Postpartum hemorrhage 12 01


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Postpartum hemorrhage 12 01

  1. 1. Postpartum Hemorrhage Jorge Garcia, MD December, 2001
  2. 2. Goals of talk Definition Rapid diagnosis and treatment Review risks
  3. 3. Case 1. Healthy 32 yo G2P1. Augmented vaginal delivery, no tears. Nurse calls you one hour after delivery because of heavy bleeding. What do you do? What do you order?
  4. 4. Case 2 26 yo G4 now P4. NSVD, with help from medical student. You leave the room to answer a page while waiting for placenta to deliver, but are called back overhead, stat. Huge blood clot seen in vagina. What is this, and what do you do next?
  5. 5. Definition Mean blood loss with vaginal delivery: 500cc > 1000cc is “hemorrhage” Mean blood loss with C/S: 1000cc >1500cc is “hemorrhage” Seen in ~5% of deliveries.
  6. 6. Early vs. Late Most authors define early as < 72h. ALSO defines it as <24h. Late hemorrhage is more likely due to infection and retained placental tissue.
  7. 7. Prenatal Risk Factors Most patients with hemorrhage have none. Pre-eclampsia (RR 5.0) Previous postpartum hemorrhage (RR 3.6) Multiple gestation (RR 3.3) Previous C/S (RR 1.7) Multiparity (RR1.5)
  8. 8. Intrapartum Risk Factors Prolonged 3rd stage (>30 min) (RR7.5) medio-lateral episiotomy (RR4.7) midline episiotomy ( RR1.6) Arrest of descent (RR 2.9) Lacerations (RR 2.0) Augmented labor ( RR1.7) Forceps delivery (RR 1.7)
  9. 9. Easy to miss Physicians underestimate blood loss by 50% Slow steady bleeding can be fatal Most deaths from hemorrhage seen after 5h Abdominal or pelvic bleeding can be hidden
  10. 10. Always look for signs of bleeding Estimate blood loss accurately. Evaluate all bleeding, including slow bleeds. If mother develops hypotension, tachycardia or pain…rule out intra- abdominal blood loss.
  11. 11. Initial Assessment Identify possible post partum hemorrhage. Simultaneous evaluation and treatment. Remember ABCs. Use O2 4L/min. If bleeding does not readily resolve, call for help. Start two 16g or 18g IVs.
  12. 12. ALSO’s 4 Ts Tone (Uterine tone) Tissue (Retained tissue--placenta) Trauma (Lacerations and uterine rupture) Thrombin (Bleeding disorders)
  13. 13. “Tone: Think of Uterine Atony” Uterine atony causes 70% of hemorrhage Assess and treat with uterine massage Use medication early Consider prophylactic medication...
  14. 14. Bimanual Uterine Exam Confirms diagnosis of uterine atony. Massage is often adequate for stimulating uterine involution.
  15. 15. Medications for Uterine Atony 1. Oxytocin promotes rhythmic contractions. Give IM or IU, not IV. (Can cause ↓ BP) 40U/L at 250cc/h. 2. Methergine 0.2mg (1 amp) IM 3. Hemabate 0.25mg IM q 15min (max X8).
  16. 16. Medications: Methergine Causes tetanic uterine contraction. May trap placenta. Can cause Hypertension, especially IV. Contraindicated in hypertensive patients and those with pre-eclampsia. Some authors skip Methergine altogether.
  17. 17. Prostaglandin F2 15-methyl Hemabate 0.25mg IM or IU. Used to be called Prostin. Controls hemorrhage in 86% when used alone, and 95% in combination with above. Can repeat up to eight times. Contraindicated in active systemic diseases. Can cause nausea/vomiting/diarrhea, ↑ BP.
  18. 18. Tissue: Retained placenta Delay of placental delivery > 30 minutes seen in ~ 6% of deliveries. Prior retained placenta increases risk. Risk increased with: prior C/S, curettage p- pregnancy, uterine infection, AMA or increased parity. Prior C/S scar & previa increases risk (25%) Most patients have no risk factors. Occasionally succenturiate lobe left behind.
  19. 19. Abnormal Placental Implantation Attempt to remove the placenta by usual methods. Excess traction on cord may cause cord tear or uterine inversion. If placenta retained for >30 minutes, this may be caused by abnormal placental implantation.
  20. 20. Abnormal implantation defined. Caused by missing or defective decidua. Placenta Accreta: Placenta adherent to myometrium. Placenta Increta: myometrial invasion. Placenta Percreta: penetration of myometrium to or beyond serosa. These only bleed when manual removal attempted.
  21. 21. Removal of Abnormal Placenta Oxytocin 10U in 20cc of NS placed in clamped umbilical vein. If this fails, get OB assistance. Check Hct, type & cross 2-4 u. Two large bore IVs. Anesthesia support.
  22. 22. Removal of Abnormal Placenta Relax uterus with halothane general anesthetic and subcutaneous terbutaline. Bleeding will increase dramatically. With fingertips, identify cleavage plane between placenta and uterus. Keep placenta intact. Remove all of the placenta.
  23. 23. Removal of Abnormal Placenta If successful, reverse uterine atony with oxytocin, Methergine, Hemabate. Consider surgical set-up prior to separation. If manual removal not successful, large blunt curettage or suction catheter, with high risk of perforation. Consider prophylactic antibiotics.
  24. 24. Trauma (3rd “T”) Episiotomy Hematoma Uterine inversion Uterine rupture
  25. 25. Uterine Inversion Rare: ~1/2000 deliveries. Causes include: Excessive traction on cord. Fundal pressure. Uterine atony.
  26. 26. Uterine Inversion Blue-gray mass protruding from vagina. Copious bleeding. Hypotension worsened by vaso-vagal reaction. Consider atropine 0.5mg IV if bradycardia is severe. High morbidity and some mortality seen: get help and act rapidly.
  27. 27. Uterine Inversion Push center of uterus with three fingers into abdominal cavity. Need to replace the uterus before cervical contraction ring develops. Otherwise, will need to use MgSO4, tocolytics, anesthesia, and treatment of massive hemorrhage. When completed, treat uterine atony.
  28. 28. Uterine Rupture Rare: 0.04% of deliveries. Risk factors include: Prior C/S: up to 1.7% of these deliveries. Prior uterine surgery. Hyperstimulation with oxytocin. Trauma. Parity > 4.
  29. 29. Uterine Rupture Risk factors include: Epidural. Placental abruption. Forceps delivery (especially mid forceps). Breech version or extraction.
  30. 30. Uterine Rupture Sometimes found incidentally. During routine exam of uterus. Small dehiscence, less than 2cm. Not bleeding. Not painful. Can be followed expectantly.
  31. 31. Uterine Rupture before delivery Vaginal bleeding. Abdominal tenderness. Maternal tachycardia. Abnormal fetal heart rate tracing. Cessation of uterine contractions.
  32. 32. Uterine Rupture after delivery May be found on routine exam. Hypotension more than expected with apparent blood loss. Increased abdominal girth.
  33. 33. Uterine Rupture When recognized, get help. ABCs. IV fluids. Surgical correction.
  34. 34. Birth Trauma Lacerations of birth tract not rare: causes post partum hemorrhage in 1/1500 deliveries.
  35. 35. Birth Trauma Risk factors include: Instrumented deliveries. Primiparity. Pre-eclampsia. Multiple gestation. Vulvovaginal varicosities. Prolonged second stage. Clotting abnormalities.
  36. 36. Birth Trauma Repair lacerations quickly. Place initial suture above the apex of laceration to control retracted arteries.
  37. 37. Repair of cervical laceration
  38. 38. Birth Trauma: Hematomas Hematomas less than 3cm in diameter can be observed expectantly. If larger, incision and evacuation of clot is necessary. Irrigate and ligate bleeding vessels. With diffuse oozing, perform layered closure to eliminate dead space. Consider prophylactic antibiotics.
  39. 39. Pelvic Hematoma
  40. 40. Vulvar hematoma
  41. 41. Thrombin (4th “T”) Coagulopathies are rare. Suspect if oozing from puncture sites noted. Work up with platelets, PT, PTT, fibrinogen level, fibrin split products, and possibly antithrombin III.
  42. 42. Prevention? Some evidence supports use of oxytocin after delivery of anterior shoulder, in umbilical vein or IV.
  43. 43. Summary: remember 4 Ts Tone Tissue Trauma Thrombin
  44. 44. Summary: remember 4 Ts “TONE”  Palpate fundus. Rule out Uterine  Massage uterus. Atony  Oxytocin 40U/L @ 250cc / h.  Methergine one amp IM (not in hypertensives)  Hemabate IM q 15min
  45. 45. Summary: remember 4 Ts “Tissue”  Inspect placenta for R/O retained placenta missing cotyledons.  Explore uterus.  Treat abnormal implantation.
  46. 46. Summary: remember 4 Ts “TRAUMA”  Obtain good exposure. R/o cervical or vaginal  Inspect cervix and lacerations. vagina.  Worry about slow bleeders.  Treat hematomas.
  47. 47. Summary: remember 4 Ts “THROMBIN”  Check labs if suspicious.