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Antepartum and Postpartum Hemorrhage

Antepartum and Postpartum Hemorrhage. Dr. Megha Jain. University College of Medical Sciences & GTB Hospital, Delhi. email: anaesthesia.co.in@gmail.com. www.anaesthesia.co.in. Antepartum hemorrhage. Bleeding from or into genital tract after 28 th week of gestation.

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Antepartum and Postpartum Hemorrhage

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  1. Antepartum and Postpartum Hemorrhage Dr. Megha Jain University College of Medical Sciences & GTB Hospital, Delhi email: anaesthesia.co.in@gmail.com www.anaesthesia.co.in

  2. Antepartum hemorrhage • Bleeding from or into genital tract after 28th week of gestation. • Incidence: 3 – 5% among hospital deliveries. CAUSES placental unexplained local lesions Placenta abruptio -trauma Praevia placentae -cervical polyp -carcinoma cervix

  3. Placenta praevia • Placenta partially or completely implanted in lower uterine segment. • Types or degrees: Type 1(lateral): placenta encroaches onto LUS Type 2(marginal): placenta reaches internal os but does not cover it Type 3(incomplete central): placenta partially covers the internal os Type 4(central): placenta completely covers the internal os even after full dilation

  4. Risk factor • Multiparity • Increased maternal age • History of previous CS or any other scar in the uterus(myomectomy) • Big size placenta

  5. Clinical presentation • 1st vaginal bleeding episode- after 36th week- 60% b/w 32 - 36 week- 30% before 32 week- 10% # painless and recurrent bleeding # GC and anemia – prop. to blood loss # Size of uterus prop. to POG # Presenting part is usually high up # FHS is usually present # Diagnosis by USG

  6. The double set up examination • Vaginal examination in OT • Preparation- # Two large bore i/v cannula # Blood for transfusion # Oral antacid # Oxygen # Skilled assistant If profuse bleeding CS GA(RSI) # Treat hypovolemia # Induction- Ketamine, intubate- Sch # Maintenance- O2, N2O # Awake extubation

  7. Abruptio placentae • Bleeding due to premature separation of placenta • Varieties: Revealed(m/c) concealed, mixed Etiology: advanced maternal age, high parity pre eclampsia trauma sudden uterine decompression short cord history of previous abruption smoking

  8. Abruptio placentae

  9. Clinical presentation • Continuous painful bleeding • Lower abdominal tenderness • Rapid abnormal uterine contractions • Fetal heart rate abnormalities • Premature labour • Intrauterine death • Maternal cardiovascular collapse • DIC, ARF • Definitive diagnosis by USG

  10. Resuscitation Rapid assessment and initial maneuvers can be life saving • O2 supplementation • 2 large bore iv cannulas • Send – CBC, BUSE, coagulation profile, BGCM • Arrange whole blood • ABG • Warm fluids

  11. Monitoring • ECG, NIBP, Pulse oximetry • Urine output monitoring • CVP monitoring • Frequent ABG analysis FLUID THERAPY -Crystalloids -Colloids if hypotension persists -Group typed blood if blood loss > allowable/ preexisting anemia is present -Use fluid warming devices -FFP and platelet according to lab values.

  12. Anesthetic management in placenta praevia The mode of delivery should be based on clinical judgment supplemented by ultrasound findings Grade III and IV Posterior Thick regional No active bleeding yes hemodynamically stable no GA Caesarean section

  13. Regional anaesthesia –associated with more blood loss because -placenta praevia patients are at increased risk of placenta accreta -obstretician may cut into placenta during uterine incision -LUS has lesser power of contraction and retraction

  14. General anesthesia • RSI – preferred technique • Induction agent- Ketamine safest for hypovolemic patients(0.5 to 1mg/kg) • Intubation with Sch(1.5mg/kg) • Maintenance with- O2(50%)+ N2O(50%)+ low conc of volatile agent if tolerated • Extubate when fully awake and responding to verbal commands

  15. Anesthetic management of abruptio placentae • Definitive treatment is delivery of the fetus • Route of delivery depends on – degree of abruption maternal hemodynamics status of the fetus • If abruption is mild to moderate and the mother is hemodynamically stable with fetus being mature – continuous lumbar epidural, caudal or SAB may be used for labour and vaginal delivery

  16. Anesthetic management (contd….) • For severe abruption – Em LSCS ↓ GA(RSI) • ↑ risk of persistent hemorrhage due to uterine atony and coagulopathy • Thus give oxytocin immediately after delivery • Other drugs used are methergin and PG analogues • Transfuse blood, FFP and platelet

  17. Postpartum hemorrhage • Definition: blood loss > 500 ml after vaginal delivery of fetus > 1000 ml after CS • Clinically it refers to any amount of bleeding from or into genital tract which adversely affects maternal condition • Incidence: 3-5% among all deliveries

  18. Types # Primary: in 24 hrs following delivery Third stage hge- before placental expulsion True PPH- after placental expulsion # Secondary: beyond 24 hrs but within puerperium

  19. Etiology 1. Atonic uterus: (80%) can be due to- # grand multipara # over distention of uterus (twins, macrosomia) # malnutrition and anemia # APH # prolonged labour # uterine fibroid • Trauma • Blood coagulation disorder

  20. Assessment of obstetric hemorrhage Severity of shock Finding % blood loss -None None <15-20% -Mild Tachycardia 20-25% Mild hypotension Peripheral vasoconstriction -Moderate HR- 100-120/min 25-35% SBP- 80-100 mmHg Restlessness Oliguria -Severe HR>120/min >35% SBP<60 mmhg Altered consc Anuria

  21. Management of third stage hemorrhage Uterine massage Injec. Oxytocin/ methergin Start RL/NS arrange for blood Catheterise the bladder Placenta Not separated separated Express by CCT Manual removal under GA

  22. Retained placenta • Definition: placenta not expelled out even 30 min. after birth of the baby. • Incidence: 1% of all vaginal deliveries • Dangers associated with prolonged retention: Hemorrhage, shock, puerperal sepsis. • If mother has epidural or spinal block from T10 to S4 MRP can be accomplished without pain. • If not then I/V sedation (BZD/ Ketamine / Fentanyl) can be tried. • But if the patient is hemodynamically unstable GA should be administered.

  23. Role of NTG in MRP • 50 – 100 µg of I/V nitroglycerine provides uterine relaxation sufficient to remove the placenta. • MOA – releases nitric oxide which relaxes uterine smooth muscle. • Advantages- 1. Avoidance of GA- reduced risk of failed intubation and aspiration 2. Onset is immediate 3. Recovery is smooth and rapid (without sedation) • S/E – hypotension and headache.

  24. Placenta accreta • Definition: Abnormal adherence of placenta to the uterine wall after the baby is born • Underlying pathology: absent decidua, placental villi attach directly to myometrium • Types:Placenta accreta- adherence to myometrium Placenta increta- invasion of myometrium Placenta percreta- invasion of uterine serosa or other pelvic structures • Risk factors: Placenta previa Prior CS Prior uterine trauma

  25. Diagnosis- retained placenta massive hemorrhage after manual removal of placenta hematuria Transvaginal color Doppler USG MRI

  26. Anesthetic mgt. of placenta accreta • Most patients require hysterectomy ↓ GA • Insert large bore I/V line • Arrange blood • Secure airway- Endotracheal intubation • Routine monitoring-ECG , NIBP, Pulse oximetry, urine output • Consider CV line and arterial line • Use fluid warming devices • May require ICU care

  27. Uterine inversion • Rare C/C of 3rd stage where uterus turns inside out partially or completely • Etiology- may be spontaneous or - due to pulling of the cord - uterine atony - inappropriate fundal pressure - placenta accreta • Dangers associated- hemorrhage, shock, pulmonary embolism

  28. Management Best T/T – early replacement of the uterus GA with volatile halogenated agent- most proven method for providing uterine relaxation Uterine relaxation may be achieved by nitroglycerine, thus avoiding GA

  29. Uterine atony - M/C cause of PPH - Conditions associated with uterine atony are- Multiple gestation Macrosomia Polyhydramnios High parity Prolonged/precipitous/augmented labor Tocolytic drugs High conc. Of volatile halogenated agents

  30. Management Resuscitation and immediate management- • Administer 100% O2 • 2 large bore I/V cannula and arrange blood • Fluid resuscitation- crystalloid/colloid using pressure bag • Transfuse cross matched blood( O-Negative if group specific not available) • Use fluid warmer and warming blanket • Monitor- ECG,NIBP,O2 sat., urine output, acid base status, hemoglobin(using hemocue) and coagulation parameters • Consider arterial line and CVP line only after definitive treatment has commenced

  31. Management (contd….) Drugs used for uterine atony 1. Oxytocin 10-40 U in 1000 ml I/V hypotension tachycardia 2. Ergometrine 200 µg I/M hypertension vasocons. vomiting 3. PG F2 alpha 250 µg I/M hypotension I/U bronchocons. Agent Dose Route S/E

  32. Management (contd….) Other maneuvers include- • Uterine massage • Repair lacerations if present • Bimanual packing of uterus • Consider vaginal/uterine packing • Interrupt arterial supply- Embolization Surgical ligation (uterine/ant. Division of internal iliac B/L) • Hysterectomy

  33. Thank You www.anaesthesia.co.in

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