Obstetric Hemorrhage

Anne McConville, MD

The Direct leading cause of pregnancy related mortality in the United States is

A B C D E

0%

55%

0%

45%

0%

– A) Failed Intubation– B) Hemorrhage– C) Thromboembolism– D) Hypertensive

disorders of pregnancy

– E) Infection

Cesarean Delivery is associated with a blood loss of about:

A B C D E

0% 0%

60%

20%20%

– A) 100 mL– B) 250 mL– C) 500 mL– D) 750 mL– E) 1000 mL

Estimated Blood Loss During Parturition

• Average EBL during NVD = 600 mL• Average EBL during CS = 1000 mL• Physiologic changes of pregnancy help to

diminish the effects

30 y.o. G2P1 at 28 weeks gestation presents with an episode of brisk vaginal bleeding. She denies having

pain. She has had 1 prior C/S. The most likely diagnosis is:

A B C D E

0% 0% 0%

100%

0%

– A) Placental abruption

– B) Uterine Rupture– C) Cervicitis– D) Placenta Previa– E) Abdominal trauma

Placenta Previa

The next step in management of patient from question 3 is:

A B C D E

0%

87%

0%

13%

0%

– A) Proceed to OR for prompt cesarean delivery

– B) Large bore IV access, fluid resuscitation and transvaginal ultrasound

– C) Cervical exam followed by induction of labor with cytotec and pitocin.

– D) Fetal non-stress test and BPP

– E) MRI

Management of Placenta Previa

• Abdominal or transvaginal ultrasound mainstay of diagnosis.

• Maternal resuscitation• Fetal monitoring by NST and BPP• Betamethasone to accelerate fetal lung

maturity• Tocolytic therapy in selected patients

Anesthetic Management of Placenta Previa

• Assess airway, volume status, and presence of ongoing bleeding

• Large bore IV access, baseline HCT, T&C• With the exception of marginal placenta

previa, Cesarean delivery will be performed• Neuraxial vs. General anesthesia• Prepare to treat intraoperative hemorrhage

32 y.o. G5P4 presents at 38 weeks with vaginal bleeding. She was having contractions that have subsided. She has had 3 prior

classical C/S. FHR tracing shows FHR 108 and minimal variability. The most likely diagnosis is:

A B C D E

7%

27%

0%

27%

40%– A) Placenta Previa– B) Placenta Accreta– C) Uterine Rupture– D) Placental

Abruption– E) Cervicitis

Uterine Rupture

32 y.o. G3P2 at 31 weeks gestation presents with brisk vaginal bleeding, abdominal pain, and contractions. No history of previous

uterine surgery. What is the most likely diagnosis:

A B C D E

13%

0%6%

81%

0%

– A) Placenta Accreta– B) Placenta Previa– C) Placenta Percreta– D) Placental

Abruption– E) Vasa Previa

Placental Abruption

What is the most appropriate next step in the management of the patient from question 6?

A B C D E

31% 31%

13%

19%

6%

– A) Prompt C/S under GETA

– B) Large bore IV access, volume resuscitation and fetal monitoring

– C) Induction of labor with cytotec followed by oxytocin

– D) Epidural analgesia, BPP, followed by C/S

– E) Abdominal ultrasound followed by observation if no abruption present

Management of Placental Abruption

• Maternal Resuscitation, LUD, Oxygen, Urinary catheter• Continuous FHR monitoring• Laboratory studies, T&C• Timing and route of delivery determined by maternal

and fetal status• Anesthesiologist must consider severity of abruption

and urgency of delivery when planning anesthetic• Neuraxial vs. GETA• Prepare to treat coagulopathy• Coexisting uterine atony may also compound bleeding

at delivery

Which of the following is NOT a treatment for Uterine Atony?

A B C D E

0% 0%6%

0%

94%– A) Uterine massage– B) Uterine balloon

tamponade– C) Nitroglycerin– D) Uterine

compression suture– E) Misoprostol

Uterine Atony

• Most common cause of severe PPH• Most common indication for peripartum

transfusion• Uterine contraction primary mechanism of

hemostasis• Risk factors include: Multiparity, macrosomia,

long labor, augmented labor, precipitous labor, chorioamnionitis, polyhydramnios, tocolytic agents, volatile halogenated anesthetics, fibroids

Management of Uterine Atony• Pharmacologic

– Oxytocin– Methylergonovine– 15-Methylprostaglandin F2α– Misoprostol

• Surgical– Uterine Massage– Uterine Compression Suture– Uterine Balloon tamponade– Arterial Ligation– Hysterectomy

• Radiologic– Uterine artery embolization

B-Lynch Suture

Bakri Balloon

40 y.o. G4P2 with low-lying placenta diagnosed during pregnancy experiences hemorrhage during repeat C/S. She has had 2 prior C/S. Other history includes D&C for miscarriage. The uterus appears to be contracting. The most likely diagnosis is:

A B C D E

23%

8%

69%

0%0%

– A) Retained Placenta– B) Placenta Previa– C) Placental

Abruption– D) Uterine Atony– E) Placenta Accreta

Placenta Accreta

Normal placenta

Placenta Accreta

Relationship Between Placenta Previa and Cesarean Section with Placenta Accreta

An 18 y.o. G2P1 experiences hemorrhage in the labor room after vaginal delivery of a preterm infant at 28 weeks gestation. She had 1 D&C previously for miscarriage.

On visual inspection there appears to be genital trauma. The most likely diagnosis is:

A B C D E

53%

13%

0%0%

33%

– A) Retained Placenta– B) Uterine Inversion– C) Uterine Atony– D) Uterine Rupture– E) Placenta Accreta

Retained Placenta

• A major cause of PPH• 3.3% of all deliveries• Placenta separates in fragments• Can be life-threatening• Involves manual removal vs. D&C• Neuraxial vs. General• Uterine relaxation may be requested

Uterine Inversion

• Rare but disastrous event• 1/5,000-10,000 delivered• Risk factors include: uterine atony, fundal

pressure, excessive umbilical cord traction, short umbilical cord, uterine anomalies

• May be incomplete (not visible)• Treatment is immediate replacement• Anesthetic usually involves uterine relaxation

followed by uterine contraction with oxytocin

All of the following are associated with DIC except:

A B C D E

0%

79%

14%7%

0%

– A) Placenta Accreta– B) Placenta Previa– C) Placental

Abruption– D) Dead Fetus

Syndrome– E) Amniotic Fluid

Embolism

Monkeys