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Postpartum Hemorrhage

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Postpartum Hemorrhage Jorge Garcia, MD December, 2001 Goals of talk Definition Rapid diagnosis and treatment Review risks Case 1. Healthy 32 yo G2P1. – PowerPoint PPT presentation

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Title: Postpartum Hemorrhage


1
Postpartum Hemorrhage
  • Jorge Garcia, MD
  • December, 2001

2
Goals of talk
  • Definition
  • Rapid diagnosis and treatment
  • Review risks

3
Case 1.
  • Healthy 32 yo G2P1.
  • Augmented vaginal delivery, no tears.
  • Nurse calls you one hour after delivery because
    of heavy bleeding.
  • What do you do?
  • What do you order?

4
Case 2
  • 26 yo G4 now P4.
  • NSVD, with help from medical student.
  • You leave the room to answer a page while waiting
    for placenta to deliver, but are called back
    overhead, stat.
  • Huge blood clot seen in vagina.
  • What is this, and what do you do next?

5
Definition
  • Mean blood loss with vaginal delivery 500cc
  • gt 1000cc is hemorrhage
  • Mean blood loss with C/S 1000cc
  • gt1500cc is hemorrhage
  • Seen in 5 of deliveries.

6
Early vs. Late
  • Most authors define early as lt 72h.
  • ALSO defines it as lt24h.
  • Late hemorrhage is more likely due to infection
    and retained placental tissue.

7
Prenatal Risk Factors
  • Most patients with hemorrhage have none.
  • Pre-eclampsia (RR 5.0)
  • Previous postpartum hemorrhage (RR 3.6)
  • Multiple gestation (RR 3.3)
  • Previous C/S (RR 1.7)
  • Multiparity (RR1.5)

8
Intrapartum Risk Factors
  • Prolonged 3rd stage (gt30 min) (RR7.5)
  • medio-lateral episiotomy (RR4.7)
  • midline episiotomy ( RR1.6)
  • Arrest of descent (RR 2.9)
  • Lacerations (RR 2.0)
  • Augmented labor ( RR1.7)
  • Forceps delivery (RR 1.7)

9
Easy to miss
  • Physicians underestimate blood loss by 50
  • Slow steady bleeding can be fatal
  • Most deaths from hemorrhage seen after 5h
  • Abdominal or pelvic bleeding can be hidden

10
Always look for signs of bleeding
  • Estimate blood loss accurately.
  • Evaluate all bleeding, including slow bleeds.
  • If mother develops hypotension, tachycardia or
    painrule out intra-abdominal blood loss.

11
Initial Assessment
  • Identify possible post partum hemorrhage.
  • Simultaneous evaluation and treatment.
  • Remember ABCs.
  • Use O2 4L/min.
  • If bleeding does not readily resolve, call for
    help.
  • Start two 16g or 18g IVs.

12
ALSOs 4 Ts
  • Tone (Uterine tone)
  • Tissue (Retained tissue--placenta)
  • Trauma (Lacerations and uterine rupture)
  • Thrombin (Bleeding disorders)

13
Tone Think of Uterine Atony
  • Uterine atony causes 70 of hemorrhage
  • Assess and treat with uterine massage
  • Use medication early
  • Consider prophylactic medication...

14
Bimanual Uterine Exam
  • Confirms diagnosis of uterine atony.
  • Massage is often adequate for stimulating uterine
    involution.

15
Medications for Uterine Atony
  • 1. Oxytocin promotes rhythmic contractions.
  • Give IM or IU, not IV. (Can cause ? BP)
  • 40U/L at 250cc/h.
  • 2. Methergine 0.2mg (1 amp) IM
  • 3. Hemabate 0.25mg IM q 15min (max X8).

16
Medications Methergine
  • Causes tetanic uterine contraction.
  • May trap placenta.
  • Can cause Hypertension, especially IV.
  • Contraindicated in hypertensive patients and
    those with pre-eclampsia.
  • Some authors skip Methergine altogether.

17
Prostaglandin F2 15-methyl
  • Hemabate 0.25mg IM or IU.
  • Used to be called Prostin.
  • Controls hemorrhage in 86 when used alone, and
    95 in combination with above.
  • Can repeat up to eight times.
  • Contraindicated in active systemic diseases.
  • Can cause nausea/vomiting/diarrhea, ? BP.

18
Tissue Retained placenta
  • Delay of placental delivery gt 30 minutes seen in
    6 of deliveries.
  • Prior retained placenta increases risk.
  • Risk increased with prior C/S, curettage
    p-pregnancy, uterine infection, AMA or increased
    parity.
  • Prior C/S scar previa increases risk (25)
  • Most patients have no risk factors.
  • Occasionally succenturiate lobe left behind.

19
Abnormal Placental Implantation
  • Attempt to remove the placenta by usual methods.
  • Excess traction on cord may cause cord tear or
    uterine inversion.
  • If placenta retained for gt30 minutes, this may be
    caused by abnormal placental implantation.

20
Abnormal implantation defined.
  • Caused by missing or defective decidua.
  • Placenta Accreta Placenta adherent to
    myometrium.
  • Placenta Increta myometrial invasion.
  • Placenta Percreta penetration of myometrium to
    or beyond serosa.
  • These only bleed when manual removal attempted.

21
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22
Removal of Abnormal Placenta
  • Oxytocin 10U in 20cc of NS placed in clamped
    umbilical vein.
  • If this fails, get OB assistance.
  • Check Hct, type cross 2-4 u.
  • Two large bore IVs.
  • Anesthesia support.

23
Removal of Abnormal Placenta
  • Relax uterus with halothane general anesthetic
    and subcutaneous terbutaline.
  • Bleeding will increase dramatically.
  • With fingertips, identify cleavage plane between
    placenta and uterus.
  • Keep placenta intact.
  • Remove all of the placenta.

24
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25
Removal of Abnormal Placenta
  • If successful, reverse uterine atony with
    oxytocin, Methergine, Hemabate.
  • Consider surgical set-up prior to separation.
  • If manual removal not successful, large blunt
    curettage or suction catheter, with high risk of
    perforation.
  • Consider prophylactic antibiotics.

26
Trauma (3rd T)
  • Episiotomy
  • Hematoma
  • Uterine inversion
  • Uterine rupture

27
Uterine Inversion
  • Rare 1/2000 deliveries.
  • Causes include
  • Excessive traction on cord.
  • Fundal pressure.
  • Uterine atony.

28
Uterine Inversion
  • Blue-gray mass protruding from vagina.
  • Copious bleeding.
  • Hypotension worsened by vaso-vagal reaction.
    Consider atropine 0.5mg IV if bradycardia is
    severe.
  • High morbidity and some mortality seen get help
    and act rapidly.

29
Uterine Inversion
  • Push center of uterus with three fingers into
    abdominal cavity.
  • Need to replace the uterus before cervical
    contraction ring develops.
  • Otherwise, will need to use MgSO4, tocolytics,
    anesthesia, and treatment of massive hemorrhage.
  • When completed, treat uterine atony.

30
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31
Uterine Rupture
  • Rare 0.04 of deliveries.
  • Risk factors include
  • Prior C/S up to 1.7 of these deliveries.
  • Prior uterine surgery.
  • Hyperstimulation with oxytocin.
  • Trauma.
  • Parity gt 4.

32
Uterine Rupture
  • Risk factors include
  • Epidural.
  • Placental abruption.
  • Forceps delivery (especially mid forceps).
  • Breech version or extraction.

33
Uterine Rupture
  • Sometimes found incidentally.
  • During routine exam of uterus.
  • Small dehiscence, less than 2cm.
  • Not bleeding.
  • Not painful.
  • Can be followed expectantly.

34
Uterine Rupture before delivery
  • Vaginal bleeding.
  • Abdominal tenderness.
  • Maternal tachycardia.
  • Abnormal fetal heart rate tracing.
  • Cessation of uterine contractions.

35
Uterine Rupture after delivery
  • May be found on routine exam.
  • Hypotension more than expected with apparent
    blood loss.
  • Increased abdominal girth.

36
Uterine Rupture
  • When recognized, get help.
  • ABCs.
  • IV fluids.
  • Surgical correction.

37
Birth Trauma
  • Lacerations of birth tract not rare causes post
    partum hemorrhage in 1/1500 deliveries.

38
Birth Trauma
  • Risk factors include
  • Instrumented deliveries.
  • Primiparity.
  • Pre-eclampsia.
  • Multiple gestation.
  • Vulvovaginal varicosities.
  • Prolonged second stage.
  • Clotting abnormalities.

39
Birth Trauma
  • Repair lacerations quickly.
  • Place initial suture above the apex of laceration
    to control retracted arteries.

40
Repair of cervical laceration
41
Birth Trauma Hematomas
  • Hematomas less than 3cm in diameter can be
    observed expectantly.
  • If larger, incision and evacuation of clot is
    necessary.
  • Irrigate and ligate bleeding vessels.
  • With diffuse oozing, perform layered closure to
    eliminate dead space.
  • Consider prophylactic antibiotics.

42
Pelvic Hematoma
43
Vulvar hematoma
44
Thrombin (4th T)
  • Coagulopathies are rare.
  • Suspect if oozing from puncture sites noted.
  • Work up with platelets, PT, PTT, fibrinogen
    level, fibrin split products, and possibly
    antithrombin III.

45
Prevention?
  • Some evidence supports use of oxytocin after
    delivery of anterior shoulder, in umbilical vein
    or IV.

46
Summary remember 4 Ts
  • Tone
  • Tissue
  • Trauma
  • Thrombin

47
Summary remember 4 Ts
  • TONE
  • Rule out Uterine Atony
  • Palpate fundus.
  • Massage uterus.
  • Oxytocin 40U/L _at_ 250cc / h.
  • Methergine one amp IM (not in hypertensives)
  • Hemabate IM q 15min

48
Summary remember 4 Ts
  • Tissue
  • R/O retained placenta
  • Inspect placenta for missing cotyledons.
  • Explore uterus.
  • Treat abnormal implantation.

49
Summary remember 4 Ts
  • TRAUMA
  • R/o cervical or vaginal lacerations.
  • Obtain good exposure.
  • Inspect cervix and vagina.
  • Worry about slow bleeders.
  • Treat hematomas.

50
Summary remember 4 Ts
  • THROMBIN
  • Check labs if suspicious.
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