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Ch 35. OBSTETRICAL HEMORRHAGE

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Title: Ch 35. OBSTETRICAL HEMORRHAGE


1
Ch 35. OBSTETRICAL HEMORRHAGE
  • ????? ????
  • R3 ? ? ?

2
  • OBSTETRICS
  • - bloody business
  • - transfusion reduce the maternal mortality
    rate
  • death from hemorrhage
  • - but, hemorrhage is leading cause of maternal
    mortality
  • and ICU care in obstetrics hospital
  • - so, prompt administration of blood are
    absolute
  • requirements for acceptable obstetrical
    care

3
  • - hemorrhage
  • antepartum placental previa, placetal
    abruption
  • postpatrum uterine atony, genital tract
    laceration

4
  • causes of hemorrhage
    number()
  • Placental abruption
    141(19)
  • Laceration/uterine rupture
    125(16)
  • Uterine atony
    115(15)
  • Coagulopathies
    108(14)
  • Placental previa
    50(7)
  • Uterine bleeding
    47(6)
  • Placenta accreta/increta/percreta
    44(6)
  • Retained placenta
    32(4)

5
  • Incidence and predisposing conditions
  • - the incidence of obstetrical hemorrhage
    cannot
  • be determined precisely
  • - Combs and colleagues(1991)
  • Hct drop of 10 vol.
  • ? 3.9 in vaginal delivery
  • 68 in cesarean delivery

6
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7
ANTEPARTUM HEMORRHAGE
  • bloody show
  • - in active labor
  • the consequence of effacement dilatation
    of cervix
  • tearing of small veins
  • Bleeding from a site above the cervix before
    delivery
  • - placenta previa
  • placental abruption
  • vasa previa
  • ? Delivery should be considered in any woman
    at term
  • with unexplained vaginal bleeding

8
  • lt PLACENTAL ABRUPTION gt
  • Definition
  • - the separation of the placenta from its
    site of
  • implantation before delivery
  • - abruptio placentae rending asunder of the
    placenta
  • - total vs. partial
  • external vs. concealed
  • concealed - much greater maternal and
    fetal hazard
  • - diagnosis typically is
    made later

9
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10
  • Frequency and significance
  • - average about 1 in 200 deliveries
  • - so extensive as to kill the fetus
  • 1 in 420 deliveries (19561967)
  • - high-parity woman ? prenatal care ?
    emergency
  • transportation improved
  • the frequency of abruption causing fetal
    death
  • dropped to about 1 in 830 deliveries
    (19741989)

11
  • Perinatal morbidity and mortality
  • - as stillbirths from other causes have
    decreased, those
  • from placental abruption have become
    especially
  • prominent
  • - but, perinatal mortality was 25-fold higher
    with
  • placental abruption
  • - if the infant does survive, there may be
    adverse
  • sequelae
  • neurological deficits (15), cerebral
    palsy (20)

12
  • Ethiology
  • risk factor
    relative risk
  • increased age and parity
    1.31.5
  • preeclampsia
    2.14.0
  • chronic hypertension
    1.83.0
  • PtPROM
    2.44.9
  • mutifetal gestation
    2.1
  • hydramnios
    2.0
  • smoking
    1.41.9
  • thrombophilias
    37
  • cocaine use
    NA
  • prior abruption
    1025
  • uterine leiomyoma
    NA

13
  • - maternal age

14
  • race (African-American, Caucasian gt Asian,
    Latin-American)
  • HTN (preeclampsia, gestational HTN ,
    chronic HTN)
  • but, the severity of preeclampsia did
    not correlate
  • with the incidence of abruption
  • Mg - reduce risk of placental abruption
  • (Magpie Trial collaborative Group, 2002)
  • external trauma
  • 26 hrs monitoring
  • uterine leiomyoma
  • especially, located behind the placental
    implantation
  • site

15
  • Recurrent Abruption
  • - recurrence rate 1 in 8 pregnancies
  • - fetal death rate was increased in a second
    time
  • - 13 wks earlier than the first time
  • - suddenly occur ay any time
  • fetal well-being is normal beforehand, and
    thus not
  • predictive
  • ex.) NST, CST normal
  • 4 hrs later placental abruption
  • ? killed the fetus

16
  • Pathology
  • - hemorrhage into the decidua basalis
  • ? decidua splits, leaving thin layer adherent
    to the
  • myometrium
  • ? decidual hematoma leads to separation,
    compression,
  • and destruction of placenta
  • - in early stage, no clinical symptom, a few
    centimeters
  • in diameter (dark and clotted blood)
  • ? a very recent separated placenta appear no
    different
  • from a normal placenta

17
  • - decidual spiral artery ruptures
  • ? retroplacental hematoma
  • ? expands disrupts more vessel placenta
  • ? separation rapidly to the margin
  • (because, the uterus still distended by
    conception,
  • so it is unable to contract to compress the
    torn
  • vessels that supply the placental site)

18
  • Concealed hemorrhage
  • - placenta margins still remain adherent
  • - placenta completely separated. but membranes
    retain
  • their attachment to the uterine wall
  • - blood gains to the amnionic cavity after
    breaking
  • through the membrane
  • - fetal head is closely applied to the lower
    uterus,
  • blood cannot pass

19
  • Chronic placental abruption
  • - retroplacental hematoma formation is somehow
  • arrested completely without delivery
  • Fetal-to-maternal hemorrhage
  • - placental abruption bleeding almost
    maternal
  • - fetal bleeding non traumatic (20, lt10ml)
  • traumatic (tear or
    fracture of placenta)

20
  • Clinical diagnosis
  • sign or symptom
    frequency()
  • vaginal bleeding
    78
  • uterine tenderness or back pain
    66
  • fetal distress
    60
  • preterm labor
    22
  • high-frequency contractions
    17
  • hypertonus
    17
  • dead fetus
    15

21
  • - but, vary .
  • profuse bleeding, but placental
    separation may not
  • so extensive to compromise the fetus
  • no external bleeding, but completely
    sheared off and
  • the fetal dead
  • - ultrasound
  • infrequently confirms
  • negative finding do not exclude placental
    abruption

22
  • Shock
  • - intensity of shock is seldom out of
    proportion to
  • maternal blood loss
  • - but, shock ? amount of hemorrhage
  • (thromboplastin from decidua placenta
    entered
  • the maternal circulation and incited
    coagulopathy
  • or amnionic embolism)
  • - oliguria caused by inadequate renal
    perfusion
  • response to vigorous treatment

23
  • Differential diagnosis
  • - severe form diagnosis generally is obvious
  • milder or common form difficult
  • - lab diagnostic method
  • detect lesser degree of abruption
    accurately
  • - painless bleeding placenta previa
  • painful bleeding placental abruption
  • ? but, variable state
  • - so, differential diagnosis is not simple
    !!!!!!!!

24
  • Consumptive coagulopathy
  • - most common
  • - hypofibrinogenemia, FDP?, D-dimer?,
  • coagulation factor?
  • ? 30, enough to kill the fetus
  • - major mechanism
  • coagulation intravascularly
    retroplacentally
  • ? the activation of plasminogen to plasmin
  • ? maintaining patency of the
    microcirculation

25
  • Renal failure
  • - severe form of placental abruption
  • the consequence of massive hemorrhage
  • treatment of hypovolemia is delayed or
    incomplete
  • - with preeclampsia
  • renal vasospasm is likely intensified
  • - proteinuria is common without preeclampsia
  • ? blood crystalloid solution apply !!!!!!

26
  • Couvelaire uterus (uteroplacental apoplexy)
  • - extravasation of blood into the uterine
    musculature
  • and beneath the uterine serosa, broad
    ligament
  • - interfere with uterine contraction
  • severe postpartum hemorrhage
  • but, not an indication for hysterectomy

27
  • Management
  • - depending on gestational age, maternal
    fetal status
  • - blood crystalloid and prompt delivery
  • Expectant management in preterm pregnancy
  • tocolytics, close observation
  • but, fetal distress was seen
  • ? prompt delivery immediate treatment

28
  • Tocolysis
  • tocolysis improved outcome in a highly
    selected
  • group (preterm, partial abruption)
  • Towers and co-workers(1995)
  • Mg or terbutaline to 95 women
  • ? perinatal mortality 5
  • (did not differ from the nontreated
    group)
  • placental abruption should be considered
    a
  • contraindication to tocolytic therapy

29
  • Cesarean delivery
  • rapid delivery (fetus alive but in
    distress)
  • Kayani and colleagues(2003)
  • ? at fetal bradycardia (33case)
  • 22 was neurologic intact (with in 20
    min 15)
  • 11 was died or cerebral palsy (beyond
    20 min 8)
  • decision time is an important factor in
    neonatal
  • outcome

30
  • Vaginal delivery
  • fetal death, no obstetrical complication
  • coagulation defect (?incision site
    bleeding)
  • ? vaginal delivery
  • hemostasis
  • uterine contraction-pharmacologically or
    massage
  • Labor
  • hypertonic -baseline gt50mmHg,
  • rhythmic contraction
    75100mmHg

31
  • Amniotomy
  • as early as possible
  • decrease bleeding from the implantation
    site
  • reduce the entry into the maternal
    circulation of
  • thromboplastin (but, no evidence)
  • Oxytocin
  • if no rhythmic uterine contraction
  • - oxytocin is given in standard doses

32
  • Timing of delivery after severe placental
    abruption
  • - when the fetus is dead or previable,
  • there is no evidence that establishing a
    time limit
  • fro delivery is necessary
  • - maternal outcome depends on
  • adequate fluid and blood replacement
    therapy rather
  • than on the interval to delivery

33
  • ltPLACENTA PREVIAgt
  • Definition
  • - the placenta is located over or very near
    the internal
  • os of cervix
  • - total
  • partial
  • marginal
  • low-lying

34
  • - vasa previa
  • the fetal vessels course through
    membranes and
  • present at the cervical os

35
  • - the degree of placenta previa
  • the cervical dilatation at the time of
    examination
  • ex) 2cm low-lying
  • 8cm patial
  • - spontaneous placental separation is
    inevitable
  • due to the formation of the lower segment
    and
  • cervical dilatation ? vessel disrupted
  • - digital palpation can incite severe
    hemorrhage !!!

36
  • Incidence
  • - 1 in 305 deliveries (Martin, 2002)
  • 1 in 300 deliveries (Crane, 1999)
  • Prenatal morbidity and mortality
  • - neonatal mortality threefold higher (?
    preterm birth)
  • - fetal anomalies 2.5-fold (reasons are
    unclear)
  • - growth restriction 20
  • - low birthweight due to preterm birth and
    growth
  • impairment

37
  • Etiology
  • - maternal age 1 in 1500 (lt19 yrs old)
  • 1 in 100 (gt35 yrs old)
  • - multiparity
  • - multifetal gestations
  • - prior cesarean delivery 1.9 (2 times
    c/sec)
  • 4.1 (gt3
    times c/sec)
  • ?prior uterine incision with a previa
    increases the
  • incidence of cesarean hysterectomy
  • - smoking
  • CO hypoxemia ? compensatory placetal
    hypertrophy

38
  • Clinical findings
  • - painless hemorrhage, usuallydoes not appear
    until
  • near the end of the 2nd trimester or after
  • - the initial bleeding is rarely so profuse as
    to prove
  • fatal, usually cease spontaneously
  • - because the lower segment contracts poorly
    compared
  • with the body, hemorrhage from implantation
    site may
  • continue after delivery
  • - bleeding from cervical or lower segment
    laceration
  • following manual removal

39
  • Placenta accreta, increta, and percreta
  • - placenta previa is associated placenta
    accreta
  • - because of poorly developed decidua in the
    lower
  • uterine segment
  • - 7 of 514 case of previa (Frederiksen, 1999)
  • Coagulation defects
  • - rarely
  • - because of thromboplastin escape through the
    cervical
  • canal rather than into the maternal
    circulation

40
  • Diagnosis
  • - uterine bleeding during the later half of
    pregnancy
  • - unless a finger is passed through the cervix
    and
  • the placenta is palpated
  • ? but, digital examination torrential
    hemorrhage!!!
  • - placental location can almost be obtained by
  • sonography

41
  • Localization by sonography
  • - transabdominal sonography
  • accuracy - 98
  • false positive - ? bladder distention
  • large placenta
  • - transvaginal sonography
  • be superior than transabdominal
    sonogparhy
  • visualize cervical os in all case (70,
    transabdomen)
  • - transperineal sonography
  • - MRI

42
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43
  • Placental Migration
  • - 1820 weeks low lying, not cover internal
    os
  • ? did not persist
    previa
  • - midpregnancy cover internal os
  • ? 40 persisted as a
    previa
  • - during 2nd or early 3rd trimester close
    but not cover
  • ? unlikely to persist
    as previa by term

44
  • - in absence of any
  • other abnormality, so-
  • nography need not be
  • frequently repeated
  • simply to follow place-
  • ntal position
  • - 28 weeks

45
  • - mechanism of placental movement
  • not completely understood
  • - migration
  • clearly a misnomer, because invasion of
    chorionic
  • villi into the decidua persist
  • and, relationship in a three-dimensional
    manner
  • using two-dimensional sonography
  • differential growth of lower and upper
    myometrial
  • segments as pregnancy progresses

46
  • Management
  • - may be considered as follows
  • 1. fetus is preterm and no indication for
    delivery
  • 2. fetus is reasonably mature
  • 3. in labor
  • 4. hemorrhage is so severe as to mandate
    delivery
  • despite fetal immaturity

47
  • - preterm, but with no active bleeding
  • close observation
  • - prolonged hospitalization may be ideal,
    however,
  • usually discharged after bleeding has
    ceased and
  • her fetus judged to be healthy
  • ? prepared to transport her to the hospital
  • immediately

48
  • Delivery
  • - cesarean delivery is necessary
  • incision (transverse or vertical)
  • if incision extends through the placenta,
    maternal
  • or fetal outcome is rarely compromised
  • - poorly contractile nature of the lower
    segment, there
  • may be uncontrollable hemorrhage following
    placental
  • removal (without accreta)

49
  • - hemostasis methods
  • oversewing the implantation site with chr
    1-0
  • bilateral uterine or internal iliac
    artery ligation
  • circular interrupted suture around the
    lower segment,
  • above and below transverse incision with
    chr 1-0
  • tightly packed with gauze, and then
    removed
  • transvaginally 12 hours later
  • pelvic artery embolization
  • ? fail.. Hysterectomy !!!!!

50
  • Prognosis
  • - adequate transfusion and cesarean delivery
  • marked reduction in maternal mortality
  • - serum AFP gt 2,0 MOM
  • increased risk of bleeding early in the
    3rd trimester
  • and of preterm birth (Butler, 2001)

51
POSTPARTUM HEMORRHAGE
52
  • Definition
  • - traditionally, gt 500mL
  • after completion of
  • the third stage of
  • labor

53
  • - gt1,000mL blood loss 5
  • - commonly estimated blood loss (EBL)
  • only about half the actual loss
  • ? so, EBL gt 500mL danger !!!

54
  • - normal pregnancy induced hypervolemia
  • nonpregnant total blood volume (TBV)
  • height(inch)x50 weight(pound)x25 /
    2
  • increases by 3060 , 15002000ml
  • but increase is less in preeclampsia or
    eclampsia
  • and more with multiple fetus
  • so, normally pregnant woman tolerates
    blood loss
  • at delivery without any remarkable
    decrease in
  • postpartum Hct

55
  • - blood loss can be estimated
  • calculated pregnancy hypervolemia
  • 500mL (each 3 vol.
    drop in Hct)
  • - mean postpartum Hct decline
  • 2.64.3 vol. (vaginal delivery)
  • 4.2 vol. (c/sec)
  • - late postpartum hemorrhage
  • hemorrhage after the first 24 hours

56
  • Hemostasis at the placental site
  • - near term, 600mL/min of blood flows through
    the
  • intervillous space
  • - hemostasis
  • depend on intrinsic vasospasm and
    formation of
  • blood clot locally
  • contraction and retraction of the
    myometrium to
  • compress the large vessel and obliterate
    lumen
  • - adherent pieces of placenta or large blood
    clots
  • prevent effective contraction and retraction

57
  • Clinical characteristics
  • - begins before or after placental delivery
  • no massive bleeding, steady bleeding
  • - the effect of hemorrhage depend to
  • nonpregnant blood volume
  • magnitude of pregnancy induced
    hypervolemia
  • degree of anemia at the time of delivery
  • ex) normotensive ? hypertensive at
    initially
  • hypertensive ? normotensive
    although remarkably
  • hypovolemic

58
  • - with severe preeclampsia
  • not normally expanded blood volume
  • very sensitive and intolerant to blood
    loss
  • so, when excessive hemorrhage is
    suspected,
  • prompt vigorous crystalloid and blood
    replacement
  • - blood may not escape vaginally
  • distended, gt1000mL
  • adequate fundus monitored massage

59
  • Diagnosis
  • - except intrauterine intravaginal
    accumulation of
  • blood or intraperitoneal bleeding (uterine
    rupture)
  • ? diagnosis of postpartum hemorrhage is
    obvious
  • - well contracted uterus, fresh bleeding
  • ? laceration !!!
  • - atony laceration bleeding
  • ? inspection of the cervix, vagina
  • confirm uterine contraction
  • (with adequate anesthesia)

60
  • Sheehan syndrome (pituitary failure)
  • - after severe intrapartum or postpartum
    hemorrhage
  • - character lactation(x), ammenorrhea, breast
    atpophy,
  • pubic axillary hair loss,
    hypothyroidism,
  • adrenal cortical
    insufficiency
  • - but, do not developed in most severe
    bleeding women
  • - pathogenesis ant. pituitary necrosis
  • ? endocrine
    abnormalities

61
  • - lactation after delivery, but not always,
    excludes
  • extensive pituitary necrosis
  • - average duration of onset of symptom 5
    years
  • - incidence 1 in 10,000 deliveries
  • less common today
  • - pituitary CT pituitary was abnormal
  • sella turcica was totally
    or partially empty
  • (Bakiri, 1991)

62
  • ltTHIRD-SATGE BLEEDINGgt
  • - the result of transient partial separation
    of the placenta
  • - Duncan blood escape into vagina
    immediately
  • Schultze blood may be concealed behind
    the
  • placenta and membrane until
    the placenta
  • is delivered
  • - descent of the placenta cord become slack
  • but, if bleeding continue, manual removal
    of the
  • placenta is mandatory
  • - when uterine atony, cord traction may cause
    uterine
  • inversion

63
  • Prolonged third-stage bleeding
  • - there is still no definite answer the length
    of time
  • - Combs and Laros (1991)
  • median duration - 6 min
  • 3.3 - gt 30 min
  • Technique of manual removal
  • - adequate analgesia of anesthesia
  • - aseptic surgical technique
  • - after delivery, wipe out the uterine cavity
    with a
  • sponge

64
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65
  • Management after delivery of placenta
  • - always fundus should be palpated and fundal
  • massage
  • - oxytocin 20 IU / 1,000mL fluid IV 10
    mL/min
  • - oxytocin should never be given as an
    undilutes
  • bolus dose
  • hypotension or cardiac arrhythmia may
    occur

66
  • ltUTERINE ATONYgt
  • - overdistended uterus large fetus, multi
    fetuses,
  • hydramnios
  • - labor initiated or augmented with oxytocin
  • - high parity
  • - previous postpartum hemorrhage
  • - constant kneading and squeezing of the
    uterus that
  • already is contracted impedes the
    physiologic
  • mechanism of placental detachment
  • causing incomplete placental separation
    and
  • increased blood loss

67
  • Ergot derivatives
  • - IM methylergonovine (0.2 mg)
  • - IV administered, dangerous hypertension,
    especially
  • in women with preeclampsia

68
  • Prostaglandins
  • - 15-methyl derivative of prostaglandin F2a
  • initial dose 0.25 mg IM
  • 1590 min interval, Max 8 doses
  • side effect diarrhea, HBP, vomiting,
    fever,
  • flushing, tachycardia
  • arterial oxygen desaturation - pulmonary
    airway

  • and vascular constriction

69
  • - prostaglandin E2
  • rectally 20 mg
  • - misoprostol (Cytotec, prostaglandin E1
    analogue)
  • 1,000? rectally
  • response time 1.4 min
  • - Villar (2002)
  • oxytocin and ergot preparation
    administered during
  • the third stage of labor were more
    effective than
  • misoprostol for the prevention of
    postpartum
  • hemorrhage

70
  • Bleeding unresponsive to oxytocics
  • 1. bimanual uterine compression
  • 2. help !
  • 3. 2nd IV line crystalloid with oxytocin
  • 4. blood transfusion ABO type, Coombs test
  • O(-)
    universal donor
  • 5. explore uterine cavity manually
  • placental remnant or laceration
  • 6. inspect the cervix and vagina
  • 7. foley keep urine output check (renal
    perfusion)

71
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72
  • Internal iliac artery ligation
  • - reduce the hemorrhage
  • technically difficult, successful in less
    than half
  • - nonabsorbable material suture
  • - mechanism
  • 85 reduction in pulse pressure in those
    arteries
  • distal to the ligation
  • more amenable to hemostasis via simple
    clot
  • fromation
  • - bilateral dose not intefere subsequent
    reproduction

73
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74
  • Uterine compression sutures
  • - B-Lynch (1997)
  • - chromic 2-0
  • - be effective some cases, however, published
  • experience with these technique remains
    limited

75
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76
  • Uterine packing
  • - who wish to preserve fertility
  • - cause of concealed bleeding and infection
  • - Roman and Rebarber (2003)
  • 24F foley with 30 mL balloon
  • 6080 mL ballooning
  • typically remove after 124 hours
  • - be packed directly with gauze
    (Glistrap,2002)
  • - after hysterectomy (Howard,2002)
  • umbrella packing (sterile x-ray bag)
  • removed vaginally after 24 hrs

77
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78
  • Recombinant activated factor VII
  • - vitamin K-dependent protein
  • - administration for treatment of hemophilia,
    acquired
  • antibodies to components of the intrinsic
    pathway
  • and congenital factor VII deficiency
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