Bleeding in Pregnancy: Antepartum & Postpartum Hemorrhage OB & GY Dept. First Hospital, Xi’An Jiao Tong University

Learning Objectives Definition of Post Partum Hemorrhage Management of PPH Risk Factors for PPH Differential Diagnosis of Third Trimester Bleeding Management of Placenta Previa and Abruptio Placenta

“Worst Case Scenario” An insulin dependent diabetic was induced for suspect fetal macrosomia and delivered a 4300 gram male infant because of late decelerations. A low forceps delivery was done. An episiotomy was done. Thee was a Shoulder Dystocia. Immediately after delivery of the placenta the patient bled uncontrollably and the anesthesiologist yelled, “The patient is in shock.” There is a 4th degree perineal laceration and the uterus is “boggy” and there is a left side wall laceration as well.

Definitions of Postpartum Hemorrhage Estimated blood loss a. > 500 mL with vaginal birth b. > 1000 mL with cesarean delivery c. > 1500 mL with cesarean hysterectomy Decline from antepartum to postpartum hematocrit of > 10% Postpartum hematocrit < 27% Transfusion of red blood cells

Risk Factors of Postpartum Hemorrhage: Results of Logistic Regression Vaginal Birth (N=9.598) Cesarean Deliveries (N=3.052) Anesthesia (general vs. epidural) -- 2.94 Amnionitis NS 2.69 Episiotomy (mediolateral vs. none/midline) 4.67 Labor abnormalities Protracted active phase Arrest of descent (present vs. absent) 2.91 2.40 1.90 Lacerations (cervical/vaginal/perineal vs. none) 2.05 Multiple gestations (twins vs. singletons) 3.31 Preeclampsia (present vs. absent) 5.02 2.18 Prior postpartum hemorrhage (present vs. absent) 3.55 Third stage (>30 minutes vs. <30 minutes) 7.56

Postpartum Hemorrhage An event, not a diagnosis. Excessive blood loss Atony Abnormal Implantation Site Placenta Accreta Uterine Inversion Genital Tract Injury Cervical or Vaginal Lacerations Pelvic Hematoma

Postpartum Hemorrhage Vaginal Birth Antepartum - postpartum > 10% (Hct) Risk Factors Prolonged 3rd stage of labor Preeclampsia Mediolateral episiotomy Combs CA et al, obstet Gnecol. 1991:77:63

Postpartum Hemorrhage C/S Risk Factors General anesthesia Amnionitis Preeclampsia Combs CA et al, obstet Gynecol 1991:77;77

Postpartum Hemorrhage Vaginal Birth Postpartum Hct <27% or Blood Transfusion Risk Factors Estimated blood loss > 500 ml Marginal previa Placental abruption Third stage of labor > 30 minutes Chorioamnionitis Nicol B et al obstet Gynecol 1997;90:514

Postpartum Hemorrhage Antepartum - Postpartum > 10% (Hct) Risk Factors Preeclampsia Disorders of active phase of labor Native American ethnicity Previous PPH Maternal weight > 250 lbs

Postpartum Hemorrhage Knowing the risk factors associated with postpartum hemorrhage means the obstetricians can effectively manage at-risk patients. One can ancticipate those patients where there is a greater likelihood of a postpartum hemorrhage

Postpartum Hemorrhage Medical Management Atony - Bimanual compression - 15 methyl PGF 2: 0.25 mg 15’ IM or intra-myometrium - Methylergonovine : 0.2 mg 1M No IV => severe hypertension - Misoprostol (100 mg) rectally

Postpartum Hemorrhage Prevention Vaginal deliveries Active Management of 3rd stage of labor Uterotonic agents Cesarean deliveries Spontaneous delivery placenta Repair uterine incision in situ

Management of Postpartum Hemorrhage

Postpartum Hemorrhage Surgical Management Uterine artery ligation Hypogastic artery ligation Ovarian vessels B-Lynch technique Selective arterial embolization Hysterectomy

Figure

Hematoma Pelvic Hematoma Vulvar Vaginal Retroperitoneal

Risk Factors Episiotomy Primiparity Preeclampsia Multiple gestation Vulvovaginal varicosities Prolonged 2nd stage of labor Clotting abnormalities

Hematoma Vulvar hematoma Laceration of vessels in the superficial fascia of pelvic triangle Volume support < 3 cm: observation > 3 cm: surgical evacuation with suture closure and dressing compression

Hematoma Vaginal hematoma Accumulation of blood above the pelvic diaphragm More associated with forceps deliveries Incision and evacuation Vaginal packing for 12 – 18 hours

Hematoma Retroperitoneal hematomas Sudden onset of hypotensive shock Laceration of a branch of hypogastric artery Inadequate hemostasis of the uterine arteries (C/S) Rupture of low transverse scar Surgical exploration and ligation of the hypogastric vessel

Potential Complications of Puerperal Hematomas Transfusion Coagulation Defects Anemia Fever Reformation Deep vein thrombosis Scarring with resultant dyspareunia Fistula Formation Prolonged Hospitalization and Recuperation

Placenta Accreta/Increta/Percreta Accreta: villi attatched to myometrium (85%) Increta: villi invading the myometrium (15%) Percreta: villi beneath or through the uterine serosa (5%)

Placenta Accreta/Increta/Percreta Risk factors Early 30s Parity (2 or 3 prior births) Prior C/S H/O of D& C Prior manual placental removal Prior retained placenta Infection

Postpartum Accreta Postpartum hemorrhage 39 – 64% 2600 ml (without previa) 4700 ml (with previa)

Placenta Accreta/Increta/Percreta Postpartum hemorrhage Conservative Management Hysterectomy

Placenta Accreta/Percreta/Increta Conservative management Leaving the placenta in place Localized resection and repair Oversewing a defect (esp percreta) Blunt disection/curretage

Uterine Inversion 1/2000  1/6400 Partial delivery of placenta Rapid onset of maternal shock Degree 1st (Incomplete) - Corpus does not pass through the cervix 2nd (Complete) - Corpus passes through the cervix 3rd (Prolapse) - Corpus extends through vaginal introitus

Uterine Inversion Treatment Fluid therapy Restoration of uterus Pushing the fundus with a fisted hand along the axis of vagina through cervix back into pelvis If failed Terbutaline Mg SO4 General anesthesia Laparotomy

Uterine Rupture 0.05% for all pregnancies 0.8% after a previous low transverse c/s 75% in prior classical c/s 25% in prior uterine myomectomy

Uterine Rupture Risk Factors Surgical procedures of uterus C/S, myomectomy, perforation, cornual resection, hysteroscopic or laparoscopic injuries, penetrating abdominal wounds • Grand multiparity Obstetric trauma Fetal macrosomia Malpresentation Breech extraction Instrumental vaginal deliveries

Uterine Rupture Symptoms and signs Ripping lower abdominal Pain Referred Shoulder Pain Vaginal Hemorrhage Fetal Bradycardia Loss of fetal presentation part

Uterine Rupture Management Hysterectomy Repair  recurrent rupture: 19%

Third Trimester Bleeding: Antepartum Hemorrhage Placental Abruption Placental Previa

“Real Life Situation” A patient calls you by telephone and tells you that she has some vaginal bleeding with some crampy lower abdominal pain at 32 weeks gestation. She is hypertensive and has used drugs in the past as well. She has had 2 previous CS and was transfused with the last one. She was told that she had a placenta previa earlier in her pregnancy with her ultrasound exam at 20 weeks.

Placental Abruption External hemorrhage Concealed hemorrhage Total Partial 1/200 – 1/1550 deliveries Perinatal mortality: 25% Recurrence: 4 – 12.5%

Placental Abruption Increased Maternal age and parity N/A Risk Factors RR Increased Maternal age and parity N/A Preeclampsia 2.1 – 4.0 Chronic hypertension 1.8 – 3.0 PROM 2.4 – 3.0 Smoking 1.4 – 1.9 Cocaine N/A (13%) Prior abruption 10 – 25

Placental Abruption Symptoms & Signs Frequency (%) Vaginal bleeding 78 Uterine tenderness or back pain 66 Fetal distress 60 High frequency of contractions 17 Hypertonus 17 Idiopathic preterm labor 22 IUFD 15

Placental Abruption DIC Acute renal failure Couvelaire uterus

Placental Abruption Management Gestational age Maternal status Fetal status Correct maternal hypovolemia, anemia, hypoxia ? Tocolysis Vaginal vs. C/S

Placenta Previa Incidence: 0.3- 0.7 % Definitions: Total Partial Marginal Low-lying

Tubal Occlusion:

Placental Previa Risk Factors Increased maternal age Increase parity Smoking Prior C/S One: 2X – 3X (0.5-0.75%) Two: 1.9% Three: 4.1% Diagnosis: U/S (TVU), MRI

Placental Previa GA at U/S (wk) Previa or Bleeding at Delivery < 20 2.3% 20 – 25 3.2% 25 – 30 5.2% 30 – 35 24%

Placental Previa Management ? Fetal lung maturity ? Labor ? Preterm ? Fetal lung maturity ? Labor ? Severe hemorrhage Vaginal delivery vs. C/S