1. 8th Edition APGO Objectives for Medical Students Third Trimester Bleeding, Postpartum Hemorrhage, & Shock Management Case Scenarios

2. Rationale (why we care…) 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!)

3. Objectives The student will be able to: Describe the approach to the patient with: third-trimester bleeding postpartum hemorrhage resulting hypovolemic shock Compare symptoms, physical findings, and diagnostic methods that differentiate bleeding etiologies Describe management and delivery options for 3rd trimester bleeding etiologies Describe potential maternal and fetal morbidity & mortality Describe management of postpartum hemorrhage Describe blood products & indications for use  Apply knowledge in the discussion of clinical case scenarios

4. Vaginal Bleeding: Differential diagnosis 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!)

5. Placental abruption: definition Separation of placenta from uterine wall Incidence 0.5-1.5% of all pregnancies Recurrence risk 10% after 1st episode 25% after 2nd episode

6. Placental abruption: risk factors & associations Cocaine Maternal hypertension Abdominal trauma Smoking Prior abruption Preeclampsia Multiple gestation Prolonged PROM Uterine decompression Short umbilical cord Chorioamnionitis multiparity Prolonged PROM Uterine decompression Short umbilical cord Chorioamnionitis multiparity

7. Placental abruption: symptoms Vaginal bleeding Abdominal or back pain Uterine contractions Uterine tenderness

8. Placental abruption: physical findings Vaginal bleeding Uterine contractions Hypertonus Tetanic contractions Non-reassuring fetal status or demise Can be concealed hemorrhage

9. Placental abruption: laboratory findings 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

10. Placental abruption: diagnosis Clinical scenario Physical exam NOT DIGITAL PELVIC EXAMS UNTIL RULE OUT PREVIA Careful speculum exam Ultrasound Can evaluate previa Not accurate to diagnose abruption

11. Placental abruption: management 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

12. Placenta previa: definition 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

13. Placenta previa: incidence 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%

14. Placenta previa: risk factors & associations Prior cesarean delivery/myomectomy Prior previa (4-8% recurrence risk) Previous abortion Increased parity Multifetal gestation Advanced maternal age Abnormal presentation Smoking

15. Placenta previa: symptoms 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

16. Placenta previa: physical findings 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

17. Placenta previa: diagnosis 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!

18. Placenta previa: management Initial evaluation/diagnosis Observe/admit to L&D IV access, routine (maybe serial) labs Continuous electronic fetal monitoring Continuous at least initally May re-evaluate later if stable, no further bleeding Delivery???

19. Placenta previa: management 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

20. Placenta previa: management 36+ weeks gestation Cesarean delivery if positive fetal lung maturity by amniocentesis Delivery vs expectant mgmt if fetal lung immaturity Schedule cesarean delivery @ 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!)

21. Placenta previa: other considerations 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

22. Vasa previa: definition In cases of velamentous cord insertion fetal vessels cover cervical os

23. Vasa previa: incidence 0.1-1.0% Greater in multiple gestations Singleton - 0.2% Twins - 6-11% Triplets - 95%

24. Vasa previa: symptoms, findings, diagnosis Painless vaginal bleeding Fetal bleeding Positive Kleihauer Betke test Ultrasound Routine vs at time of symptoms

25. Vasa previa: management 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

26. Third trimester bleeding: other etiologies Cervicitis infection Cervical erosion Trauma Cervical cancer Foreign body Bloody show/labor

27. Perinatal mortality and morbidity 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.

28. Postpartum hemorrhage: definitions & ddx EBL >500 cc, vaginal delivery EBL >1000 cc, cesarean delivery Uterine atony Lacerations Uterine inversion Amniotic fluid embolism coagulopathy

29. 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)

30. Uterine atony: 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!!!

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

32. Uterine inversion: 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)

33. Uterine inversion: 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

34. Amniotic fluid embolism 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

35. Management of shock 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!)

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

37. Management of shock 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 plasma Clotting factors V, VIII, fibrinogen200-250cc CryoprecipitateFactor VIII; 25% fibrinogen, von Willebrand’s factor 10-40cc

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

39. Management of shock Risks of blood transfusion Immunologic reactions Fever - 1/100 Hemolysis - 1/25,000 Fatal hemolytic reaction - 1/1,000,000

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

41. References Baron F, Hill WC. “Placenta previa, placenta abruption”, Clinical Obstetrics and Gynecology, Sep 1998 41(3) pp527- 532. Benedetti T. Obstetric hemorrhage, in obstetrics: normal and problem pregnancies, Gabbe S, Niebyl J, Simpson J, 3rd ed. New York: Churchill Livingston 1996, pp161-184. Hertzberg B. “Ultrasound evaluation of third trimester bleeding,” The Radiologist, July 1997 4(4) pp227-234. Sheiner E, Shohan-Vardi I. “Placenta previa: obstetric risk factors and pregnancy outcome,” Journal of Maternal-Fetal Medicine, December 2001 10(6) pp414-418. Adapted from Association of Professors of Gynecology and Obstetrics Medical Student Educational Objectives, 7th edition, copyright 1997.