Obstetrical Hemorrhage. Obstetrics is " bloody business ." hemorrhage still remains a leading cause of maternal mortality . 12 % of maternal deaths were caused by obstetrical hemorrhage. hemorrhage is the single most important cause of maternal death worldwide. - PowerPoint PPT Presentation
Obstetrical Hemorrhage Obstetrics is "bloody business." hemorrhage still remains a leading cause of maternal mortality. 12 %of maternal deaths were caused by obstetrical hemorrhage. hemorrhage is the single most important cause of maternal death worldwide. Obstetrical hemorrhage accounts for almost half of all postpartum deaths in developing countries
2Calculation of Maternal Total Blood Volume
Pregnant blood volume:increase 30 -60 % of calculated nonpregnant volume Increases across gestational age and plateaus at approximately 34 weeks Usually hematocrit between 30- 38 Average increase is 40 -80 % with multifetal gestation Average increase is less with preeclampsiavolumes vary inversely with severity3most maternal deaths from hemorrhage is associated with substandard care.many hemorrhage-related maternal deaths were preventable and were associated with inadequate facilities4 . . .5 Stable
7 . Volume expansion stable 18 ( - fDP CBC PT PTT 5 15- 10 88 . double set-up 9 . . .10Antepartum Hemorrhage
11Placental Abruption Placenta Previa
Causes of Obstetrical HemorrhagePlacental Abruption:Placental separation from its implantation site before delivery variously called placental abruption, abruptio placentae, accidental hemorrhage , abruptioplacentae 12complicationsShockConsumptive CoagulopathyRenal FailureSheehan Syndrome
13Shockshock sometimes seen with placental abruption was disproportionate to the amount of hemorrhage. because placental thromboplastin enters the maternal circulation and incites intravascular coagulation hypovolemic shock is directly due to maternal blood loss.
Placental abruption is one of the most common causes of clinically significant consumptive coagulopathy in obstetrics. In approximately a third of women with an abruption severe enough to kill the fetus
there are measurable changes in coagulation factors. 1515Renal Failureit is more common if treatment of hypovolemia is delayed or incomplete. most cases of acute kidney injury are reversible, however, acute cortical necrosis, when it occurs, is usually caused by placental abruption. Seriously impaired renal perfusion is the consequence of massive hemorrhage. Because preeclampsia frequently coexists with placental abruption, renal vasospasm and hypoperfusion are likely intensified.
16Sheehan SyndromeSevere intrapartum or early postpartum hemorrhage rarely is followed by pituitary failure or Sheehan syndrome. characterized by :failure of lactation, amenorrhea, breast atrophy, loss of pubic and axillary hair, hypothyroidism, adrenal cortical insufficiency. exact pathogenesis is not understood, 17diagnosissonography confirmes clinical diagnosis in only 25 % of women
negative findings with sonographic examination do not exclude placental abruption18Management
with massive external bleeding, intensive resuscitation with blood plus crystalloid and prompt delivery to control hemorrhage are lifesaving for mother and hopefully, for fetus. If the diagnosis is uncertain and the fetus is alive but without evidence of compromise, then close observation can be practiced in facilities capable of immediate intervention. for the welfare of the distressed fetus, steps should be initiated immediately to correct maternal hypovolemia, anemia, and hypoxia to restore and maintain function of any placenta that is still implanted.
Placenta previa is used to describe a placenta that is implanted over or very near the internal cervical os. 20Kinds:Total placenta previa internal os is covered completely by placenta Partial placenta previa internal os is partially covered by placenta Marginal placenta previa edge of the placenta is at the margin of internal os Low-lying placenta placenta is implanted in lower uterine segment such that the placental edge does not reach the internal os, but is in close proximity to it
The most characteristic event is painless hemorrhageusually appear near the end of the second trimester and without warningbleeding maybe appear in the onset of labor. it may vary from slight to profuse clinically may mimic placental abruption.Hemorrhage from the implantation site in the lower uterine segment may continue after placental delivery because the lower uterine segment contracts poorly.
The simplest, safest, and most accurate method of placental localization is provided by transabdominal sonography. (average accuracy is 96 %) False-positive results are often a result of bladder distension , placenta is large and extended downward all the way to the internal cervical os. transvaginal sonography Magnetic Resonance (MR) Imaging (useful for diagnosis of placenta accreta )
Cesarean delivery is necessary in practically all women with placenta previa if fetus is reasonably mature :c/s The fetus is preterm and there are no other indications for delivery :close observation
24postpartum hemorrhage25The single most significant cause of maternal death worldwideOne of the top three causes of maternal mortality in all of countriesSerious morbidity may follow PPH: ARDS, coagulopathy, shock, loss of fertility, sheehan syn.26IncidenceThe incidence varies widely: 1-5% of deliveries27DefinitionThere is no single, satisfactory definition of PPH. PPH is excessive bleeding that makes the patient symptomatic
Most common definition: Excess blood loss (>500ml in NVD or >1000ml in C/S)
Decline in Hct of 10%(not a clinically useful definition)28There is no single, satisfactory definition of PPH. PPH is best defined and diagnosed clinically as excessive bleeding that makes the patient symptomatic (pallor, lightheadedness, weakness, palpitations, diaphoresis, restlessness, confusion, air hunger, syncope) and/or results in signs of hypovolemia (hypotension, tachycardia, oliguria, low O2 saturation [500ml in NVD or >1000ml in C/S) A decline in Hct of 10%( is not a clinically usefull deffinition)28Types of PPH Primary PPH(early): in the first 24 hours, 4-6% of pregnancies Secondary PPH(late): between 24h to 6-12 weeks,(0.5-2% of pregnancies)29Atony The most common cause of PPH is uterine atony
Complicates 1 in 20 births
Responsible for at least 80 % of cases of PPH 30only a small proportion of women with any risk factors for PPH develop the disorder and many women without risk factors experience hemorrhage after delivery; thus, knowledge of risk factors is not very useful clinically31 32Planning & prevention training team
Protocol for management of PPH
equipments of medications and instruments are readily available in Labor and delivery units 33Diagnosis
The differentiation between bleeding from uterine atony and genital tract lacerations is tentatively determined by predisposing risk factors and the condition of uterus.If bleeding persists despite a firm, well-contracted uterus, the cause of the hemorrhage most likely is from lacerations Bright red blood also suggests arterial blood from lacerations. careful inspection of the vagina, cervix, and uterus is essential.
34Management management of PPH is multifaceted and can involve many teams (obstetricians, nurses, anesthesiologists, blood bank personnel, laboratory medicine, surgical subspecialists, interventional radiology). These teams are often required to work together under great stress and time pressures Coordination is essential and can be facilitated by protocols and flow diagrams that anticipate how these teams will communicate and function together.35Management of postpartum hemorrhage at vaginal delivery3637Initial Interventions
Fundal massage Massage should be maintained while other interventions are being initiated Intravenous access Laboratory testsCBC, fibrinogen concentration , platelet count, PT, activated PTT, typed and crossed for multiple units of packed red blood cells. 38
Fluid resuscitation and transfusion Monitoring vital signs Bladder catheter A large volume of crystalloid is infused Replacement of blood components 39 Uterotonic drugsOxytocin 40 units in 1 liter of normal saline 10 units IM (including directly into the myometrium). Higher doses of oxytocin (up to 80 units in 1000 mL for a short duration (eg, over 30 minutesMethylergonovine 0.2 mg IM (or directly into the myometrium) (never IV). May repeat at 2-4h intervals, as needed. If there has not been a good response to the first dose, quickly move on to a different uterotonic agent. Carboprost tromethamine(15 methyl-PGF2)(Hemabate) 250 mcg IM (or directly into the myometrium) every 15-90 min, [a total dose of 2 mg (8 doses)], no asthma.(75 % respond to a single dose) move on to a different uterotonic agent if no response after one or two doses. 4040 Uterotonic drugs(con)
Misoprostol(PGE1) Is most useful for reducing blood loss in settings where injectable uterotonics are unavailable. The optimum dose and route of administration are unclear. A dose of 400 mcg with the sublingual route is probably the optimal route of administration Can be given to women with hypertension or asthma. Maternal temperature should be monitored closely
Dinoprostone(PGE2) 20 mg vaginal or rectal suppository is an alternative PGE to misoprostol (PGE1). Can be repeated at 2-4h intervals.
Carbetocin, 41Secondary Interventions Provide adequate anesthesia Inspect for and repair cervical and vaginal lacerations Exclude uterine rupt