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Postpartum Hemorrhage

Postpartum Hemorrhage. Dr.B Khani MD. Postpartum Hemorrhage. EBL > 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. Uterine Atony.

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Postpartum Hemorrhage

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  1. Postpartum Hemorrhage Dr.B Khani MD

  2. Postpartum Hemorrhage • EBL > 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

  3. 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

  4. 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

  5. Uterine Atony:Ergot 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.

  6. Uterine Atony:Prostaglandins •  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

  7. 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

  8. 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)

  9. 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

  10. 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)

  11. 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

  12. 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)

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