Management of Obstetrical Hemorrhage

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Management of Obstetrical Hemorrhage

• Jeffrey Stern, M.D.

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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

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Etiology of Obstetrical Hemorrhage Antepartum

• Placenta previa
• Abruption
• Coagulopathy ITP/pre-eclampsia, FDIU

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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

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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

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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

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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

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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.

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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 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)

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Retained Products of Conception Etiology

• Succentiurate lobe
• Placenta accreta, increta, percreta
• Previous C-section hysterotomy
• Previous puerperal curettage
• Previous placenta previa
• High parity

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Management of Retained Products of Conception

• Examine placenta carefully
• Manual exploration of uterus
• Careful curettage-Banjo curret

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Placenta Accreta, Increta, Percreta Risk Factors

• High Parity
• Previous placenta previa
• Previous C-section
• GTN
• Advanced maternal age
• Previous uterine abnormal placentation

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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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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

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Coagulopathy

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

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Genital Tract Laceration and Hematomas Etiology

• Macrosomia
• Forceps
• Episiotomy
• Precipitous delivery
• C-section incision extension
• Uterine rupture

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Therapy of Genital Tract Lacerations

• Superficial lacerations and small hematomas
  expectant
• Large laceration
• Repair in layers
• Consider a drain

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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

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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 accreta
• Analgesics, anti-nausea medications, antibiotics

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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

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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
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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

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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 GTN, cervical cancer
• Extra-tubal ectopics

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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 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

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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
• (Plauche, W.C 1993)

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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