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Third Trimester Bleeding, Postpartum Hemorrhage, & Shock Management UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series.

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Presentation on theme: "Third Trimester Bleeding, Postpartum Hemorrhage, & Shock Management UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series."— Presentation transcript:

1 Third Trimester Bleeding, Postpartum Hemorrhage, & Shock Management UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series

2 Objectives for Third Trimester Bleeding  List the causes of third trimester bleeding  Describe the initial evaluation of a patient with third trimester bleeding  Differentiate the signs and symptoms of third trimester bleeding  Describe the maternal and fetal complications of placenta previa and abruption placenta  Describe the initial evaluation and management plan for acute blood loss  List the indications and potential complications of blood product transfusion

3 Objectives for Postpartum Hemorrhage  Identify the risk factors for postpartum hemorrhage  Construct a differential diagnosis for immediate and delayed postpartum hemorrhage  Develop an evaluation and management plan for the patient with postpartum hemorrhage

4  4-5% of pregnancies complicated by 3rd trimester bleeding  Immediate evaluation needed  Significant threat to mother & fetus (consider physiologic increase in uterine blood flow)  Consider causes of maternal & fetal death  Priorities in management (triage!) Rationale (why we care….)

5  Common:  Abruption, previa, preterm labor, labor  Less common:  Uterine rupture, fetal vessel rupture, lacerations/lesions, cervical ectropion, polyps, vasa previa, bleeding disorders  Unknown  NOT vaginal bleeding!!!  (happens more than you think!) Vaginal Bleeding: Differential Diagnosis

6  Stabilize patient – two large bore IVs if bleeding is heavy, EBL is significant or patient is clearly unstable  Auscultate fetal heart rate - Confirm reassuring pattern  Focused history  PE  Vitals  Brief inspection for petechiae, bruising  Careful inspection of vulva  Speculum exam of vagina and cervix – NO DIGITAL EXAM until r/o previa  Labs – CBC, coag profile, type and cross match  Ultrasound exam to assess placental location and fetal condition Initial Management for Third Trimester Bleeding

7  Separation of placenta from uterine wall  Incidence  % of all pregnancies  Recurrence risk  10% after 1st episode  25% after 2nd episode Placental Abruption: Definition

8  Cocaine  Maternal hypertension  Abdominal trauma  Smoking  Prior abruption  Preeclampsia  Multiple gestation  Prolonged PROM  Uterine decompression  Short umbilical cord  Chorioamnionitis  Multiparity Placental abruption: Risk factors and associations

9  Vaginal bleeding  Abdominal or back pain  Uterine contractions  Uterine tenderness Placental Abruption: Symptoms

10  Vaginal bleeding  Uterine contractions  Hypertonus  Tetanic contractions  Non-reassuring fetal status or demise  Can be concealed hemorrhage Placental Abruption: Physical Findings

11  Anemia  May be out of proportion to observed blood loss  DIC  Can occur in up to 10% (30% if “severe”)  First, increase in fibrin split products  Followed by decrease in fibrinogen Placental Abruption: Laboratory Findings

12  Clinical scenario  Physical exam  NOT DIGITAL PELVIC EXAMS UNTIL RULE OUT PREVIA  Careful speculum exam  Ultrasound  Can evaluate previa  Not accurate to diagnose abruption Placental Abruption: Diagnosis

13  Physical exam  Continuous electronic fetal monitoring  Ultrasound  Assess viability, gestational age, previa, fetal position/lie  Expectant mgmt  vaginal vs cesarean delivery  Available anesthesia, OR team for stat cesarean delivery Placental Abruption: Management

14  Placental tissue covers cervical os  Types:  Complete - covers os  Partial  Marginal - placental edge at margin of internal os  Low-lying  placenta within 2 cm of os Placenta Previa: Definition

15  Most common abnormal placentation  Accounts for 20% of all antepartum hemorrhage  Often resolves as uterus grows  ~ 1:20 at 24 wk.  1:200 at 40 wk.  Nulliparous - 0.2%  Multiparous - 0.5% Placenta Previa: Incidence

16  Prior cesarean delivery/myomectomy  Prior previa (4-8% recurrence risk)  Previous abortion  Increased parity  Multifetal gestation  Advanced maternal age  Abnormal presentation  Smoking Placenta Previa: Risk factors and associations

17  Painless vaginal bleeding  Spontaneous  After coitus  Contractions  No symptoms  Routine ultrasound finding  Avg gestational age of 1st bleed, 30 wks  1/3 before 30 weeks Placenta Previa: Symptoms

18  Bleeding on speculum exam  Cervical dilation  Bleeding a sx related to PTL/normal labor  Abnormal position/lie  Non-reassuring fetal status  If significant bleeding:  Tachycardia  Postural hypertension  Shock Placenta Previa: Physical Findings

19  Ultrasound  Abdominal 95% accurate to detect  Transvaginal (TVUS) will detect almost all  Consider what placental location a TVUS may find that was missed on abdominal  Physical/speculum exam  remember: no digital exams unless previa RULED OUT! Placenta Previa: Diagnosis

20  Initial evaluation/diagnosis  Observe/admit to L&D  IV access, routine (maybe serial) labs  Continuous electronic fetal monitoring  Continuous at least initially  May re-evaluate later if stable, no further bleeding  Delivery??? Placenta Previa: Management

21  Less than 36 wks gestation - expectant management if stable, reassuring  Bed rest (negotiable)  No vaginal exams (not negotiable)  Steroids for lung maturation (<32 wks)  Possible mgmt at home after 1st bleed  70% will have recurrent vaginal bleeding before 36 completed weeks requiring emergent cesarean Placenta Previa: Management

22  36+ weeks gestation  Cesarean delivery if positive fetal lung maturity by amniocentesis  Delivery vs expectant mgmt if fetal lung immaturity  Schedule cesarean 37 weeks  Discussion/counseling regarding cesarean hysterectomy  Note: given stable maternal and reassuring fetal status, none of these management guidelines are absolute (this is why OB is so much fun!) Placenta Previa: Management

23  Placenta accreta, increta, percreta  Cesarean delivery may be necessary  History of uterine surgery increases risk  Must consider these diagnoses if previa present  Could require further evaluation, imaging (MRI considered now)  NOT the delivery you want to do at 2 am Placenta Previa: Other considerations

24  In cases of velamentous cord insertion fetal vessels cover cervical os Vasa Previa: Definition

25  %  Greater in multiple gestations  Singleton - 0.2%  Twins %  Triplets - 95% Vasa Previa: Incidence

26  Painless vaginal bleeding  Fetal bleeding  Positive Kleihauer Betke test  Ultrasound  Routine vs at time of symptoms Vasa Previa: Symptoms, Findings, Diagnosis

27  If bleeding, plan for emergent delivery  If persistent bleeding, nonreassuring fetal status, STAT cesarean… not a time for conservative mgmt!  Fetal blood loss NOT tolerated Vasa Previa: Management

28  Cervicitis  Infection  Cervical erosion  Trauma  Cervical cancer  Foreign body  Bloody show/labor Third Trimester Bleeding: Other Etiologies

29  Previa  Decreased mortality from 30% to 1% over last 60 years  Now emergent cesarean delivery often possible  Risk of preterm delivery  Abruption  Perinatal mortality rate 35%  Accounts for 15% of 3rd trimester stillbirths  Risk of preterm delivery  Most common cause of DIC in pregnancy  Massive hemorrhage --> risk of ARF, Sheehan’s, etc. Perinatal Morbidity and Mortality

30  EBL >500 cc, vaginal delivery  EBL >1000 cc, cesarean delivery  Differential Diagnosis:  Uterine atony  Lacerations  Uterine inversion  Amniotic fluid embolism  Coagulopathy Postpartum Hemorrhage: Definition and Differential Diagnosis

31  Prolonged labor  Augmented labor  Rapid labor  h/o prior PPH  Episiotomy  Preeclampsia  Overdistended uterus (macrosomia, twins, hydramnios)  Operative delivery  Asian or Hispanic ethnicity  Chorioamnionitis Risk Factors for Postpartum Hemorrhage

32 Uterine Atony (same overall mgmt regardless of delivery type)  Recognition  Uterine exploration  Uterine massage  Medical mgmt:  Pitocin (20-80 u in 1 L NS)  Methergine (ergonovine maleate 0.2 mg IM)  Not advised for use if hypertension  Hemabate (prostaglandin F 2  mg IM or intrauterine)

33  B-lynch suture (to compress uterus)  Uterine artery ligation  Must understand anatomy  Risk of ureteral injury  Uterine artery embolization  Typically an IR procedure  Plan “ahead” and let them know you may need them  Hysterectomy (last resort)  Anesthesia involved  Whether in L&D room or the OR!!! Uterine Atony

34  Recognition  Perineal, vaginal, cervical  All can be rather bloody!  Assistance  Lighting  Appropriate repair  Control of bleeding  Identify apex for initial stitch placement Lacerations

35  Uncommon, but can be serious, especially if unrecognized  Consider if difficult placental delivery  Consider if cannot recognize bleeding source  Consider… always!  Delayed recognition is bad news  Patient can have shock out of proportion to EBL  (though not all sources will agree on this) Uterine Inversion

36  Management  Call for help  Manual replacement of uterus  Uterotonics to necessary to relax uterus & allow thorough manual exploration of uterine cavity  IV nitroglycerin (100  g)  Appropriate anesthesia to allow YOU to manually explore uterine cavity  Concern for shock… to be discussed (and managed by the help you’ve called into the room!)  Exploratory laparotomy may be necessary Uterine Inversion

37  High index of suspicion  Recognition  Again… call for help!  Supportive treatment  Replete blood, coagulation factors as able  Plan for delivery (if diagnose antepartum) if able to stabilize mom first Amniotic Fluid Embolism

38  Stabilize mother  Large-bore IV x 2  Place patient in Trendelenburg position  Crossmatch for pRBCs (2, 4, more units)  Rapidly infuse 5% dextrose in lactated Ringer’s  Monitor urine output  Ins/Outs very important  (and often not well-recorded prior to emergency situation -- how many times did she really void while in labor??? How dehydrated was she when presented???)  By the way… get help (calling for help works quickly on L&D!) Management of Shock

39  Serial labs  CBC and platelets  Prothrombin time (factors II, V, VII, X {extrinsic})  Partial thromboplastin time (factors II, V, XIII, IX, X, XI {intrinsic}) Management of Shock

40 Transfusion products ProductContentVolume Whole bloodRBCs, 2,3 DPG, coagulation factors (50 V, VIII), plasma proteins 500 cc Packed RBCsRBCs240cc Platelets55 x 10 6 platelets/unit50cc Fresh frozen plasmaClotting factors V, VIII, fibrinogen cc CryoprecipitateFactor VIII; 25% fibrinogen, von Willebrand’s factor 10-40cc Management of Shock

41  No universally accepted guidelines for replacement of blood components  If lab data available, most providers will transfuse patients with hemoglobin values less than 7.5 to 8 g/dL  If no labs, it is reasonable to transfuse 2 units of packed red blood cells (pRBCs) if hemodynamics do not improve after the administration of 2 to 3 liters of normal saline and continued bleeding is likely. Indications for Transfusion

42 Risks of blood transfusion Infectious DiseaseRisk Factor Hepatitis B1/200,000 Hepatitis C1/3,300 HIV1/225,000 CMV1/20 MTLV-1/111/50,000 Management of Shock

43  Risks of blood transfusion  Immunologic reactions  Fever - 1/100  Hemolysis - 1/25,000  Fatal hemolytic reaction - 1/1,000,000 Management of Shock

44  Delivery  Vaginally unless other obstetrical indication, i.e. fetal distress, herpes, etc.  Best to stabilize mother before initiating labor or going to delivery Management of Shock

45 Bottom Line Concepts  Common causes of third trimester bleeding - Abruption, previa, preterm labor, labor  NO DIGITAL EXAMS until placenta previa has been ruled out  Ultrasound – c an use to evaluate previa but not accurate to diagnose abruption  Postpartum hemorrhage refers to EBL >500 cc, vaginal delivery or EBL >1000 cc, cesarean delivery  Most common cause of PPH – uterine atony  No universal rule for when to transfuse – decision made with clinical judgment and based on each patient’s individual circumstance and presentation

46 References and Resources  APGO Medical Student Educational Objectives, 9 th edition, (2009), Educational Topic 23, 27 (p48-49, 56-57).  Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 12, 21 (p133-39, ).  Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 10 (p ).  Baron F, Hill WC. “Placenta previa, placenta abruption”, Clinical Obstetrics and Gynecology, Sep (3) pp  Benedetti T. Obstetric hemorrhage, in obstetrics: normal and problem pregnancies, Gabbe S, Niebyl J, Simpson J, 3rd ed. New York: Churchill Livingston 1996, pp  Hertzberg B. “Ultrasound evaluation of third trimester bleeding,” The Radiologist, July (4) pp  Sheiner E, Shohan-Vardi I. “Placenta previa: obstetric risk factors and pregnancy outcome,” Journal of Maternal-Fetal Medicine, December (6) pp  Jacobs, Allan J. “Management of postpartum hemorrhage at vaginal delivery.” UpToDate. May 2011


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