage
  • A 34yo G6P6 patient at term has just delivered
    a 4000gm infant after second stage of labor
    lasting 3 ½ hours. The placenta delivered
    spontaneously and the patient is bleeding
    briskly.
  • What is average EBL w/ SVD?
  • 500cc
  • What is average EBL w/ C/S?
  • 1000cc

10
Classes of Hemorrhage
  • Class 1
  • lt900cc
  • Minimal symptoms
  • Class 2
  • 1200-1500cc
  • Tachycardia, tachypnea
  • Class 3
  • 1800-2100cc
  • Overt Hypotension, cold, clammy skin
  • Class 4
  • 2400cc
  • Shock, absent BP

11
Management
  • Fluids
  • Crystalloid, open wide/bolus
  • Labs
  • Cbc, coags, fibrinogen
  • Transfuse PRPCs
  • FFP
  • Larger vol (250cc/unit, all coagulation factors)
  • Cryopercipitate
  • Smaller volume (20cc/unit, many coagulation
    factors)

12
Differential Diagnosis
  • Atony
  • Uterine inversion
  • Laceration (cervical, vaginal)
  • Retained Placenta

13
Uterine Atony
  • Risk factors
  • multiparity, multiple gestation, macrosomia,
    abruption, retained POCs, placenta previa,
    induction (prolonged pitocin)
  • Management
  • Bimanual exam/massage
  • IV acess/fluids
  • Oxytocin, methergine 0.2mg IM, Hemabate 250mcg
    IM, misoprostol 800 to 1000mcg rectally
  • Laparotomy
  • Uterine artery ligation
  • B Lynch
  • Hysterectomy
  • UAE

14
Uterine Inversion
  • Inverted fundus extends beyond cervix (looks
    beefy red)
  • Stop pitocin if infusing
  • Replace uterus
  • Relaxants if necessary (terbutaline, MgSo4,
    Nitrogylcerin)
  • Anesthesia
  • Laparotomy
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