Obstetrical Hemorrhage

2. Obstetrical Hemorrhage • Obstetrics is "bloody business." • hemorrhage still remains a leading cause of maternal mortality. • 12 %of maternal deaths were caused by obstetrical hemorrhage. • hemorrhage is the single most important cause of maternal death worldwide. • Obstetrical hemorrhage accounts for almost half of all postpartum deaths in developing countries

3. most maternal deaths from hemorrhage is associated with substandard care. • many hemorrhage-related maternal deaths were preventable and were associated with inadequate facilities

4. خونریزی در طی حاملگی باید بدون تاخیر در بیمارستان ارزیابی شود. خونریزی مامایی نیاز به ارزیابی سریع دارد زیرا بدون توجه به منشاء خونریزی، هر خونریزی مامایی می تواند سریعا ً تبدیل به خونریزی شدید شود. وقتی خونریزی شروع می شود غیر ممکن است بتوان پیشگویی کرد که کی و چه مقدار شدید می شود.

5. چه مراقبت های اورژانسی می بایست برای زنانی که دچار خونریزی شدید و مخاطره آمیز شده اند انجام گیرد؟ کردن وضعیت بیمار Stable تعیین محل خونریزی

6. کمک بخواهید بدهیم. Volume expansion کردن بیمار stable برای ایجاد راه وریدی با سوزن شماره 18 یا بزرگتر(گاهی اوقات خونریزی بحدی است که باید چند رگ گرفته و با سرعت مناسب مایع را جایگزین کرد رینگر لاکتات- انفوزیون سریع سالن انفوزیون سریع خون انجام آزمایشات لازم ارسال نمونه برای گروه خونی و کراس مچ حداقل چهار واحد خون، fDP CBC، PTو PTT شمارش پلاکت، سطح فیبرینوژن، تهیه5میلی لیتر خون در داخل لوله فاقد مواد آنتی کواگولانت و مشاهده آن 15- 10 دقیقه بعد ازنظر ایجاد لخته کنترل حجم ادرار ارزیابی سلامت جنین و سن حاملگی

7. اگر خونریزی متوقف نشد و زایمان شروع نشدسریع ختم حاملگی داده شود. در صورتی که بیمار بتواند جراحی را تحمل کند باید سریع سزارین گردد اگر زایمان شروع شده باشد در حالت بیمار را معاینه می کنیم double set-up برای تعیین علت خونریزی اگر خونریزی متوقف شد و یا کم شد و بیمار و ضربان قلب جنین خوبست اقدام لازم را برای تعیین محل خونریزی انجام دهید

8. خونریزی مامائی می تواند روی جنین اثر داشته باشد یا باعث به مخاطره افتادن جنین، مرگ جنین و بیماری نوزاد شود.بنابراین در حین زایمان تیم مناسب برای احیاء نوزاد در اتاق زایمان آماده باشد. در مورد وضعیت بیمار با فامیلش صحبت می کنیم درصورت گروه خونی منفی مادرو مثبت بودن گروه خونی نوزاد به تجویز رگام باید توجه کرد.

9. Antepartum Hemorrhage • Placental Abruption • Placenta Previa

10. Causes of Obstetrical Hemorrhage • Placental Abruption: • Placental separation from its implantation site before delivery • variously called placental abruption, abruptioplacentae, accidental hemorrhage , abruptioplacentae

11. complications • Shock • Consumptive Coagulopathy • Renal Failure • Sheehan Syndrome

12. Shock • shock sometimes seen with placental abruption was disproportionate to the amount of hemorrhage. • because placental thromboplastin enters the maternal circulation and incites intravascular coagulation • hypovolemic shock is directly due to maternal blood loss.

13. Consumptive Coagulopathy • Placental abruption is one of the most common causes of clinically significant consumptive coagulopathy in obstetrics. • In approximately a third of women with an abruption severe enough to kill the fetus • there are measurable changes in coagulation factors.

14. Renal Failure • it is more common if treatment of hypovolemia is delayed or incomplete. • most cases of acute kidney injury are reversible, however, acute cortical necrosis, when it occurs, is usually caused by placental abruption. • Seriously impaired renal perfusion is the consequence of massive hemorrhage. • Because preeclampsia frequently coexists with placental abruption, renal vasospasm and hypoperfusion are likely intensified.

15. Sheehan Syndrome • Severe intrapartum or early postpartum hemorrhage rarely is followed by pituitary failure or Sheehan syndrome. • characterized by : • failure of lactation, • amenorrhea, • breast atrophy, • loss of pubic and axillary hair, • hypothyroidism, • adrenal cortical insufficiency. • exact pathogenesis is not understood,

16. diagnosis • sonographyconfirmes clinical diagnosis in only 25 % of women • negative findings with sonographic examination do not exclude placental abruption

17. Management • with massive external bleeding, intensive resuscitation with blood plus crystalloid and prompt delivery to control hemorrhage are lifesaving for mother and hopefully, for fetus. • If the diagnosis is uncertain and the fetus is alive but without evidence of compromise, then close observation can be practiced in facilities capable of immediate intervention. • for the welfare of the distressed fetus, steps should be initiated immediately to correct maternal hypovolemia, anemia, and hypoxia to restore and maintain function of any placenta that is still implanted.

18. Placenta Previa • Placenta previa is used to describe a placenta that is implanted over or very near the internal cervical os.

19. Kinds: • Total placenta previa— internal os is covered completely by placenta • Partial placenta previa—internal os is partially covered by placenta • Marginal placenta previa—edge of the placenta is at the margin of internal os • Low-lying placenta —placenta is implanted in lower uterine segment such that the placental edge does not reach the internal os, but is in close proximity to it

20. Clinical Findings • The most characteristic event is painless hemorrhage • usually appear near the end of the second trimester and without warning • bleeding maybe appear in the onset of labor. • it may vary from slight to profuse • clinically may mimic placental abruption. • Hemorrhage from the implantation site in the lower uterine segment may continue after placental delivery because the lower uterine segment contracts poorly.

21. Diagnosis • The simplest, safest, and most accurate method of placental localization is provided by transabdominalsonography. (average accuracy is 96 %) • False-positive results are often a result of bladder distension ,placenta is large and extended downward all the way to the internal cervical os. • transvaginalsonography • Magnetic Resonance (MR) Imaging (useful for diagnosis of placenta accreta )

22. Management • Cesarean delivery is necessary in practically all women with placenta previa • if fetus is reasonably mature :c/s • The fetus is preterm and there are no other indications for delivery :close observation

23. postpartum hemorrhage

24. The single most significant cause of maternal death worldwide • One of the top three causes of maternal mortality in all of countries • Serious morbidity may follow PPH: • ARDS, • coagulopathy, • shock, • loss of fertility, • sheehan syn.

25. Incidence The incidence varies widely: 1-5% of deliveries

26. Definition • There is no single, satisfactory definition of PPH. • PPH is excessive bleeding that makes the patient symptomatic • Most common definition: Excess blood loss (>500ml in NVD or >1000ml in C/S) • Decline in Hct of 10%(not a clinically useful definition)

27. Types of PPH • Primary PPH(early): in the first 24 hours, 4-6% of pregnancies • Secondary PPH(late): between 24h to 6-12 weeks,(0.5-2% of pregnancies)

28. Atony • The most common cause of PPH is uterine atony • Complicates 1 in 20 births • Responsible for at least 80 % of cases of PPH

29. only a small proportion of women with any risk factors for PPH develop the disorder and many women without risk factors experience hemorrhage after delivery; thus, knowledge of risk factors is not very useful clinically

30. اقدامات پیشگیری کننده یا کاهش دهنده خونریزی بعد از زایمان استفاده از داروهای یوتروتونیک مشاهده جفت مشاهده کانال زایمانی کنترل دقیق در یک ساعت اول بعد از زایمان

31. Planning & prevention • training team • Protocol for management of PPH • equipments of medications and instruments are readily available in Labor and delivery units

32. Diagnosis • The differentiation between bleeding from uterine atony and genital tract lacerations is tentatively determined by predisposing risk factors and the condition of uterus. • If bleeding persists despite a firm, well-contracted uterus, the cause of the hemorrhage most likely is from lacerations • Bright red blood also suggests arterial blood from lacerations. • careful inspection of the vagina, cervix, and uterus is essential.

33. Management • management of PPH is multifaceted and can involve many teams (obstetricians, nurses, anesthesiologists, blood bank personnel, laboratory medicine, surgical subspecialists, interventional radiology). • These teams are often required to work together under great stress and time pressures • Coordination is essential and can be facilitated by protocols and flow diagrams that anticipate how these teams will communicate and function together.

34. Management of postpartum hemorrhage at vaginal delivery

35. Initial Interventions • Fundal massage  • Massage should be maintained while other • interventions are being initiated • Intravenous access • Laboratory tests  •  CBC, fibrinogen concentration , platelet count, PT, activated PTT, typed and crossed for multiple units of packed red blood cells.

37. Fluid resuscitation and transfusion  Monitoring vital signs Bladder catheter A large volume of crystalloid is infused Replacement of blood components

38. Uterotonic drugs • Oxytocin • 40 units in 1 liter of normal saline • 10 units IM (including directly into the myometrium). • Higher doses of oxytocin (up to 80 units in 1000 mL for a short duration (eg, over 30 minutes • Methylergonovine • 0.2 mg IM (or directly into the myometrium) (never IV). • May repeat at 2-4h intervals, as needed. • If there has not been a good response to the first dose, quickly move on to a different uterotonic agent. • Carboprosttromethamine • (15 methyl-PGF2α)(Hemabate) 250 mcg IM (or directly into the myometrium) every 15-90 min, [a total dose of 2 mg (8 doses)], no asthma.(75 % respond to a single dose) • move on to a different uterotonic agent if no response after one or two doses.

39. Uterotonic drugs(con) • Misoprostol (PGE1) • Is most useful for reducing blood loss in settings where injectableuterotonics are unavailable. • The optimum dose and route of administration are unclear. A dose of 400 mcg with the sublingual route is probably the optimal route of administration • Can be given to women with hypertension or asthma. • Maternal temperature should be monitored closely • Dinoprostone (PGE2) • 20 mg vaginal or rectal suppository is an alternative PGE to misoprostol (PGE1). • Can be repeated at 2-4h intervals. • Carbetocin,

40. Secondary Interventions • Provide adequate anesthesia • Inspect for and repair cervical and vaginal lacerations • Exclude uterine rupture  • Remove retained products of conception • Uterine tamponade

41. Uterine tamponade • Uterine tamponade is effective in many patients with atony or lower segment bleeding • Balloons  • Packs

42. INDICATIONS FOR LAPAROTOMY • If vital signs are worse than expected for the estimated blood loss, • the possibility of internal hemorrhage should be considered • When a vaginal laceration has extended above the fornix • Management of uterine atony unresponsive to the conservative interventions described

43. ثبت دقیق مدارک پزشکی

45. Hypovolemic Shock .

46. Definitions Hypovolemic Shock :there is an inadequate circulating blood volume resulting from hemorrhage or acute volume depletion.

48. Management of Shock

49. A team approach staff trained in intensive care medicine O R D E R Oxygenate Restore circulatory volume Drug therapy Evaluate response to therapy Remedy the underlying cause

50. Restore Circulating Volume • Rapid volume repletion is indicated . • Delayed therapy can lead to ischemic injury and possibly to irreversible shock and multiorgan system failure. • 1- to 2-liter fluid challenge with an isotonic electrolyte solution, preferably Ringer's lactate. • Fluid repletion continues at the initial rapid rate as long as the systemic blood pressure remains low.