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
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?
First line treatment for PPH
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
Hemorrhage as a cause of maternal mortality
Developing world: Top cause! 3rd in teh US, direclty responsible for 1/6 of maternal deaths.
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
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
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?
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.
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
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