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Management of Obstetrical Hemorrhage

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... may need ultrasound Inspect for ... cervical cancer Extra-tubal ectopic pregnancy Classic Symptoms of Uterine ... Do not divide vessel Interventional ... – PowerPoint PPT presentation

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Title: Management of Obstetrical Hemorrhage


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

2
Management of Obstetrical Hemorrhage
  • VS q 15 minutes, oxygen by mask 10 liter/min.
    to keep O2 saturation gt 94
  • 1st IV LR w/ Pitocin 20-40 units at 1000 ml/ 30
    minutes
  • Start 2nd, 18 G IV warm LR - administer wide
    open
  • CBC, fibrinogen, PT/PTT, platelets, TC 4u PRBCs
  • Monitor IO, urinary Foley catheter
  • Get help

    -Anesthesia,Interventional Radiology, GYN ONC,
    Intensivist, etc.

3
Management of Obstetrical Hemorrhage
  • LR or NS replaces blood loss at 31
  • Volume expander 11 (albumin, hetastarch,
    dextran)
  • Administer uterotonic medications
  • Anticipate disseminated Intravascular
    coagulapathy (DIC)
  • Verify complete removal of placenta, may need
    ultrasound
  • Inspect for bleeding
  • episiotomy, laceration, hematomas, inversion,
    rupture
  • Emperic transfusion
  • 2 u PRBC FFP 1-2 u/4-5 u PRBC
  • Cryo 10 u, uncrossed (O neg.) PRBC
  • Warm blood products and I.V.infusions
  • prevent hypothermia, coagulopathy, arrhythmias

4
Target Values
  • Invasive monitoring central/ arterial lines
  • Maintain systolic BPgt90 mmHg
  • Maintain urine output gt 0.5 ml per kg per hour
  • Hct gt 21
  • Platelets gt 50,000/ul
  • Fibrinogen gt 100 mg/dl
  • PT/PTT lt 1.5 times control
  • Repeat labs as needed every 30 minutes

5
Blood Component Therapy
  • Fresh Frozen Plasma (45 minutes to thaw)
  • INR gt 1.5 - 2u FFP
  • INR 2-2.5 - 4u FFP
  • INR gt 2.5 - 6u FFP
  • Cryoprecipitate (1 hour to thaw)
  • Fibrinogen lt 100 mg/dl 10u cryo
  • Fibrinogen lt 50 mg/dl 20u cryo
  • Platelets (5 minutes when in stock)
  • Platelet. count. lt 100,000 1u plateletpheresis
  • Platelet. count. lt 50,000 2u plateletpheresis

6
Blood Component Therapy
Blood Comp Contents Volume (ml) Effect
Packed RBCs RBC, Plasma 300 Inc. Hgb by 1 g/dl
Platelets Platelets, Plasma 250 Inc. count by 25,000
FFP Fibrinogen, antithrombin III, clotting factors, plasma 250 Inc. Fibrinogen 10 mg/dl
Cryoprecipitate Fibrinogen, antithrombin III, clotting factors, plasma 40 Inc. Fibrinogen 10 mg/dl
7
Uterine Atony 120 to 1100 deliveries (80 of
Obstetrical Hemorrhage)
  • Uterine over distension
  • Polyhydramnios, Multiple gestations, Macrosomia
  • Prolonged labor uterine fatigue (3.4 odds
    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- can
    temporize
  • Modified B-Lynch Suture (2chromic)
  • Uterine/ utero-ovarian artery ligation
  • Hypogastric artery ligation
  • Subtotal or Total abdominal hysterectomy

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 mcg 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 E1 Misoprostol (Cytotec) 75 -100
    success
  • 1000 mcg per rectum or sublingual (100 or 200 mcg
    tabs)

10
Uterine Inversion 1 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

11
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

12
Uterine Rupture Etiology
  • Oxytocics
  • Grand multiparity
  • Obstructed labor
  • Fetal abnormalities-macrosomia, malposition,
    anomalies
  • Placenta percreta
  • Tumors Trophoblastic disease, cervical cancer
  • Extra-tubal ectopic pregnancy

13
Classic Symptoms of Uterine Rupture
  • Fetal distress
  • Vaginal bleeding
  • Cessation of labor
  • Shock
  • Easily palpable fetal parts
  • Loss of uterine catheter pressure

14
Uterine Rupture
  • Myth Uterine incisions that do not enter the
    endometrial cavity will not rupture
    in the future
  • 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

15
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- lower uterine segment is
    very thin
  • Therapy is expectant if defect small and
    asymptomatic
  • Diagnosed at C-section
  • Simple debridement and layered closure

16
Management of Uterine Rupture
  • Laparotomy
  • Debride and repair in 2-3 layers of Maxon/PDS
  • Subtotal Hysterectomy
  • Total Hysterectomy

17
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
  • Plauce WC, 1993

18
Prepare for Laparotomy
  • General anesthesia usually best
  • Allen or Yellowfin stirrups
  • Uterine cavity manual exploration for retained
    placenta with ultrasound present/ uterine rupture
  • Uterine inversion
  • Uterine packing (treatment vs. temporizing)
  • 4 gauze (Kerlex) soaked in 5000 u of thrombin in
    5ml of sterile saline
  • 24 Fr. Foley with 30ml balloon filled with 30-80
    ml of saline (may need more than one)
  • Bakri (intrauterine) balloon - 500 cc
  • Antibiotics
  • Remove in 24-48 hours

19
Intraoperatively
  • Consider vertical abdominal incision
  • General anesthesia usually best
  • Get Help!
  • Avoid compounding problems by making major
    mistakes
  • Direct manual uterine compression / uterotonics
  • Direct aortic compression
  • Modified B-Lynch Suture for atony 2 chromic
  • Ligation of uterine and utero-ovarian vessels 1
    chromic

20
Intraoperatively
  • Internal iliac (hypogastric) artery ligation (
    50 success)
  • Desirous of children
  • Experience of surgeon
  • Palpate common iliac bifurcation
  • Ligate at least 2-3 cm from bifurcation
  • 1 silk. Do not divide vessel
  • Interventional Radiology uterine artery
    embolization (catheters placed pre-op)
  • Hysterectomy/ subtotal hysterectomy (put ring
    forceps on anterior lip of dilated cervix, to
    help identify it)
  • Cell saver investigational (amniotic fluid
    problems)

21
Modified B-Lynch Suture
22
Artery Ligation
23
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

24
Post-Hysterectomy Bleeding
  • Patient usually has DIC Rx with whole blood,
    FFP, platelets, etc.
  • Military Anti-Shock Trousers (MAST)
  • Increases pelvic and abdominal pressure to reduce
    bleeding
  • Can use at any point in the procedure
  • Transvaginal or transabdominal (pelvic) pressure
    pack
  • Bowel bag with opening pulled through vagina
    cuff/ abd. wall
  • Stuff with 4 inch gauze tied end-to-end until
    pelvis packed tight
  • Tie to 10-20 lbs. Weight and hang over edge of
    bed to help keep constant pressure
  • May have to leave clamps or accept ligation of
    ureter or a major side wall vessel
  • Interventional Radiology

25
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 placenta accreta
  • Analgesics, anti-nausea medications, antibiotics

26
Selective Artertial Embolization by Angiography
  • Real time X-Ray (Fluoroscopy)
  • Access right femoral artery
  • Single bleeding blood vessel is best
  • Embolize
  • - Both uterine or hypogastric arteries
  • - May need to treat entire anterior
    division or all of internal iliac artery
  • - Sometimes need a small catheter distally
    to prevent reflux into
  • non-target vessel
  • Risks Can embolize nearby organs and presacral
    tissue, resulting in tissue necrosis
  • Technique
  • Gelfoam pads/slurry Temporary, allows
    recanalization
  • Autologous blood clot or tissue
  • Vasopressin, dopamine, Norepinephrine
  • Balloons, steel coils

27
(No Transcript)
28
Evaluate for Ovarian Collaterals May need to
embolize
29
Mid-Embolization Pruned Tree Vessels
30
Post Embolization
31
Post Embolization
Pre Embo
Post Embo
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