1. Antepartum and Postpartum Hemorrhage Dr. Megha Jain www.anaesthesia.co.in email: anaesthesia.co.in@gmail.com University College of Medical Sciences & GTB Hospital, Delhi

2. Antepartum hemorrhage Bleeding from or into genital tract after 28 th week of gestation. Bleeding from or into genital tract after 28 th week of gestation. Incidence: 3 – 5% among hospital deliveries. Incidence: 3 – 5% among hospital deliveries. CAUSES CAUSES placental unexplained local lesions placental unexplained local lesions Placenta abruptio -trauma Praevia placentae -cervical polyp -carcinoma cervix -carcinoma cervix

3. Placenta praevia Placenta partially or completely implanted in lower uterine segment. Placenta partially or completely implanted in lower uterine segment. Types or degrees: Types or degrees: Type 1(lateral): placenta encroaches onto LUS Type 1(lateral): placenta encroaches onto LUS Type 2(marginal): placenta reaches internal os Type 2(marginal): placenta reaches internal os but does not cover it but does not cover it Type 3(incomplete central): placenta partially covers the internal os Type 3(incomplete central): placenta partially covers the internal os Type 4(central): placenta completely covers the internal os even after full dilation Type 4(central): placenta completely covers the internal os even after full dilation

6. Risk factor Multiparity Multiparity Increased maternal age Increased maternal age History of previous CS or any other scar in the uterus(myomectomy) History of previous CS or any other scar in the uterus(myomectomy) Big size placenta Big size placenta

7. Clinical presentation 1 st vaginal bleeding episode- 1 st vaginal bleeding episode- after 36 th week- 60% after 36 th week- 60% b/w 32 - 36 week- 30% b/w 32 - 36 week- 30% before 32 week- 10% before 32 week- 10% # painless and recurrent bleeding # painless and recurrent bleeding # GC and anemia – prop. to blood loss # GC and anemia – prop. to blood loss # Size of uterus prop. to POG # Size of uterus prop. to POG # Presenting part is usually high up # Presenting part is usually high up # FHS is usually present # FHS is usually present # Diagnosis by USG # Diagnosis by USG

8. The double set up examination Vaginal examination in OT Vaginal examination in OT Preparation- Preparation- # Two large bore i/v cannula # Two large bore i/v cannula # Blood for transfusion # Blood for transfusion # Oral antacid # Oral antacid # Oxygen # Oxygen # Skilled assistant # Skilled assistant If profuse bleeding CS GA(RSI) If profuse bleeding CS GA(RSI) # Treat hypovolemia # Treat hypovolemia # Induction- Ketamine, intubate- Sch # Induction- Ketamine, intubate- Sch # Maintenance- O2, N2O # Maintenance- O2, N2O # Awake extubation # Awake extubation

9. Abruptio placentae Bleeding due to premature separation of placenta Bleeding due to premature separation of placenta Varieties: Varieties: Revealed(m/c) Revealed(m/c) concealed, concealed, mixed mixedEtiology: advanced maternal age, high parity advanced maternal age, high parity pre eclampsia pre eclampsia trauma trauma sudden uterine decompression sudden uterine decompression short cord short cord history of previous abruption history of previous abruption smoking smoking

10. Abruptio placentae

11. Clinical presentation Continuous painful bleeding Continuous painful bleeding Lower abdominal tenderness Lower abdominal tenderness Rapid abnormal uterine contractions Rapid abnormal uterine contractions Fetal heart rate abnormalities Fetal heart rate abnormalities Premature labour Premature labour Intrauterine death Intrauterine death Maternal cardiovascular collapse Maternal cardiovascular collapse DIC, ARF DIC, ARF Definitive diagnosis by USG Definitive diagnosis by USG

12. Resuscitation Rapid assessment and initial maneuvers can be life saving 1. O2 supplementation 2. 2 large bore iv cannulas 3. Send – CBC, BUSE, coagulation profile, BGCM 4. Arrange whole blood 5. ABG 6. Warm fluids

13. Monitoring 1. ECG, NIBP, Pulse oximetry 2. Urine output monitoring 3. CVP monitoring 4. Frequent ABG analysis FLUID THERAPY -Crystalloids -Colloids if hypotension persists -Group typed blood if blood loss > allowable/ preexisting anemia is present -Use fluid warming devices -FFP and platelet according to lab values.

14. Anesthetic management in placenta praevia The mode of delivery should be based on clinical judgment supplemented by ultrasound findings Grade III and IV Posterior Thick regional No active bleeding yes hemodynamically stable no No active bleeding yes hemodynamically stable no GA GA Caesarean section

15. Regional anaesthesia –associated with more blood loss because Regional anaesthesia –associated with more blood loss because -placenta praevia patients are at increased risk of placenta accreta -placenta praevia patients are at increased risk of placenta accreta -obstretician may cut into placenta during uterine incision -obstretician may cut into placenta during uterine incision -LUS has lesser power of contraction and retraction -LUS has lesser power of contraction and retraction

16. General anesthesia RSI – preferred technique RSI – preferred technique Induction agent- Ketamine safest for hypovolemic patients(0.5 to 1mg/kg) Induction agent- Ketamine safest for hypovolemic patients(0.5 to 1mg/kg) Intubation with Sch(1.5mg/kg) Intubation with Sch(1.5mg/kg) Maintenance with- O2(50%)+ N2O(50%)+ low conc of volatile agent if tolerated Maintenance with- O2(50%)+ N2O(50%)+ low conc of volatile agent if tolerated Extubate when fully awake and responding to verbal commands Extubate when fully awake and responding to verbal commands

17. Anesthetic management of abruptio placentae Definitive treatment is delivery of the fetus Definitive treatment is delivery of the fetus Route of delivery depends on – Route of delivery depends on – degree of abruption degree of abruption maternal hemodynamics maternal hemodynamics status of the fetus status of the fetus If abruption is mild to moderate and the mother is hemodynamically stable with fetus being mature – continuous lumbar epidural, caudal or SAB may be used for labour and vaginal delivery If abruption is mild to moderate and the mother is hemodynamically stable with fetus being mature – continuous lumbar epidural, caudal or SAB may be used for labour and vaginal delivery

18. Anesthetic management (contd….) For severe abruption – Em LSCS ↓ GA(RSI) For severe abruption – Em LSCS ↓ GA(RSI) ↑ risk of persistent hemorrhage due to uterine atony and coagulopathy ↑ risk of persistent hemorrhage due to uterine atony and coagulopathy Thus give oxytocin immediately after delivery Thus give oxytocin immediately after delivery Other drugs used are methergin and PG analogues Other drugs used are methergin and PG analogues Transfuse blood, FFP and platelet Transfuse blood, FFP and platelet

19. Postpartum hemorrhage Definition: blood loss > 500 ml after vaginal delivery of fetus > 1000 ml after CS Definition: blood loss > 500 ml after vaginal delivery of fetus > 1000 ml after CS Clinically it refers to any amount of bleeding from or into genital tract which adversely affects maternal condition Clinically it refers to any amount of bleeding from or into genital tract which adversely affects maternal condition Incidence: 3-5% among all deliveries Incidence: 3-5% among all deliveries

20. Types # Primary: in 24 hrs following delivery # Primary: in 24 hrs following delivery Third stage hge- before placental expulsion True PPH- after placental expulsion Third stage hge- before placental expulsion True PPH- after placental expulsion # Secondary: beyond 24 hrs but within puerperium # Secondary: beyond 24 hrs but within puerperium

21. Etiology 1. Atonic uterus: (80%) can be due to- # grand multipara # grand multipara # over distention of uterus (twins, macrosomia) # over distention of uterus (twins, macrosomia) # malnutrition and anemia # malnutrition and anemia # APH # APH # prolonged labour # prolonged labour # uterine fibroid # uterine fibroid 2. Trauma 3. Blood coagulation disorder

22. Assessment of obstetric hemorrhage -None None <15-20% -Mild Tachycardia 20-25% Mild hypotension Mild hypotension Peripheral vasoconstriction Peripheral vasoconstriction -Moderate HR- 100-120/min 25-35% SBP- 80-100 mmHg SBP- 80-100 mmHg Restlessness Restlessness Oliguria Oliguria -Severe HR>120/min >35% SBP<60 mmhg SBP<60 mmhg Altered consc Altered consc Anuria Anuria Severity of shock Finding% blood loss

23. Management of third stage hemorrhage Uterine massage Uterine massage Injec. Oxytocin/ methergin Injec. Oxytocin/ methergin Start RL/NS arrange for blood Start RL/NS arrange for blood Catheterise the bladder Catheterise the bladder Placenta Not separated Placenta Not separated separated separated Express by CCT Manual removal under GA

24. Retained placenta Definition: placenta not expelled out even 30 min. after birth of the baby. Definition: placenta not expelled out even 30 min. after birth of the baby. Incidence: 1% of all vaginal deliveries Incidence: 1% of all vaginal deliveries Dangers associated with prolonged retention: Hemorrhage, shock, puerperal sepsis. Dangers associated with prolonged retention: Hemorrhage, shock, puerperal sepsis. If mother has epidural or spinal block from T10 to S4 MRP can be accomplished without pain. If mother has epidural or spinal block from T10 to S4 MRP can be accomplished without pain. If not then I/V sedation (BZD/ Ketamine / Fentanyl) can be tried. If not then I/V sedation (BZD/ Ketamine / Fentanyl) can be tried. But if the patient is hemodynamically unstable GA should be administered. But if the patient is hemodynamically unstable GA should be administered.

25. Role of NTG in MRP 50 – 100 µg of I/V nitroglycerine provides uterine relaxation sufficient to remove the placenta. 50 – 100 µg of I/V nitroglycerine provides uterine relaxation sufficient to remove the placenta. MOA – releases nitric oxide which relaxes uterine smooth muscle. MOA – releases nitric oxide which relaxes uterine smooth muscle. Advantages- 1. Avoidance of GA- reduced risk of failed intubation and aspiration Advantages- 1. Avoidance of GA- reduced risk of failed intubation and aspiration 2. Onset is immediate 3. Recovery is smooth and rapid (without sedation) 2. Onset is immediate 3. Recovery is smooth and rapid (without sedation) S/E – hypotension and headache. S/E – hypotension and headache.

26. Placenta accreta Definition: Abnormal adherence of placenta to the uterine wall after the baby is born Definition: Abnormal adherence of placenta to the uterine wall after the baby is born Underlying pathology: absent decidua, placental villi attach directly to myometrium Underlying pathology: absent decidua, placental villi attach directly to myometrium Types: Placenta accreta- adherence to myometrium Placenta increta- invasion of myometrium Placenta percreta- invasion of uterine serosa or other pelvic structures Types: Placenta accreta- adherence to myometrium Placenta increta- invasion of myometrium Placenta percreta- invasion of uterine serosa or other pelvic structures Risk factors: Placenta previa Prior CS Prior uterine trauma Risk factors: Placenta previa Prior CS Prior uterine trauma

27. Diagnosis- Diagnosis- retained placenta retained placenta massive hemorrhage after manual removal of placenta massive hemorrhage after manual removal of placenta hematuria hematuria Transvaginal color Doppler USG Transvaginal color Doppler USG MRI MRI

28. Anesthetic mgt. of placenta accreta Most patients require hysterectomy ↓ GA Most patients require hysterectomy ↓ GA Insert large bore I/V line Insert large bore I/V line Arrange blood Arrange blood Secure airway- Endotracheal intubation Secure airway- Endotracheal intubation Routine monitoring-ECG, NIBP, Pulse oximetry, urine output Routine monitoring-ECG, NIBP, Pulse oximetry, urine output Consider CV line and arterial line Consider CV line and arterial line Use fluid warming devices Use fluid warming devices May require ICU care May require ICU care

29. Uterine inversion Rare C/C of 3 rd stage where uterus turns inside out partially or completely Rare C/C of 3 rd stage where uterus turns inside out partially or completely Etiology- may be spontaneous or Etiology- may be spontaneous or - due to pulling of the cord - due to pulling of the cord - uterine atony - uterine atony - inappropriate fundal pressure - inappropriate fundal pressure - placenta accreta - placenta accreta Dangers associated- hemorrhage, shock, pulmonary embolism Dangers associated- hemorrhage, shock, pulmonary embolism

31. Management Best T/T – early replacement of the uterus Best T/T – early replacement of the uterus GA with volatile halogenated agent- most proven method for providing uterine relaxation GA with volatile halogenated agent- most proven method for providing uterine relaxation Uterine relaxation may be achieved Uterine relaxation may be achieved by nitroglycerine, thus avoiding GA by nitroglycerine, thus avoiding GA

32. Uterine atony - M/C cause of PPH - M/C cause of PPH - Conditions associated with uterine atony are- - Conditions associated with uterine atony are- Multiple gestation Multiple gestation Macrosomia Macrosomia Polyhydramnios Polyhydramnios High parity High parity Prolonged/precipitous/augmented labor Prolonged/precipitous/augmented labor Tocolytic drugs Tocolytic drugs High conc. Of volatile halogenated agents High conc. Of volatile halogenated agents

33. Management Resuscitation and immediate management- Resuscitation and immediate management- Administer 100% O2 Administer 100% O2 2 large bore I/V cannula and arrange blood 2 large bore I/V cannula and arrange blood Fluid resuscitation- crystalloid/colloid using pressure bag Fluid resuscitation- crystalloid/colloid using pressure bag Transfuse cross matched blood( O-Negative if group specific not available) Transfuse cross matched blood( O-Negative if group specific not available) Use fluid warmer and warming blanket Use fluid warmer and warming blanket Monitor- ECG,NIBP,O2 sat., urine output, acid base status, hemoglobin(using hemocue) and coagulation parameters Monitor- ECG,NIBP,O2 sat., urine output, acid base status, hemoglobin(using hemocue) and coagulation parameters Consider arterial line and CVP line only after definitive treatment has commenced Consider arterial line and CVP line only after definitive treatment has commenced

34. Management (contd….) Drugs used for uterine atony 1. Oxytocin 10-40 U in 1000 ml I/V hypotension tachycardia tachycardia 2. Ergometrine 200 µg I/M hypertension vasocons. vasocons. vomiting vomiting 3. PG F2 alpha 250 µg I/M hypotension I/U bronchocons. I/U bronchocons. AgentDoseRouteS/E

35. Management (contd….) Other maneuvers include- Other maneuvers include- Uterine massage Uterine massage Repair lacerations if present Repair lacerations if present Bimanual packing of uterus Bimanual packing of uterus Consider vaginal/uterine packing Consider vaginal/uterine packing Interrupt arterial supply- Interrupt arterial supply- Embolization Embolization Surgical ligation (uterine/ant. Division of internal iliac B/L) Surgical ligation (uterine/ant. Division of internal iliac B/L) Hysterectomy Hysterectomy

36. Thank You www.anaesthesia.co.in