OBGYN - Obstetrical Emergencies crc

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Blood mass increase

RBC 25% increase
Plasma 40% increase

Definition of postpartum hemorrhage

Decline in Hct 10%
Est blood loss >500ml vaginal
>1000 ml C-section

Hypotension, pallor, oliguria occurs when

Until 10% or more blodo is lost, substantial amount

Classified of PPH

Primary - w/i 24 horus
Secondary - 24h to 6-12 weeks postpartum

Primary PPH causes

Uterine atony
REtained placenta - placenta accreta
Defects in coagulation
Uterine inversion

Secondary PPH causes

Subinvolution of placental site
Retained POCs
Infection
Inherited coag defects

Clinical thing behind postpartum hemorrhage

Msot common cause - uterine atony ---> Bimanual exam for soft, poorly contracted uterus --> atony as a caustiave factor

Compression or massag eof uterine corpus can diminish bleeding, explel blood and clots, and allow time for other interventions.

Atony not a factor for PPH, what now

Other causes --> lacerations
Gential tract hematomas - enlarging mass
POC retention --> US can help, normal stripe can help r/o, should be done before instrumentation
Coagulopathy

Risk factors for PPH

Prolonged labor
Augmented labor
RApid labor
Hx of PPH
Episiotomy, esp mediolateral
Preeclampsia
Overdistnded uterus (macrosomia, twins, hydramnios)
Operative delivery
Asian or hispanic ethnicity
Chorioamnionitis

Medical management of PPH

Oxytocin cont
Methergine
Carboprost (Hemabate)
Dinoprostone
Misoprostol

Surgical mgmt of PPH

Bilateral uterine artery ligation
B-Lynch technique --> to the corpus
Hypogastric artery ligation (old)
Repair of rupture
Hysterectomy

Risk factors for placenta accreta

Previoucs palcenta previa
Prior myomectomy
Prior C-delivery
Asherman syndrome
Submucous leiomyomata
Age>35

Who gets arterial embolization in PPH

STable VS
Persistent bleeding esp if rate of loss is not excessive

RAdiographic identification --> gelfoam, coils, or glue... Balloon occlusion

Can also be used for bleeding post hysterectomy, or as an alternative for hysterectomy.

Postpartum transfusion rates

0.4-1.6%

Mgmt approach for hemorrhage due to ruptured uterus

Rutpure --> previous c-delivery or otehr surgical procedure involving the uterine wall.. or from congenital malformation

Congential malformation that increases risk of ruptured uterus

Samll uterine horn

Mgmt of uterine rupture of previous C-delivery scar

Revision of edges of prior incision with primary closure.. in adddition, cosnideration must be givent o neugboring structures such as the broad ligament, paramterial vessels, ureters, and bladder.

PE findings that suggest inversion

Firm mass belwo or near the cervix, coupled with absence of identification of uterine corpus...

Placenta still attached to an inverted uterine corpus... how to manage

Do not attempt to detachor remove placenta... this will lead to additional rupture.. replacement of the uterine corpus involves placing the palm of yout hand against he fundus as if holding a tennis ball with teh ingertips exerting upward pressure circumferentially....

Medical mgmt of uterine inversion

Relaxation may be necessary --> terbutaline, mag sulfate, halogenated general anestehteics, and nitroglcyerin...

If manual replacement of uterine prolapse is not sucessful..

Surgery!
Two approaches: Huntington procedure, with progressive upward traction on the inverted corpus using Babcock or Allis forceps
Haultain procedure --> incision of cervical ring posterioruly... subsequent repair

How often secondary PPH

1% of all pregnancies

Secondary PPH, what should be considered

VW disease
Uterine atony
US for POC

Treatment for 2/ PPH

Uterotonic agents
Antibiotics
Curettage - often removal of tissue is minimal yet bleeding subsides promptly...

How to avoid complication of uterine perforation during D&C

Concurrent U/S
Counsel on possibility of hysterectomy before procedure!!1

Once patient is stable and blood is gone, mgmt of PPH

Prenatal vitamin (60mg of elemental iron)
Mineral capsule
Additional iron tablets (300mg --> 60mg of elemental iron)
Consider EPO (but not approved)

PPH once, consequent risk of PPH?

10%

First line treatment for PPH

Uterotonic agents

When uterotonics fail..

Tamponade, but usually exp lap..

If C-delivery is done for uterine atony, there should be documentation of other attempts!!!

PPH other def

>500 ml vaginal.... but actual measured blood loss during uncomplicated vag deliveries averages 700ml... blood loss may often be underestimated...

Incidence of excessive blood loss during vaginal delivery

5-8%

Hemorrhage as a cause of maternal mortality

Developing world: Top cause!
3rd in teh US, direclty responsible for 1/6 of maternal deaths.

Cause of PPH

Uterine atony (50% !)
Obstetric lacerations (20%)
Retained placental tissue
Coag defects

Predisposing causes of PPH

Excessive manipulation of uterus
General anesthesia (halogenated compounds!)
Uterine overdistention (twins, polyhydramnios)
Prolonged labor
Grand multiparity
Uterine leiomyomas
Op delivery and intrauterine manipulation
oxytoxinc induction or augmentation
Previous hemorrhage in the third stage
Uterine infection
Extravasation of blood into the myometrium (Couvelaire uterus)
Intrinsic myometrial dysfunction

Couvelaire uterus

Life threatening. Loosing of placenta --> bleeding that penetrates into the uterine myometrium --> peritoneal cavity

Persistent bright red bleeding with a well contracted uterus

Laceration or episiotomy source.

Risk factors for spontaneous rupture

Grand multiparity
Malpresentation
Previous uterine surgery
Oxytocin induction of labor
Rupture after C-delivery

How often is retained placental tissue a cause of bleeding

5-10%, usually in placenta accreta (increaseing in freq due to c-deliveries)

Also in manual removal of placenta, mismanagement of third stage of labor, and in unrecognized succenturiate placenta.

Imaging findings of retained placental prodcuts

U/S findings of echogenic uterine mass

usually U/S used in hemorrhage occuring a few hours after delivery or in late postpartum hemorrhage

Coagulopathies in pregnancy may be associated with what

Abruptio placentae
Excess thromboplastin from retained dead fetus
Amniotic fluid embolism
Severe preeclampsia
Eclampsia
Sepsis

may present as hypofibrongenemia, thrombocytopenia

How to evaluate a patient of risk of PPH

Coagulopathy
Hemorrhage
Blood transfusions during previous pregnancy
Anemia during labor
Grand multiparity
Multiple gestation
Larg einfants
Polyhydramnios
Dysfunctional labor
Oxytocin induction or augmentation
Rapid or tumultuous labor
Severe preeclampsia or eclampsia
Vaginal delivery after prev C--delivery
General anesthesia for deliery
Forceps delivery
Delay in placental delivery after vaginal delivery of infant

Complications of hemorrhage

Puerperal infection
Partial or total necrosis of anterior pituitary --> Sheehan syndrome

Sheehan syndrome

Failure to lactate
Amenorrhea
Decreased breast size
Loss of pubic and axillary hair
Hypothyroidism
Adrenal insufficiency

Prevalence of Sheehan

Rare <1 / 10,000

Hypotensive post partum with normal lactation, probably does not have this.

Predelivery prep for PPH

Type and screen

At risk:
Type and cross match for at risk, with reservation for up to 24h post deliverty
Large bore IV cath
Alert to risk of hemorrhage

Spontaneous placental separation, signs?

Uterus becomes roudn and firm
Sudden gush of blood
Uterus seens it rise in abdomen
Umbilical cord moves down and out of vagina

Hemorrhage with the placenta?

Opinion divided.... a placenta that has not delivered by 18 mintue sshould be removed...
Active bleeding/hemorrhage --> manual removal right away.

Risk of manual placental removal?

Endometritis postpartum

Steps to take in the immediate postpartum period to lower incidence of PPH

Oxytocin during delviery of anterior shoulder, with controlled cord traction (instead of around placental delivery). Recues by 40%

Potential risk of entrapment of undiagnosed second twin, thus not to be done in people without U/S screening.

What may be just as effective as IV oxytocin for prevention of PPH

Sublingual misoprostol, useful for low resource areas because misoprostol does not have to be refrigerated or require specialized equipment for administration.... but still a useful adjucnt everywhere...

Ergot alkaloids for PPH, problems?

Not more effective than oxytocin, and can pose more risk because they rarely cause marked hypertension (usually with IV or when regional anesthesia is used)..

Do NOT use in hypertensive women or in women with cardiac disease.

Cardinal principles of vaginal laceration repair

Begin repair above the highest extent of the laceration. This is because the tendency of bleeding vessels to retract from the laceration site. Highest suture is also used to provide gental traction to bring the laceration site closer to the introitus

Post delivery and repair of vaginal uterine lacerations and hematomas

Recovery room attendants should frequently massage the uterus and check for vaginal bleeding.

Vaginal bleeding is persisting after placental delivery, what steps need to be taken?

1. Manually compress the uterus
2. Obtain assistance
3. If not already done, obtain blood for typing and cross matching
4. Observe blood for clotting to rule out coagulopathy
5. Begin fluid or blood replacement
6. Explore uterine cavity carefully
7. Inspect cervix and vagina
8. Insert second IV cath

When should manual exploration of the uterus be considered

TOLAC
Intrauterine manipulation such as version and extraction
Malpresentation has occurred during L&D
Premature infant has been delivered
Abnormal uterine contour prior to delivery
Possibility of undiagnosed multiple pregnancy to r/o twins

Most important first step in controlling atonic postpartum hemorrhage

Bimanual uterine compression --> 20-30 minutes or more
Fluid replacement
T&S blood is given when available
Manual compression of uterus will controlm most causes of hemorrhage due to uterine atony, retained POCs, coagulopathies

Technique for bimanual massage

With one hand, grasp uterine fundus and bring it down over symphysis pubis

With other hand, place first and second finers on either side of the cervix and push it cephalad and anteriorly. Pulsating uterine arteries should be felt by the fingertips. Massage the uterus with both hands while maintaining compression. Prolonged compression may be required but is almost always successful in controlling bleeding.

usually you need a foley too.

Asherman syndrome

Amenorrhea and 2/ sterility due to intrauterine adhesions and uterine synechiae

Alternative to uterine packing

Bakri balloon. Inflatable balloon that inflates up to 800ml. Double lumen port so drainage of blood can still occur so that concealed hemorrhage does not occur...

Contraindication to methylergonovine

Hypertension

Delayed PPH >=2 weeks almost always due to what

Subinvolution of placental bed or retained placental fragments.

Involution of placental site is normally delayed, but for weird reasons, subivolution of adjacent endometrium and the decidua basalis

CI to hemabate

Asthma

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