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Peripartum Hemorrhage

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Anita M. Backus, M.D. Associate Clinical Professor, UCLA School of Medicine Director of Obstetric Anesthesia, UCLA Medical Center Peripartum Hemorrhage Causes of ... – PowerPoint PPT presentation

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Title: Peripartum Hemorrhage


1
Peripartum Hemorrhage
  • Anita M. Backus, M.D.
  • Associate Clinical Professor, UCLA School of
    Medicine
  • Director of Obstetric Anesthesia, UCLA Medical
    Center

2
Peripartum Hemorrhage
  • Causes of maternal death in US, 1987-90
    (9.1/100,000)
  • hemorrhage 28.7 (?)
  • embolism 19.7 (?)
  • pregnancy-induced hypertension 17.6 (?)
  • infection 13.1 (?)
  • cardiomyopathy 5.6 (?)
  • anesthesia 2.5 (?)
  • compared with 1979-86

3
Antepartum Hemorrhage
  • 4 of women may develop antepartum hemorrhage.
  • Causes
  • placenta previa (1/200)
  • placental abruption (1/100)
  • uterine rupture (lt1 in scarred uterus)
  • vasa previa (1/2000-3000)

4
Placenta Previa
  • Definitions
  • Total covers the cervical os
  • Partial covers part of the os
  • Marginal lies close to, but does not cover, the
    os
  • Risk factors
  • multiparity
  • advanced maternal age
  • prior C/S or other uterine surgery
  • prior placenta previa

5
Placenta Previa Diagnosis
  • Painless vaginal bleeding in 2nd/3rd trimester
  • Confirmed by ultrasound
  • Vaginal exams are avoided
  • Up to 10 may have simultaneous abruption
  • Maternal shock is uncommon with 1st presentation
    of bleeding

6
Placenta Previa Obstetric Management
  • If possible, delay delivery until fetus is mature
  • Indications for delivery
  • active labor
  • documented fetal lung maturity
  • ? 37 weeks gestational age
  • excessive bleeding
  • development of another obstetric complication
    mandating delivery

7
Placenta Previa Anesthetic Management
  • Evaluation on arrival
  • airway
  • volume status
  • large bore IV access
  • type and cross
  • HCT
  • Patient has ? bleeding risk during surgery
  • OB may have to cut into placenta to remove baby
  • lower uterine implantation site does not contract
    as well as normal fundal site
  • ? risk of placenta accreta (esp. if prior C/S)

8
Placenta Previa Anesthetic Management II
  • Large bore IV(s)
  • Low threshold for type and cross / blood in room
  • If active hemorrhage, GA, RSI, ketamine (0.5-1.0
    mg/kg) or etomidate (0.3 mg/kg), succinylcholine
  • Maintenance 50/50 nitrous oxide and oxygen (may
    omit nitrous if severe fetal distress) low
    concentration inhalational agent if tolerated
  • After delivery pitocin and ? or omit halogenated
    agent ? nitrous oxide, add opioid
  • Be alert for placenta accreta, massive blood
    loss, C-hyst
  • May require invasive monitoring (aline, CVP)

9
Placenta Previa Anesthetic Management III
  • Elective, not in labor
  • regional anesthesia (spinal vs. epidural)
    preferred
  • In labor, not hemorrhaging
  • regional anesthesia preferred
  • Importance of history of prior C/Ss

10
Placental Abruption
  • Premature separation of placenta from endometrium
  • Diagnosis vaginal bleeding, uterine tenderness,
    ? uterine tone
  • Risk factors
  • HTN multiparity
  • AMA smoking
  • PROM cocaine
  • trauma h/o abruption

11
Placental Abruption II
  • Complications
  • shock
  • acute renal failure
  • DIC (coagulopathy in 10 of these pts.)
  • fetal distress/demise
  • Hidden blood loss may approach 2500 cc

12
Placental Abruption Obstetric Management
  • Depends on fetal maturity, size of abruption,
    presence of fetal distress
  • continuation of pregnancy
  • induction/augmentation of labor
  • Cesarean section

13
Placental Abruption Anesthetic Management
  • Be alert for possibility of coagulopathy and/or
    hypovolemia before considering regional
    anesthesia
  • For stat C/S, GA most appropriate if known or
    suspected hypovolemia or DIC
  • ketamine (or etomidate)
  • volume resuscitation
  • ? invasive monitoring

14
Uterine Rupture vs. Dehiscence
  • Uterine scar dehiscence
  • fetal membranes remain intact, fetus is not
    extruded intraperitoneally, separation limited to
    old scar, peritoneum overlying is intact
  • usually no fetal distress / mat. hemorrhage
  • Uterine rupture
  • separation of scar ? extension, rupture of fetal
    membranes with extrusion
  • results in fetal distress / mat. hemorrhage
  • fetal mortality 35

15
Uterine Rupture II
  • Diagnostic features
  • vaginal bleeding
  • hypotension
  • cessation of labor
  • fetal distress
  • pain present in only 10
  • postpartum hemorrhage may be a sign
  • Treatment uterine repair, arterial ligation,
    hysterectomy (may be preferred)

16
Comparison of Presentation of Abruption v.
Previa v. Rupture
  • abruption previa rupture
  • abd. pain present absent variable
  • vag. blood old fresh fresh
  • DIC common rare rare
  • acute fetal common rare common
  • distress

17
Vasa Previa
  • Umbilical vessels separate in the membranes at a
    distance from the placental margin and some of
    the vessels (fetal) cross the internal os and
    occupy a position ahead of the presenting part of
    the fetus.
  • ROM may cause fetal exsanguination.
  • High fetal mortality (50-75)
  • Risk factor multiple gestation (esp., triplets)

18
Vasa Previa II
  • Diagnosis
  • moderate vag bleeding fetal distress
  • vessels may be palpable thru dilated cervix
  • vessels may be visible on ultrasound
  • Difficult to distinguish clinically from
    abruption
  • Can look for fetal Hb (Kleihauer-Betke test) or
    nucleated RBCs in shed blood
  • Rx C/S, resuscitation of infant (volume)

19
Postpartum Hemorrhage
  • EBL gt 500 cc
  • 10 of deliveries
  • If within 24 hrs. pp 1? pp hemorrhage
  • If 24 hrs. - 6 wks. pp 2? pp hemorrhage
  • Causes
  • uterine atony genital trauma
  • retained placenta placenta accreta
  • uterine inversion

20
Uterine Atony
  • Most common cause of pp hemorrhage
  • Contraction of uterus is 1? mechanism for
    controlling blood loss at delivery
  • oxytocin and prostaglandins
  • Risk factors
  • multiple gestation chorioamnionitis
  • macrosomia precipitous labor
  • polyhydramnios tocolytics
  • high parity halogenated agents
  • prolonged labor

21
Uterine Atony Treatment
  • uterine massage
  • oxytocin
  • produced by posterior pituitary
  • causes peripheral vasodilation, reflex
    tachycardia
  • administered diluted in IV fluid, not IV push
  • metabolized/excreted by liver, kidney,
    oxytocinase
  • ergot derivatives
  • prostaglandins
  • If drugs fail, embolization of arterial supply,
    ligation, or hysterectomy

22
Uterine Atony Ergot Derivatives
  • ergonovine and methylergonovine (methergine)
  • act via ?-adrenergic mechanism
  • adverse effects nausea/vomiting,
    vasoconstriction (including coronary), HTN,? PAP
  • relative contraindications chronic HTN, PIH,
    PVD, CAD
  • dose 0.2 mg IM (not IV), last 2-3 hrs.

23
Uterine Atony Prostaglandins
  • ? myometrial intracellular free Ca, enhance
    action of other oxytocics
  • Side effects fever, nausea/vomiting, diarrhea
  • 15-methyl PG F2? (Carboprost, Hemabate)
  • may cause bronchospasm, altered VQ, ?
    shunt, hypoxemia, HTN
  • 250 ?g IM or intramyometrially q 15-30 min, up to
    max 2 mg.
  • contraindications asthma, hypoxemia

24
Genital Trauma
  • Vaginal associated with forceps, vacuum,
    prolonged 2nd stage, multiple gestation, PIH
  • Rx I D and packing
  • Vulvar bleeding from branches of pudendal
    arteries
  • Retroperitoneal least common, most dangerous
  • laceration of branch of hypogastric during C/S
    (or uterine rupture)
  • Dx CT
  • Rx expl. lap., ligation of hypogastric, hyst

25
Retained Placenta
  • Obstetric management
  • manual removal, oxytocin
  • Anesthetic management
  • epidural or spinal anesthesia, if not hypovolemic
  • or MAC
  • or GA (ketamine, RSI, intubate, 50 nitrous,
    fentanyl)
  • Uterine relaxation may be requested (NTG)

26
Placenta Accreta
  • Definitions
  • accreta vera adherence of placenta to myometrium
  • increta invasion of placenta into myometrium
  • percreta invasion of placenta to/thru the
    serosa
  • Risk factors
  • prior uterine trauma placenta previa

27
Placenta Accreta II
  • Placenta previa prior C/S v. accreta risk
  • Number of prior C/S Incidence of accreta
  • 0 5
  • 1 24
  • 2 47
  • 3 40
  • 4 67
  • Rx uterine curettage, oversewing of plac. bed,
    usually hysterectomy (accreta is most common
    indication for C-hyst)

28
Uterine Inversion
  • Low mortality
  • Risk factors
  • uterine atony
  • inappropriate fundal pressure
  • unbilical cord traction
  • uterine anomaly
  • Rx replace the uterus, oxytocin, Hemabate,
    methergine
  • may need uterine relaxation transiently
  • NTG (50-100 ?g IV) vs. halogenated agent
  • anecdotal reports of other nitrates, terb, Mg

29
Invasive Treatment Options for Obstetric
Hemorrhage
  • Uterine arteries are branches of internal iliacs
    (major supply to uterus)
  • Ovarian arteries also contribute during preg.
  • Options
  • angiographic embolization
  • bil. surgical ligation of uterine, ovarian,
    internal iliacs (preserves fertility) 42
    success
  • Cesarean or pp hysterectomy
  • EBL ?2500 cc (emergent), ?1300 cc (elective)
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