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Management of Obstetrical Hemorrhage

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Retained products of conception with atony. Placental site involution ... Uterine Atony: 1 in 20 to 1 in 100 deliveries (80% of PPH) ... – PowerPoint PPT presentation

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Title: Management of Obstetrical Hemorrhage


1
Management of Obstetrical Hemorrhage
  • Jeffrey Stern, M.D.

2
Incidence of Obstetrical Hemorrhage
  • 4 of SVD
  • 6.4 of C-sections
  • 13 of maternal deaths (110,000 to 11,000)
  • 10 risk of recurrence

3
Etiology of Obstetrical Hemorrhage Antepartum
  • Placenta previa
  • Abruption
  • Coagulopathy ITP/pre-eclampsia, FDIU

4
Etiology of Obstetrical Hemorrhage Intrapartum
  • Placenta previa
  • Abruption
  • Abnormal placentation
  • Genital tract lacerations (2.4 odds ratio)
  • Uterine rupture
  • Coagulopathy infection, abruption, amniotic
    fluid embolism

5
Etiology of Postpartum Hemorrhage
(Primary) (Within 24 hours of delivery)
  • Uterine atony (3.3 odds ratio)
  • Induction or Augmentation of labor (1.4 odds
    ratio)
  • Retained products of conception (3.5 odds ratio)
  • Placenta accreta, increta, percreta (3.3 odds
    ratio)
  • Coagulopathy
  • Fetal death in utero
  • Uterine inversion may need MgSO4, Halothane,
    Terbutaline, NTG
  • Amniotic fluid embolism

6
Etiology of Postpartum Hemorrhage
(Secondary) (After 24 hours of delivery to 6
weeks postpartum)
  • 0.5-2 of patients
  • Infection
  • Retained products of conception with atony
  • Placental site involution
  • Rx DC, ABX, uterotonic medications

7
Uterine Atony 1 in 20 to 1 in 100 deliveries
(80 of PPH)
  • Uterine over distension (Polyhydramnios, Multiple
    gestations, Macrosomia)
  • Prolonged labor uterine fatigue (3.4 odd
    ratio)
  • Precipitory labor
  • High parity
  • Chorioamnionitis
  • Halogenated anesthetic
  • Uterine inversion

8
Treatment of Uterine Atony
  • Message fundus continuously
  • Uterotonic agents
  • Foley catheter/Bakri balloon (500cc)
  • Uterine packing usually ineffective but can
    temporize
  • Modified B-Lynch stitch (2chromic)
  • Uterine, utero-ovarian, hypogastric artery
    ligation
  • Subtotal/Total abdominal hyst.

9
Treatment of Uterine Atony
  • Oxytocin 90 success
  • 10-40 units in 1 liter NS or LR rapid infusion
  • Methylergonovine (Methergine) 90 success
  • 0.2 mg IM q 2-4 hours max. 5 doses avoid with
    hypertension
  • Prostaglandin F2 Alpha (Hemabate) 75 success
  • 250 micrograms IM, intramyometrial, repeat q
    20-90 min. max. 8 doses Avoid if asthma/Hi BP
  • Prostaglandin E2 suppositories (Dinoprostone,
    Prostin E2) 75 success
  • 20 mg per rectum q 2 hours avoid with
    hypotension
  • Prostaglandin PGE 1 Misoprostol (Cytotec) 75 -
    100 success
  • 1000 microgram per rectum or sublingual (ten 100
    micrograms tabs/five 200 micrograms tabs)

10
Retained Products of Conception Etiology
  • Succentiurate lobe
  • Placenta accreta, increta, percreta
  • Previous C-section hysterotomy
  • Previous puerperal curettage
  • Previous placenta previa
  • High parity

11
Management of Retained Products of Conception
  • Examine placenta carefully
  • Manual exploration of uterus
  • Careful curettage-Banjo curret

12
Placenta Accreta, Increta, Percreta Risk Factors
  • High Parity
  • Previous placenta previa
  • Previous C-section
  • GTN
  • Advanced maternal age
  • Previous uterine abnormal placentation

13
Management of Abnormal Placentation
  • Placenta will not separate with usual maneuvers
  • Curettage of uterine cavity
  • Localized resection and uterine repair
    (Vasopressin 1cc/10cc N.S-sub endometrial)
  • Leave placenta in situ
  • If not bleeding Methotrexate
  • Uterus will not be normal size by 8 weeks
  • Uterine, utero-ovarian, hypogastric artery
    ligation
  • Subtotal/total abdominal hysterectomy

14
Uterine Inversion 1 in 2500 Deliveries
  • Risk factors Abnormal placentation, excessive
    cord traction
  • Treatment
  • Manual replacement
  • May require halothane/general anesthesia
  • Remove placenta after re-inversion
  • Uterine tonics and massage after placenta is
    removed
  • May require laparotomy

15
Coagulopathy
  • Hereditary
  • Acquired
  • Preganancy induced hypertension
  • Abruption
  • Sepsis
  • Fetal death in utero
  • Amniotic fluid embolism
  • Massive blood loss

16
Genital Tract Laceration and Hematomas Etiology
  • Macrosomia
  • Forceps
  • Episiotomy
  • Precipitous delivery
  • C-section incision extension
  • Uterine rupture

17
Therapy of Genital Tract Lacerations
  • Superficial lacerations and small hematomas
    expectant
  • Large laceration
  • Repair in layers
  • Consider a drain

18
Hematomas
  • Below pelvic diaphragm (vulva, paracolpos,
    ischiorectal fossa)
  • Leave alone if possible
  • Legate bleeder - often difficult to find
  • Pack open
  • Drain
  • May need combined abdominal/perineal approach
  • Above the pelvic diaphragm
  • Laparotomy- especially if expanding
  • Combined abdominal/perineal approach

19
Selective Artertial Embolization by Angiography
  • Clinically stable patient Try to correct
    coagulopathy
  • Takes approximately 1-6 hours to work
  • Often close to shock, unstable, require close
    attention
  • Can be used for expanding hematomas
  • Can be used preoperatively, prophylactically for
    patients with accreta
  • Analgesics, anti-nausea medications, antibiotics

20
Selective Artertial Embolization by Angiography
  • Real time X-Ray (Fluoroscopy)
  • Access right common iliac artery
  • Single blood vessel best
  • Embolize both uterine or hypogastric arteries
  • Sometimes need a small catheter distally to
    prevent reflux into non-target vessels
  • May need to treat entire anteriordivision or even
    all of the internal iliac artery.
  • Risks Can embolize nearby organs and presacral
    tissue, resulting in necrosis
  • Technique
  • Gelfoam pads Temporary, allows recanalization
  • Autologous blood clot or tissue
  • Vasopressin, dopamine, Norepinephrine
  • Balloons, steel coils

21
(No Transcript)
22
Evaluate for Ovarian Collaterals May need to
embolize
23
Mid-Embolization Pruned Tree Vessels
24
Post Embolization
25
Post Embolization
Pre Embo
Post Embo
26
Uterine Rupture
  • Scarred versus scarless uterus
  • Uterine scar dehiscence separation of scar
    without rupture of membranes
  • 2-4 of deliveries after previous transverse
    uterine incision
  • Morbidity is usually minimal unless placenta is
    underneath or it tears into the uterine vessels
  • Diagnosis after vaginal delivery
  • Often asymptomatic, incidental finding
  • Difficult to diagnose because lower uterine
    segment is very thin
  • Therapy is expectant if small and asymptomatic
  • Diagnosed at C-section Simple debridement and
    layered closure

27
Uterine Rupture Etiology
  • Previous uterine surgery - 50 of cases
  • C-section, Hysterotomy, Myomectomy
  • Spontaneous (1/1900 deliveries)
  • Version-external and internal
  • Fundal pressure
  • Blunt trauma
  • Operative vaginal delivery
  • Penetrating wounds

28
Uterine Rupture Etiology
  • Oxytocics
  • Grand multiparity
  • Obstructed labor
  • Fetal abnormalities-macrosomia, malposition,
    anomalies
  • Placenta percreta
  • Tumors GTN, cervical cancer
  • Extra-tubal ectopics

29
Classic Symptoms of Uterine Rupture
  • Fetal distress
  • Vaginal bleeding
  • Cessation of labor
  • Shock
  • Easily palpable fetal parts
  • Loss of uterine catheter pressure

30
Uterine Rupture
  • Myth Uterine incisions which do not enter the
    endometrial cavity will not
  • subsequently rupture
  • Type of closure no relation to tensile strength
  • Continuous or interrupted sutures chromic,
    vicryl, Maxon
  • Inverted or everted endometrial closure
  • Degree of complications
  • Inciting event- spontaneous, traumatic
  • Gestational age
  • Placental site in relation to rupture site
  • Presence or absence of uterine scar
  • Scar 0.8 mortality rate
  • No scar 13 mortality rate
  • Location of scar
  • Classical scar- majority of catastrophic ruptures
  • Transverse scar- less vascular less likely to
    involve placenta
  • Extent of rupture

31
Management of Uterine Rupture
  • Laparotomy
  • Debride and repair in 2-3 layers of Maxon/PDS
  • Subtotal Hysterectomy
  • Total Hysterectomy

32
Pregnancy After Repair of Uterine Rupture
  • Not possible to predict rupture by HSG/Sono/MRI
  • Repair location
  • Classical -------------------------48
  • Low transverse------------------16
  • Not recorded---------------------36
  • Re-rupture-------------------12
  • Maternal death--------------1
  • Perinatal death--------------6
  • (Plauche, W.C 1993)

33
Modified Smead-Jones Closure
  • Running looped 1 PDS/Maxon
  • Contaminated wounds/under tension
  • Additional Interruptured sutures - 2 cm apart
  • Fascial edges should be approximated
  • No tension
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