Obstetric Hemorrhage

1. Obstetric Hemorrhage Anne McConville, MD

2. The Direct leading cause of pregnancy related mortality in the United States is • A) Failed Intubation • B) Hemorrhage • C) Thromboembolism • D) Hypertensive disorders of pregnancy • E) Infection

3. Cesarean Delivery is associated with a blood loss of about: • A) 100 mL • B) 250 mL • C) 500 mL • D) 750 mL • E) 1000 mL

4. Estimated Blood Loss During Parturition • Average EBL during NVD = 600 mL • Average EBL during CS = 1000 mL • Physiologic changes of pregnancy help to diminish the effects

5. 30 y.o. G2P1 at 28 weeks gestation presents with an episode of brisk vaginal bleeding. She denies having pain. She has had 1 prior C/S. The most likely diagnosis is: • A) Placental abruption • B) Uterine Rupture • C) Cervicitis • D) Placenta Previa • E) Abdominal trauma

6. Placenta Previa

7. The next step in management of patient from question 3 is: • A) Proceed to OR for prompt cesarean delivery • B) Large bore IV access, fluid resuscitation and transvaginal ultrasound • C) Cervical exam followed by induction of labor with cytotec and pitocin. • D) Fetal non-stress test and BPP • E) MRI

8. Management of Placenta Previa • Abdominal or transvaginal ultrasound mainstay of diagnosis. • Maternal resuscitation • Fetal monitoring by NST and BPP • Betamethasone to accelerate fetal lung maturity • Tocolytic therapy in selected patients

9. Anesthetic Management of Placenta Previa • Assess airway, volume status, and presence of ongoing bleeding • Large bore IV access, baseline HCT, T&C • With the exception of marginal placenta previa, Cesarean delivery will be performed • Neuraxial vs. General anesthesia • Prepare to treat intraoperative hemorrhage

10. 32 y.o. G5P4 presents at 38 weeks with vaginal bleeding. She was having contractions that have subsided. She has had 3 prior classical C/S. FHR tracing shows FHR 108 and minimal variability. The most likely diagnosis is: • A) Placenta Previa • B) Placenta Accreta • C) Uterine Rupture • D) Placental Abruption • E) Cervicitis

11. Uterine Rupture

12. 32 y.o. G3P2 at 31 weeks gestation presents with brisk vaginal bleeding, abdominal pain, and contractions. No history of previous uterine surgery. What is the most likely diagnosis: • A) Placenta Accreta • B) Placenta Previa • C) Placenta Percreta • D) Placental Abruption • E) VasaPrevia

13. Placental Abruption

14. What is the most appropriate next step in the management of the patient from question 6? • A) Prompt C/S under GETA • B) Large bore IV access, volume resuscitation and fetal monitoring • C) Induction of labor with cytotec followed by oxytocin • D) Epidural analgesia, BPP, followed by C/S • E) Abdominal ultrasound followed by observation if no abruption present

15. Management of Placental Abruption • Maternal Resuscitation, LUD, Oxygen, Urinary catheter • Continuous FHR monitoring • Laboratory studies, T&C • Timing and route of delivery determined by maternal and fetal status • Anesthesiologist must consider severity of abruption and urgency of delivery when planning anesthetic • Neuraxial vs. GETA • Prepare to treat coagulopathy • Coexisting uterine atony may also compound bleeding at delivery

16. Which of the following is NOT a treatment for Uterine Atony? • A) Uterine massage • B) Uterine balloon tamponade • C) Nitroglycerin • D) Uterine compression suture • E) Misoprostol

17. Uterine Atony • Most common cause of severe PPH • Most common indication for peripartum transfusion • Uterine contraction primary mechanism of hemostasis • Risk factors include: Multiparity, macrosomia, long labor, augmented labor, precipitous labor, chorioamnionitis, polyhydramnios, tocolytic agents, volatile halogenated anesthetics, fibroids

18. Management of Uterine Atony • Pharmacologic • Oxytocin • Methylergonovine • 15-Methylprostaglandin F2α • Misoprostol • Surgical • Uterine Massage • Uterine Compression Suture • Uterine Balloon tamponade • Arterial Ligation • Hysterectomy • Radiologic • Uterine artery embolization

19. B-Lynch Suture

20. Bakri Balloon

21. 40 y.o. G4P2 with low-lying placenta diagnosed during pregnancy experiences hemorrhage during repeat C/S. She has had 2 prior C/S. Other history includes D&C for miscarriage. The uterus appears to be contracting. The most likely diagnosis is: • A) Retained Placenta • B) Placenta Previa • C) Placental Abruption • D) Uterine Atony • E) Placenta Accreta

22. Placenta Accreta

23. Normal placenta

24. Placenta Accreta

25. Relationship Between Placenta Previa and Cesarean Section with Placenta Accreta

26. An 18 y.o. G2P1 experiences hemorrhage in the labor room after vaginal delivery of a preterm infant at 28 weeks gestation. She had 1 D&C previously for miscarriage. On visual inspection there appears to be genital trauma. The most likely diagnosis is: • A) Retained Placenta • B) Uterine Inversion • C) Uterine Atony • D) Uterine Rupture • E) Placenta Accreta

27. Retained Placenta • A major cause of PPH • 3.3% of all deliveries • Placenta separates in fragments • Can be life-threatening • Involves manual removal vs. D&C • Neuraxial vs. General • Uterine relaxation may be requested

28. Uterine Inversion • Rare but disastrous event • 1/5,000-10,000 delivered • Risk factors include: uterine atony, fundal pressure, excessive umbilical cord traction, short umbilical cord, uterine anomalies • May be incomplete (not visible) • Treatment is immediate replacement • Anesthetic usually involves uterine relaxation followed by uterine contraction with oxytocin

29. All of the following are associated with DIC except: • A) Placenta Accreta • B) Placenta Previa • C) Placental Abruption • D) Dead Fetus Syndrome • E) Amniotic Fluid Embolism

31. Monkeys