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 PreviaAnesthetic 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 PreviaAnesthetic 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 PreviaAnesthetic 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 AbruptionObstetric Management

• Depends on fetal maturity, size of abruption,
  presence of fetal distress
• continuation of pregnancy
• induction/augmentation of labor
• Cesarean section

13
Placental AbruptionAnesthetic 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 AtonyErgot 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 AtonyProstaglandins

• ? 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)