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Management of Obstetrical Hemorrhage

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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 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


22 Evaluate for Ovarian Collaterals
May need to embolize

23 Mid-Embolization “Pruned Tree Vessels”

24 Post Embolization

25 Post Embolization Pre Embo Post Embo

26 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

27 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

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

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

30 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

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

32 Pregnancy After Repair of Uterine Rupture
Not possible to predict rupture by HSG/Sono/MRI Repair location Classical % Low transverse % Not recorded % Re-rupture % Maternal death % Perinatal death % (Plauche, W.C 1993)

33 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

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