Management of Obstetrical Hemorrhage

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Management of Obstetrical Hemorrhage

• Jeffrey L. Stern, M.D.

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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.

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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

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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

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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

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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
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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

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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

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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)

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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

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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

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Uterine Rupture Etiology

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

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Classic Symptoms of Uterine Rupture

• Fetal distress
• Vaginal bleeding
• Cessation of labor
• Shock
• Easily palpable fetal parts
• Loss of uterine catheter pressure

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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

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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

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Management of Uterine Rupture

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

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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

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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

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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

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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)

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Modified B-Lynch Suture
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Artery Ligation
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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

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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

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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

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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

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Evaluate for Ovarian Collaterals May need to
embolize
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Mid-Embolization Pruned Tree Vessels
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Post Embolization
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Post Embolization
Pre Embo
Post Embo