1 / 33

Comprehensive Guide to Managing Obstetrical Hemorrhage

Learn about the incidence, etiology, and treatment of obstetrical hemorrhage, including antepartum, intrapartum, and postpartum causes. Understand the management of uterine atony, retained products of conception, abnormal placentation, uterine inversion, coagulopathy, and genital tract lacerations. Gain insights into the approaches and techniques for addressing these critical obstetrical emergencies. Stay informed on risk factors, diagnostic procedures, and therapeutic interventions to optimize outcomes in obstetric care.

roxanne
Download Presentation

Comprehensive Guide to Managing Obstetrical Hemorrhage

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Management of Obstetrical Hemorrhage Jeffrey Stern, M.D.

  2. Incidence of Obstetrical Hemorrhage • 4% of SVD • 6.4 % of C-sections • 13% of maternal deaths (1:10,000 to 1:1,000) • 10% risk of recurrence

  3. Etiology of Obstetrical Hemorrhage: Antepartum • Placenta previa • Abruption • Coagulopathy: ITP/pre-eclampsia, FDIU

  4. Etiology of Obstetrical Hemorrhage: Intrapartum • Placenta previa • Abruption • Abnormal placentation • Genital tract lacerations: (2.4 odds ratio) • Uterine rupture • Coagulopathy: infection, abruption, amniotic fluid embolism

  5. Etiology of Postpartum Hemorrhage (Primary)(Within 24 hours of delivery) • Uterine atony (3.3 odds ratio) • Induction or Augmentation of labor (1.4 odds ratio) • Retained products of conception (3.5 odds ratio) • Placenta accreta, increta, percreta (3.3 odds ratio) • Coagulopathy • Fetal death in utero • Uterine inversion – may need MgSO4, Halothane, Terbutaline, NTG • Amniotic fluid embolism

  6. Etiology of Postpartum Hemorrhage (Secondary)(After 24 hours of delivery to 6 weeks postpartum) • 0.5-2% of patients • Infection • Retained products of conception with atony • Placental site involution • Rx: D+C, ABX, uterotonic medications

  7. Uterine Atony: 1 in 20 to 1 in 100 deliveries (80% of PPH) • Uterine over distension (Polyhydramnios, Multiple gestations, Macrosomia) • Prolonged labor: “uterine fatigue” (3.4 odd ratio) • Precipitory labor • High parity • Chorioamnionitis • Halogenated anesthetic • Uterine inversion

  8. Treatment of Uterine Atony • Message fundus continuously • Uterotonic agents • Foley catheter/Bakri balloon (500cc) • Uterine packing usually ineffective but can temporize • Modified B-Lynch stitch (#2chromic) • Uterine, utero-ovarian, hypogastric artery ligation • Subtotal/Total abdominal hyst.

  9. Treatment of Uterine Atony • Oxytocin – 90% success • 10-40 units in 1 liter NS or LR rapid infusion • Methylergonovine (Methergine) 90% success • 0.2 mg IM q 2-4 hours max. 5 doses; avoid with hypertension • Prostaglandin F2 Alpha (Hemabate) 75% success • 250 micrograms IM, intramyometrial, repeat q 20-90 min. max. 8 doses; Avoid if asthma/Hi BP • Prostaglandin E2 suppositories (Dinoprostone, Prostin E2) 75% success • 20 mg per rectum q 2 hours; avoid with hypotension • Prostaglandin PGE 1 Misoprostol (Cytotec) 75% - 100% success • 1000 microgram per rectum or sublingual (ten 100 micrograms tabs/five 200 micrograms tabs)

  10. Retained Products of Conception: Etiology • Succentiurate lobe • Placenta accreta, increta, percreta • Previous C-section; hysterotomy • Previous puerperal curettage • Previous placenta previa • High parity

  11. Management of Retained Products of Conception • Examine placenta carefully • Manual exploration of uterus • Careful curettage-Banjo curret

  12. Placenta Accreta, Increta, Percreta: Risk Factors • High Parity • Previous placenta previa • Previous C-section • GTN • Advanced maternal age • Previous uterine abnormal placentation

  13. Management of Abnormal Placentation • Placenta will not separate with usual maneuvers • Curettage of uterine cavity • Localized resection and uterine repair: (Vasopressin 1cc/10cc N.S-sub endometrial) • Leave placenta in situ • If not bleeding: Methotrexate • Uterus will not be normal size by 8 weeks • Uterine, utero-ovarian, hypogastric artery ligation • Subtotal/total abdominal hysterectomy

  14. Uterine Inversion: 1 in 2500 Deliveries • Risk factors: Abnormal placentation, excessive cord traction • Treatment • Manual replacement • May require halothane/general anesthesia • Remove placenta after re-inversion • Uterine tonics and massage after placenta is removed • May require laparotomy

  15. Coagulopathy • Hereditary • Acquired • Preganancy induced hypertension • Abruption • Sepsis • Fetal death in utero • Amniotic fluid embolism • Massive blood loss

  16. Genital Tract Laceration and Hematomas: Etiology • Macrosomia • Forceps • Episiotomy • Precipitous delivery • C-section incision extension • Uterine rupture

  17. Therapy of Genital Tract Lacerations • Superficial lacerations and small hematomas: expectant • Large laceration • Repair in layers • Consider a drain

  18. Hematomas • Below pelvic diaphragm: (vulva, paracolpos, ischiorectal fossa) • Leave alone if possible • Legate bleeder - often difficult to find • Pack open • Drain • May need combined abdominal/perineal approach • Above the pelvic diaphragm • Laparotomy- especially if expanding • Combined abdominal/perineal approach

  19. Selective Artertial Embolization by Angiography • Clinically stable patient – Try to correct coagulopathy • Takes approximately 1-6 hours to work • Often close to shock, unstable, require close attention • Can be used for expanding hematomas • Can be used preoperatively, prophylactically for patients with accreta • Analgesics, anti-nausea medications, antibiotics

  20. Selective Artertial Embolization by Angiography • Real time X-Ray (Fluoroscopy) • Access right common iliac artery • Single blood vessel best • Embolize both uterine or hypogastric arteries • Sometimes need a small catheter distally to prevent reflux into non-target vessels • May need to treat entire anteriordivision or even all of the internal iliac artery. • Risks: Can embolize nearby organs and presacral tissue, resulting in necrosis • Technique • Gelfoam pads – Temporary, allows recanalization • Autologous blood clot or tissue • Vasopressin, dopamine, Norepinephrine • Balloons, steel coils

  21. Evaluate for Ovarian Collaterals May need to embolize

  22. Mid-Embolization “Pruned Tree Vessels”

  23. Post Embolization

  24. Post Embolization Pre Embo Post Embo

  25. Uterine Rupture • Scarred versus scarless uterus • Uterine scar dehiscence: separation of scar without rupture of membranes • 2-4% of deliveries after previous transverse uterine incision • Morbidity is usually minimal unless placenta is underneath or it tears into the uterine vessels • Diagnosis after vaginal delivery • Often asymptomatic, incidental finding • Difficult to diagnose because lower uterine segment is very thin • Therapy is expectant if small and asymptomatic • Diagnosed at C-section: Simple debridement and layered closure

  26. Uterine Rupture Etiology • Previous uterine surgery - 50% of cases • C-section, Hysterotomy, Myomectomy • Spontaneous (1/1900 deliveries) • Version-external and internal • Fundal pressure • Blunt trauma • Operative vaginal delivery • Penetrating wounds

  27. Uterine Rupture Etiology • Oxytocics • Grand multiparity • Obstructed labor • Fetal abnormalities-macrosomia, malposition, anomalies • Placenta percreta • Tumors: GTN, cervical cancer • Extra-tubal ectopics

  28. Classic Symptoms of Uterine Rupture • Fetal distress • Vaginal bleeding • Cessation of labor • Shock • Easily palpable fetal parts • Loss of uterine catheter pressure

  29. Uterine Rupture • Myth: Uterine incisions which do not enter the endometrial cavity will not • subsequently rupture • Type of closure: no relation to tensile strength • Continuous or interrupted sutures: chromic, vicryl, Maxon • Inverted or everted endometrial closure • Degree of complications • Inciting event- spontaneous, traumatic • Gestational age • Placental site in relation to rupture site • Presence or absence of uterine scar • Scar: 0.8 mortality rate • No scar: 13% mortality rate • Location of scar • Classical scar- majority of catastrophic ruptures • Transverse scar- less vascular; less likely to involve placenta • Extent of rupture

  30. Management of Uterine Rupture • Laparotomy • Debride and repair in 2-3 layers of Maxon/PDS • Subtotal Hysterectomy • Total Hysterectomy

  31. Pregnancy After Repair of Uterine Rupture • Not possible to predict rupture by HSG/Sono/MRI • Repair location • Classical -------------------------48% • Low transverse------------------16% • Not recorded---------------------36% • Re-rupture-------------------12% • Maternal death--------------1% • Perinatal death--------------6% • (Plauche, W.C 1993)

  32. Modified Smead-Jones Closure • Running looped #1 PDS/Maxon • Contaminated wounds/under tension • Additional Interruptured sutures - 2 cm apart • Fascial edges should be approximated • No tension

More Related