Ch 35. OBSTETRICAL HEMORRHAGE

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Ch 35. OBSTETRICAL HEMORRHAGE

• ????? ????
• R3 ? ? ?

2

• OBSTETRICS
• - bloody business
• - transfusion reduce the maternal mortality
  rate
• death from hemorrhage
• - but, hemorrhage is leading cause of maternal
  mortality
• and ICU care in obstetrics hospital
• - so, prompt administration of blood are
  absolute
• requirements for acceptable obstetrical
  care

3

• - hemorrhage
• antepartum placental previa, placetal
  abruption
• postpatrum uterine atony, genital tract
  laceration

4

• causes of hemorrhage
  number()
• Placental abruption
  141(19)
• Laceration/uterine rupture
  125(16)
• Uterine atony
  115(15)
• Coagulopathies
  108(14)
• Placental previa
  50(7)
• Uterine bleeding
  47(6)
• Placenta accreta/increta/percreta
  44(6)
• Retained placenta
  32(4)

5

• Incidence and predisposing conditions
• - the incidence of obstetrical hemorrhage
  cannot
• be determined precisely
• - Combs and colleagues(1991)
• Hct drop of 10 vol.
• ? 3.9 in vaginal delivery
• 68 in cesarean delivery

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ANTEPARTUM HEMORRHAGE

• bloody show
• - in active labor
• the consequence of effacement dilatation
  of cervix
• tearing of small veins
• Bleeding from a site above the cervix before
  delivery
• - placenta previa
• placental abruption
• vasa previa
• ? Delivery should be considered in any woman
  at term
• with unexplained vaginal bleeding

8

• lt PLACENTAL ABRUPTION gt
• Definition
• - the separation of the placenta from its
  site of
• implantation before delivery
• - abruptio placentae rending asunder of the
  placenta
• - total vs. partial
• external vs. concealed
• concealed - much greater maternal and
  fetal hazard
• - diagnosis typically is
  made later

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• Frequency and significance
• - average about 1 in 200 deliveries
• - so extensive as to kill the fetus
• 1 in 420 deliveries (19561967)
• - high-parity woman ? prenatal care ?
  emergency
• transportation improved
• the frequency of abruption causing fetal
  death
• dropped to about 1 in 830 deliveries
  (19741989)

11

• Perinatal morbidity and mortality
• - as stillbirths from other causes have
  decreased, those
• from placental abruption have become
  especially
• prominent
• - but, perinatal mortality was 25-fold higher
  with
• placental abruption
• - if the infant does survive, there may be
  adverse
• sequelae
• neurological deficits (15), cerebral
  palsy (20)

12

• Ethiology
• risk factor
  relative risk
• increased age and parity
  1.31.5
• preeclampsia
  2.14.0
• chronic hypertension
  1.83.0
• PtPROM
  2.44.9
• mutifetal gestation
  2.1
• hydramnios
  2.0
• smoking
  1.41.9
• thrombophilias
  37
• cocaine use
  NA
• prior abruption
  1025
• uterine leiomyoma
  NA

13

• - maternal age

14

• race (African-American, Caucasian gt Asian,
  Latin-American)
• HTN (preeclampsia, gestational HTN ,
  chronic HTN)
• but, the severity of preeclampsia did
  not correlate
• with the incidence of abruption
• Mg - reduce risk of placental abruption
• (Magpie Trial collaborative Group, 2002)
• external trauma
• 26 hrs monitoring
• uterine leiomyoma
• especially, located behind the placental
  implantation
• site

15

• Recurrent Abruption
• - recurrence rate 1 in 8 pregnancies
• - fetal death rate was increased in a second
  time
• - 13 wks earlier than the first time
• - suddenly occur ay any time
• fetal well-being is normal beforehand, and
  thus not
• predictive
• ex.) NST, CST normal
• 4 hrs later placental abruption
• ? killed the fetus

16

• Pathology
• - hemorrhage into the decidua basalis
• ? decidua splits, leaving thin layer adherent
  to the
• myometrium
• ? decidual hematoma leads to separation,
  compression,
• and destruction of placenta
• - in early stage, no clinical symptom, a few
  centimeters
• in diameter (dark and clotted blood)
• ? a very recent separated placenta appear no
  different
• from a normal placenta

17

• - decidual spiral artery ruptures
• ? retroplacental hematoma
• ? expands disrupts more vessel placenta
• ? separation rapidly to the margin
• (because, the uterus still distended by
  conception,
• so it is unable to contract to compress the
  torn
• vessels that supply the placental site)

18

• Concealed hemorrhage
• - placenta margins still remain adherent
• - placenta completely separated. but membranes
  retain
• their attachment to the uterine wall
• - blood gains to the amnionic cavity after
  breaking
• through the membrane
• - fetal head is closely applied to the lower
  uterus,
• blood cannot pass

19

• Chronic placental abruption
• - retroplacental hematoma formation is somehow
• arrested completely without delivery
• Fetal-to-maternal hemorrhage
• - placental abruption bleeding almost
  maternal
• - fetal bleeding non traumatic (20, lt10ml)
• traumatic (tear or
  fracture of placenta)

20

• Clinical diagnosis
• sign or symptom
  frequency()
• vaginal bleeding
  78
• uterine tenderness or back pain
  66
• fetal distress
  60
• preterm labor
  22
• high-frequency contractions
  17
• hypertonus
  17
• dead fetus
  15

21

• - but, vary .
• profuse bleeding, but placental
  separation may not
• so extensive to compromise the fetus
• no external bleeding, but completely
  sheared off and
• the fetal dead
• - ultrasound
• infrequently confirms
• negative finding do not exclude placental
  abruption

22

• Shock
• - intensity of shock is seldom out of
  proportion to
• maternal blood loss
• - but, shock ? amount of hemorrhage
• (thromboplastin from decidua placenta
  entered
• the maternal circulation and incited
  coagulopathy
• or amnionic embolism)
• - oliguria caused by inadequate renal
  perfusion
• response to vigorous treatment

23

• Differential diagnosis
• - severe form diagnosis generally is obvious
• milder or common form difficult
• - lab diagnostic method
• detect lesser degree of abruption
  accurately
• - painless bleeding placenta previa
• painful bleeding placental abruption
• ? but, variable state
• - so, differential diagnosis is not simple
  !!!!!!!!

24

• Consumptive coagulopathy
• - most common
• - hypofibrinogenemia, FDP?, D-dimer?,
• coagulation factor?
• ? 30, enough to kill the fetus
• - major mechanism
• coagulation intravascularly
  retroplacentally
• ? the activation of plasminogen to plasmin
• ? maintaining patency of the
  microcirculation

25

• Renal failure
• - severe form of placental abruption
• the consequence of massive hemorrhage
• treatment of hypovolemia is delayed or
  incomplete
• - with preeclampsia
• renal vasospasm is likely intensified
• - proteinuria is common without preeclampsia
• ? blood crystalloid solution apply !!!!!!

26

• Couvelaire uterus (uteroplacental apoplexy)
• - extravasation of blood into the uterine
  musculature
• and beneath the uterine serosa, broad
  ligament
• - interfere with uterine contraction
• severe postpartum hemorrhage
• but, not an indication for hysterectomy

27

• Management
• - depending on gestational age, maternal
  fetal status
• - blood crystalloid and prompt delivery
• Expectant management in preterm pregnancy
• tocolytics, close observation
• but, fetal distress was seen
• ? prompt delivery immediate treatment

28

• Tocolysis
• tocolysis improved outcome in a highly
  selected
• group (preterm, partial abruption)
• Towers and co-workers(1995)
• Mg or terbutaline to 95 women
• ? perinatal mortality 5
• (did not differ from the nontreated
  group)
• placental abruption should be considered
  a
• contraindication to tocolytic therapy

29

• Cesarean delivery
• rapid delivery (fetus alive but in
  distress)
• Kayani and colleagues(2003)
• ? at fetal bradycardia (33case)
• 22 was neurologic intact (with in 20
  min 15)
• 11 was died or cerebral palsy (beyond
  20 min 8)
• decision time is an important factor in
  neonatal
• outcome

30

• Vaginal delivery
• fetal death, no obstetrical complication
• coagulation defect (?incision site
  bleeding)
• ? vaginal delivery
• hemostasis
• uterine contraction-pharmacologically or
  massage
• Labor
• hypertonic -baseline gt50mmHg,
• rhythmic contraction
  75100mmHg

31

• Amniotomy
• as early as possible
• decrease bleeding from the implantation
  site
• reduce the entry into the maternal
  circulation of
• thromboplastin (but, no evidence)
• Oxytocin
• if no rhythmic uterine contraction
• - oxytocin is given in standard doses

32

• Timing of delivery after severe placental
  abruption
• - when the fetus is dead or previable,
• there is no evidence that establishing a
  time limit
• fro delivery is necessary
• - maternal outcome depends on
• adequate fluid and blood replacement
  therapy rather
• than on the interval to delivery

33

• ltPLACENTA PREVIAgt
• Definition
• - the placenta is located over or very near
  the internal
• os of cervix
• - total
• partial
• marginal
• low-lying

34

• - vasa previa
• the fetal vessels course through
  membranes and
• present at the cervical os

35

• - the degree of placenta previa
• the cervical dilatation at the time of
  examination
• ex) 2cm low-lying
• 8cm patial
• - spontaneous placental separation is
  inevitable
• due to the formation of the lower segment
  and
• cervical dilatation ? vessel disrupted
• - digital palpation can incite severe
  hemorrhage !!!

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• Incidence
• - 1 in 305 deliveries (Martin, 2002)
• 1 in 300 deliveries (Crane, 1999)
• Prenatal morbidity and mortality
• - neonatal mortality threefold higher (?
  preterm birth)
• - fetal anomalies 2.5-fold (reasons are
  unclear)
• - growth restriction 20
• - low birthweight due to preterm birth and
  growth
• impairment

37

• Etiology
• - maternal age 1 in 1500 (lt19 yrs old)
• 1 in 100 (gt35 yrs old)
• - multiparity
• - multifetal gestations
• - prior cesarean delivery 1.9 (2 times
  c/sec)
• 4.1 (gt3
  times c/sec)
• ?prior uterine incision with a previa
  increases the
• incidence of cesarean hysterectomy
• - smoking
• CO hypoxemia ? compensatory placetal
  hypertrophy

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• Clinical findings
• - painless hemorrhage, usuallydoes not appear
  until
• near the end of the 2nd trimester or after
• - the initial bleeding is rarely so profuse as
  to prove
• fatal, usually cease spontaneously
• - because the lower segment contracts poorly
  compared
• with the body, hemorrhage from implantation
  site may
• continue after delivery
• - bleeding from cervical or lower segment
  laceration
• following manual removal

39

• Placenta accreta, increta, and percreta
• - placenta previa is associated placenta
  accreta
• - because of poorly developed decidua in the
  lower
• uterine segment
• - 7 of 514 case of previa (Frederiksen, 1999)
• Coagulation defects
• - rarely
• - because of thromboplastin escape through the
  cervical
• canal rather than into the maternal
  circulation

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• Diagnosis
• - uterine bleeding during the later half of
  pregnancy
• - unless a finger is passed through the cervix
  and
• the placenta is palpated
• ? but, digital examination torrential
  hemorrhage!!!
• - placental location can almost be obtained by
• sonography

41

• Localization by sonography
• - transabdominal sonography
• accuracy - 98
• false positive - ? bladder distention
• large placenta
• - transvaginal sonography
• be superior than transabdominal
  sonogparhy
• visualize cervical os in all case (70,
  transabdomen)
• - transperineal sonography
• - MRI

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• Placental Migration
• - 1820 weeks low lying, not cover internal
  os
• ? did not persist
  previa
• - midpregnancy cover internal os
• ? 40 persisted as a
  previa
• - during 2nd or early 3rd trimester close
  but not cover
• ? unlikely to persist
  as previa by term

44

• - in absence of any
• other abnormality, so-
• nography need not be
• frequently repeated
• simply to follow place-
• ntal position
• - 28 weeks

45

• - mechanism of placental movement
• not completely understood
• - migration
• clearly a misnomer, because invasion of
  chorionic
• villi into the decidua persist
• and, relationship in a three-dimensional
  manner
• using two-dimensional sonography
• differential growth of lower and upper
  myometrial
• segments as pregnancy progresses

46

• Management
• - may be considered as follows
• 1. fetus is preterm and no indication for
  delivery
• 2. fetus is reasonably mature
• 3. in labor
• 4. hemorrhage is so severe as to mandate
  delivery
• despite fetal immaturity

47

• - preterm, but with no active bleeding
• close observation
• - prolonged hospitalization may be ideal,
  however,
• usually discharged after bleeding has
  ceased and
• her fetus judged to be healthy
• ? prepared to transport her to the hospital
  
• immediately

48

• Delivery
• - cesarean delivery is necessary
• incision (transverse or vertical)
• if incision extends through the placenta,
  maternal
• or fetal outcome is rarely compromised
• - poorly contractile nature of the lower
  segment, there
• may be uncontrollable hemorrhage following
  placental
• removal (without accreta)

49

• - hemostasis methods
• oversewing the implantation site with chr
  1-0
• bilateral uterine or internal iliac
  artery ligation
• circular interrupted suture around the
  lower segment,
• above and below transverse incision with
  chr 1-0
• tightly packed with gauze, and then
  removed
• transvaginally 12 hours later
• pelvic artery embolization
• ? fail.. Hysterectomy !!!!!

50

• Prognosis
• - adequate transfusion and cesarean delivery
• marked reduction in maternal mortality
• - serum AFP gt 2,0 MOM
• increased risk of bleeding early in the
  3rd trimester
• and of preterm birth (Butler, 2001)

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POSTPARTUM HEMORRHAGE
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• Definition
• - traditionally, gt 500mL
• after completion of
• the third stage of
• labor

53

• - gt1,000mL blood loss 5
• - commonly estimated blood loss (EBL)
• only about half the actual loss
• ? so, EBL gt 500mL danger !!!

54

• - normal pregnancy induced hypervolemia
• nonpregnant total blood volume (TBV)
• height(inch)x50 weight(pound)x25 /
  2
• increases by 3060 , 15002000ml
• but increase is less in preeclampsia or
  eclampsia
• and more with multiple fetus
• so, normally pregnant woman tolerates
  blood loss
• at delivery without any remarkable
  decrease in
• postpartum Hct

55

• - blood loss can be estimated
• calculated pregnancy hypervolemia
• 500mL (each 3 vol.
  drop in Hct)
• - mean postpartum Hct decline
• 2.64.3 vol. (vaginal delivery)
• 4.2 vol. (c/sec)
• - late postpartum hemorrhage
• hemorrhage after the first 24 hours

56

• Hemostasis at the placental site
• - near term, 600mL/min of blood flows through
  the
• intervillous space
• - hemostasis
• depend on intrinsic vasospasm and
  formation of
• blood clot locally
• contraction and retraction of the
  myometrium to
• compress the large vessel and obliterate
  lumen
• - adherent pieces of placenta or large blood
  clots
• prevent effective contraction and retraction

57

• Clinical characteristics
• - begins before or after placental delivery
• no massive bleeding, steady bleeding
• - the effect of hemorrhage depend to
• nonpregnant blood volume
• magnitude of pregnancy induced
  hypervolemia
• degree of anemia at the time of delivery
• ex) normotensive ? hypertensive at
  initially
• hypertensive ? normotensive
  although remarkably
• hypovolemic

58

• - with severe preeclampsia
• not normally expanded blood volume
• very sensitive and intolerant to blood
  loss
• so, when excessive hemorrhage is
  suspected,
• prompt vigorous crystalloid and blood
  replacement
• - blood may not escape vaginally
• distended, gt1000mL
• adequate fundus monitored massage

59

• Diagnosis
• - except intrauterine intravaginal
  accumulation of
• blood or intraperitoneal bleeding (uterine
  rupture)
• ? diagnosis of postpartum hemorrhage is
  obvious
• - well contracted uterus, fresh bleeding
• ? laceration !!!
• - atony laceration bleeding
• ? inspection of the cervix, vagina
• confirm uterine contraction
• (with adequate anesthesia)

60

• Sheehan syndrome (pituitary failure)
• - after severe intrapartum or postpartum
  hemorrhage
• - character lactation(x), ammenorrhea, breast
  atpophy,
• pubic axillary hair loss,
  hypothyroidism,
• adrenal cortical
  insufficiency
• - but, do not developed in most severe
  bleeding women
• - pathogenesis ant. pituitary necrosis
• ? endocrine
  abnormalities

61

• - lactation after delivery, but not always,
  excludes
• extensive pituitary necrosis
• - average duration of onset of symptom 5
  years
• - incidence 1 in 10,000 deliveries
• less common today
• - pituitary CT pituitary was abnormal
• sella turcica was totally
  or partially empty
• (Bakiri, 1991)

62

• ltTHIRD-SATGE BLEEDINGgt
• - the result of transient partial separation
  of the placenta
• - Duncan blood escape into vagina
  immediately
• Schultze blood may be concealed behind
  the
• placenta and membrane until
  the placenta
• is delivered
• - descent of the placenta cord become slack
• but, if bleeding continue, manual removal
  of the
• placenta is mandatory
• - when uterine atony, cord traction may cause
  uterine
• inversion

63

• Prolonged third-stage bleeding
• - there is still no definite answer the length
  of time
• - Combs and Laros (1991)
• median duration - 6 min
• 3.3 - gt 30 min
• Technique of manual removal
• - adequate analgesia of anesthesia
• - aseptic surgical technique
• - after delivery, wipe out the uterine cavity
  with a
• sponge

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• Management after delivery of placenta
• - always fundus should be palpated and fundal
• massage
• - oxytocin 20 IU / 1,000mL fluid IV 10
  mL/min
• - oxytocin should never be given as an
  undilutes
• bolus dose
• hypotension or cardiac arrhythmia may
  occur

66

• ltUTERINE ATONYgt
• - overdistended uterus large fetus, multi
  fetuses,
• hydramnios
• - labor initiated or augmented with oxytocin
• - high parity
• - previous postpartum hemorrhage
• - constant kneading and squeezing of the
  uterus that
• already is contracted impedes the
  physiologic
• mechanism of placental detachment
• causing incomplete placental separation
  and
• increased blood loss

67

• Ergot derivatives
• - IM methylergonovine (0.2 mg)
• - IV administered, dangerous hypertension,
  especially
• in women with preeclampsia

68

• Prostaglandins
• - 15-methyl derivative of prostaglandin F2a
• initial dose 0.25 mg IM
• 1590 min interval, Max 8 doses
• side effect diarrhea, HBP, vomiting,
  fever,
• flushing, tachycardia
• arterial oxygen desaturation - pulmonary
  airway
• 
  and vascular constriction

69

• - prostaglandin E2
• rectally 20 mg
• - misoprostol (Cytotec, prostaglandin E1
  analogue)
• 1,000? rectally
• response time 1.4 min
• - Villar (2002)
• oxytocin and ergot preparation
  administered during
• the third stage of labor were more
  effective than
• misoprostol for the prevention of
  postpartum
• hemorrhage

70

• Bleeding unresponsive to oxytocics
• 1. bimanual uterine compression
• 2. help !
• 3. 2nd IV line crystalloid with oxytocin
• 4. blood transfusion ABO type, Coombs test
• O(-)
  universal donor
• 5. explore uterine cavity manually
• placental remnant or laceration
• 6. inspect the cervix and vagina
• 7. foley keep urine output check (renal
  perfusion)

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• Internal iliac artery ligation
• - reduce the hemorrhage
• technically difficult, successful in less
  than half
• - nonabsorbable material suture
• - mechanism
• 85 reduction in pulse pressure in those
  arteries
• distal to the ligation
• more amenable to hemostasis via simple
  clot
• fromation
• - bilateral dose not intefere subsequent
  reproduction

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• Uterine compression sutures
• - B-Lynch (1997)
• - chromic 2-0
• - be effective some cases, however, published
• experience with these technique remains
  limited

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• Uterine packing
• - who wish to preserve fertility
• - cause of concealed bleeding and infection
• - Roman and Rebarber (2003)
• 24F foley with 30 mL balloon
• 6080 mL ballooning
• typically remove after 124 hours
• - be packed directly with gauze
  (Glistrap,2002)
• - after hysterectomy (Howard,2002)
• umbrella packing (sterile x-ray bag)
• removed vaginally after 24 hrs

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• Recombinant activated factor VII
• - vitamin K-dependent protein
• - administration for treatment of hemophilia,
  acquired
• antibodies to components of the intrinsic
  pathway
• and congenital factor VII deficiency