This seminar is prepared for academic purpose during my masters study.

1. By siraj Ahmed (Y-I, MSC/ACA)
srjmyn@gmail.com
August /2017
Seminar Presentation on Management
of Obstetrics Hemorrhage
Dilla University
College of Health Sciences and Medicine
Department of Anesthesiology

2. Outlines
• Objectives
• Introduction
• Causes of obstetrics hemorrhage
• Classification of obstetrics hemorrhage
• Management approches of obstetrics
hemorrhage
• References
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3. Objectives
At the end of this presentation the participants will be able
to:
• Recognize obstetrics hemorrhage
• Describe the types of obstetrics hemorrhage
• Discuss the major causes of obstetrics hemorrhage
• Discuss the management of obstetrics hemorrhage
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4. Obstetrics is "bloody business."
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5. Introduction
Definition of obstetrics hemorrhage:
• There is no consensus on definition of obstetrics
hemorrhage
• obstetrics hemorrhage/obstetrics bleeding is heavy
bleeding during pregnancy, labor or post partum
period, vaginally or less commonly internally into the
abdominal cavity.
• Hemorrhage during pregnancy carries significant
morbidity and is leading cause of maternal mortality
world wide.
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6. Introduction cont’d
• Major obstetrics hemorrhage (MOH) can be
defined as blood loss > 1500 ml, decrease in
hemoglobin of more than 4g/dl, or acute transfusion
requirement of more than 4 units of PRBCs.
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8. Risks of Obstetrics hemorrhage
Parturient at risk of obstetrics hemorrhage
• Placenta previa/accreta
• Anticoagulation Rx
• Coagulopathy
• Over distended uterus
• Grand multiparity
• Abnormal labor pattern
• Chorioamionitis
• Large myomas
• Previous history of Obstetrics hemorrhage
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9. Risks of Obstetrics hemorrhage
• A study by world health organization revealed that
25-30% of maternal deaths are due to peripartum
hemorrhage globally.
(M. Walfish,2009)
• Causes may be antepartum, intrapartum, and
postpartum bleeding.
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10. Antepartum Hemorrhage (APH)
• APH is bleeding from the genital tract after 24
weeks of gestation.
• Incidence 2-5% of all pregnancies
• Has greater effect on fetus than mother
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11. APH cont’d
•Causes of APH are
• Placenta Previa
• Placental Abruption
• Uterine Rapture
• Vasa Previa
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12. 1. Placenta Previa
• Is abnormal implantation of placenta in the lower
segment of the uterus, presenting ahead of the
leading pole of the fetus.
• Can be
1. Total placenta previa.
2. Partial placenta previa.
3. Marginal placenta previa.
4. Low-lying placenta.
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13. Placenta Previa cont’d
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14. Placenta Previa cont’d
• Occurred in 0.5% all pregnancies.
• Classic sign is painless vaginal bleeding
• Bleeding results from small disruptions in the
placental attachment during normal development
and thinning of the lower uterine segment
• often occurs in previous c/section or uterine
myomectomy and other risk factors: multiparity,
advanced maternal age, and a large placenta.
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15. Placenta Previa: Management
Severe
bleeding
Caesarean
section
Moderate
bleeding
Gestation
>34/52
<34/52
Resuscitate
Steroids Unstable
Stable
Resuscitate
Mild
bleeding Gestation
<36/52
Conservative
care
>36/52
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16. 2. Placental Abruption
• Placental abruption is defined as partial or complete
separation of the placenta from the uterine wall after 20 or
24 weeks gestation but before delivery.
• Hemorrhage from the placental abruption is arising from the
premature separation of the normally implanted placenta.
• Occurs in 1-2% of all pregnancies
• Associated with increased uterine tone, abdominal pain, and
premature labor.
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17. Placental Abruption cont’d
• May be concealed bleeding and shock with out
vaginal bleeding
• Major complications are: hemorrhagic shock,
acute renal failure, coagulopathy, and fetal
demise.
• Is the most common cause DIC in pregnancy.
• Bleeding with placental abruption is almost always
maternal
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18. Placental Abruption cont’d
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19. Placental Abruption
• Increased age and parity
• Preeclampsia
• Chronic hypertension
• Preterm ruptured of
membranes
• Cigarette smoking
• Thrombophilias
• Cocaine use
• Prior abruption
• Uterine leiomyoma
• External trauma
The primary cause of placental abruption is
unknown, but there are several associated
conditions.
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20. Placental Abruption
• The hallmark symptom of placental abruption is
pain which can vary from mild cramping to severe
pain.
• A firm, tender uterus and a possible sudden
increase in fundal height on exam.
• Importantly, negative findings with ultrasound
examination do not exclude placental
abruption. Ultrasound only shows 25% of
abruptions.
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21. Placental Abruption
• Management: Treatment for placental abruption varies
depending on gestational age and the status of the mother
and fetus.
• Admit
• History & examination
• Assess blood loss
• Nearly always more than revealed
• IV access, X match, DIC screen
• Assess fetal well-being
• Placental localization
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22. 3. Uterine Rupture
• Life threatening obstetrics emergency, relatively rare
and reported in 0.03-0.08% of all delivering women,
but 0.3-1.7% among women with a history of a
uterine scar from C/S or other
• 13% of all uterine ruptures occur outside the hospital
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23. Uterine rapture cont’d
Uterine rapture may occur due to
• (1) dehiscence of a scar
• (2) intrauterine manipulations or
use of forceps (iatrogenic); or
• (3) spontaneous rupture
following prolonged labor
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24. Uterine Rupture cont’d
Classic presentation includes
• vaginal bleeding
• pain
• cessation of contractions
• absence/ deterioration of fetal heart rate
• loss of station of the fetal head from the birth
canal
• easily palpable fetal parts and
• Profound/rapid onset maternal tachycardia and
hypotension.
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25. Risk factors associated with uterine rupture

26. Uterine Rupture cont’d
• Excessive uterine
stimulation
• Hx of previous C/S
• Trauma
• Prior rupture
• Previous uterine surgery
• Multiparity
• Non-vertex fetal
presentation
• Shoulder dystocia
• Forceps delivery
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27. Uterine Rupture cont’d
Management:
Emergent laparotomy
• Fetal delivery and repair of the ruptured uterine wall
• Uterine and internal iliac artery ligation
• Obstetrics hysterectomy for uncontrolled bleeding
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28. 4. Vasa Previa
• Is a rare condition in which velamentous insertion of
umbilical vessels occurs so that these fetal vessels
traverse the fetal membranes and are positioned
over the cervical os.
• The incidence is between 0.04% and 0.02% of
pregnancies and carries significant fetal morbidity
and mortality if not diagnosed antenatally.
• Associated with a high fetal mortality rate (50-95%)
which can be attributed to rapid fetal exsanguination
resulting from the vessels tearing during labor
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29. Vasa previa cont’d
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30. Vasa previa cont’d
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31. Vasa Previa cont’d
Risk Factors:
• Bilobed and succenturiate (accessory) placentas
• Velamentous insertion of the cord
• Low-lying placenta
• Multiple gestation
• Pregnancies resulting from in vitro fertilization
• Palpable vessel on vaginal exam
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32. Vasa Previa cont’d
Management:
• When vasa previa is detected prior to labor, the
baby has a much greater chance of surviving.
• It can be detected during pregnancy with use of
transvaginal sonography.
• When vasa previa is diagnosed prior to labor,
elective caesarian is the delivery method of choice.
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33. Postpartum Hemorrhage
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34. Postpartum Hemorrhage
• Defined as blood loss > 500ml from genital tract in
the first 24 hrs of delivery.
• Massive PPH is defined as the blood loss of 1000
ml or more.
• It can be further subdivided into minor (500-1000
ml) or major (>1000 ml).
(Chatrath, et al, 2016)
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35. Postpartum Hemorrhage cont’d
• Incidence is up to 4% of pregnancies
• often associated with a prolonged third stage of
labor, preeclampsia,multiple gestations, and forceps
delivery.
(Morgan 5th Edition,2013)
• Blood loss greater than 500 ml for vaginal and
1000 ml for cesarean delivery. OR
• 10% drop in haematocrit.
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36. PPH may result from:
• failure of the uterus to contract adequately
(atony),
• Genital tract trauma (i.e. vaginal or cervical
lacerations), uterine rupture,
• retained placental tissue, or
• maternal bleeding disorders
Postpartum Hemorrhage cont’d
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37. Studies shows that regardless of maternal characteristics and
obstetrics practice, atonic PPH is increasing.
(Mehrabadi et al, 2013)
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38. Postpartum Hemorrhage cont’d
Study done in Nigeria shows RPC resukted
from mismanagement of third stage of labor
is the common cause of PPH.
(Ajenifuja et al, Africal Health Sciences, 2010)
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39. Postpartum Hemorrhage cont’d
• Common causes include:
• uterine atony
• retained placenta
• obstetric lacerations
• uterine inversion and
• use of tocolytic agents prior to delivery.
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40. Postpartum Hemorrhage cont’d
• In spite of marked improvements in management,
PPH remains a significant contributor to maternal
morbidity and mortality both in developing and
developed countries.
• Prevention, early recognition and prompt
appropriate intervention are the keys to
minimizing its impact.
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41. Management of MOH
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42. Problems in management of MOH
• Inadequate determination of blood loss
• Unrecognized hemorrhage risk factors
• Delayed intervention
• Improper/inadequate transfusion of blood
products
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43. Role of anesthetist in management of MOH
• Assist venous access /or fluid/blood resuscitation
• Provide anesthesia for
careful examination of vagina, cervix and uterus
Repair of tear and lacerations
Extraction of retained placenta
Reversion of inverted uterus
Repair of major laceration
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44. Prevention
• Blood loss is frequently underestimated
• physiological variables especially that of systolic
blood pressure (BP) may change little until 30-
40% of circulating blood volume has been lost.
• High index of suspicion for major obstetric
hemorrhage must be maintained
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45. Prevention cont’d
• Avoidance of prolonged labor
• Minimal trauma during assisted vaginal delivery.
• Detection and treatment of anemia during
pregnancy.
• Identification of placenta previa by antenatal
ultrasound examination.
• Magnetic resonance imaging (MRI) to determine
placenta accreta/percreta.
• Active management of the third stage
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46. Management of MOH
Assessment
• Use MEOWS is good bed side tool to track
maternal physiological parameters , early
recognition and treatment and prediction of
mortality.
• MEOWS includes: sign of tachycardia,
hypotension, decreased UOP, Pallor, lower
abdominal pain, cold peripheries
• MEOWS.pdf
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47. Management of MOH cont’d
Use “Rule of 30” for assessment of the
patient
• If SBP dec.by 30%, HR inc. by 30%, RR inc
to 30/min, Hgb/HCT dec. by 30%, and UOP
dec. by to <30ml/hr, then patient is likely to
have lost 30% of her blood volume.
• Use shock index = HR/SBP, normal is upto
0.9 in obstetrics.
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48. Management of MOH cont’d
Anticipated MOH
• Two large bore IV cannulae
• Rapid infusion device
• Positioning lateral if antepartum
• Administer high flow oxygen
• X-matched blood/ blood warmer
• Invasive monitoring
• Cell salvage
• Interventional radiological procedures
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49. Management of MOH cont’d
unanticipated MOH
Bonnar describes a five-step management plan for
MOH
1. Organization of multidisciplinary team
2. Restoration of blood volume
3. Correction of defective coagulation
4. Evaluation of response to treatment
5. Treating the underlying cause of bleeding.
(Bonnar, 2000)
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50. Management of MOH cont’d
Standard Resuscitation Techniques
• Excellent communication and coordination
• Early diagnosis and timely intervention
• Use uterotonic drugs
• Resuscitate with crystalloid
• Start transfusion guided by clinical situation and
patient assessment initially rather than waiting for
laboratory values.
•
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51. Management of MOH cont’d
Standard Resuscitation Techniques
Regarding blood transfusion, The aim of
management in MOH is to maintain:
• Hgb > 8g/dl
• Platelat > 75,000/mm3
• PT< 1.5 mean control
• aPTT < 1.5 mean control
• Fibrinogen > 1.0g/dl
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52. Management of MOH cont’d
Medical management by use of uterotonic drugs
• Drug doses for management of PPH
1. Oxytocin
2. Ergometrine/ Methyl-ergometrine
3. Misoprostol
4. prostaglandin F2a
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53. Management of MOH cont’d
Invasive Techniques
1. intrauterine balloon tamponade
• Is least invasive than others, most rapid to control
bleeding and has no significant complications
2. Interventional radiology for artery embolization
(if the patient is stable for transport)
Embolization of the uterine and ovarian arteries with
oclusion of balloon with fluoroscopic guidance.
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54. Management of MOH cont’d
Radiologic arterial
embolization intrauterine balloon
tamponade
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55. Management of MOH cont’d
Invasive Techniques
3. Uterine Compression sutures(b-lynch suture)
• Incase of refractory uterine atony it has high success
rate, easy to place and preserves fertilty.
4. Uterine artery ligation
Surgical ligation of uterine and ovarian artery can
decrease uncontrolled bleeding by decreasing blood
floe to the area.
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56. Management of MOH cont’d
• Uterine ligation
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57. Management of MOH cont’d
Invasive Techniques
5. Ligation of internal iliac
(hypo gastric) artery
Early surgical ligation of
internal iliac artery can
decrease blood flow by
48% and control
bleeding in 50% of cases
and helps to avoid
hysterectomy
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58. Management of MOH cont’d
Final terminal/definitive management
• The final definative management if other methods
are failed is hysterectomy
• peripartum hysterectomy occurs in 0.8/1000
deliveries.
• If other options filed don’t delay for hysterectomy.
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59. References
1. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S: Systematic
review of conservative management of postpartum hemorrhage: what
to do when medical treatment fails, Obstet Gynecol Surv 62:540-547,
2007.
2. Bonnar J. Massive obstetric haemorrhage. Baillieres Best Pract Res
Clin Obstet Gynaecol 2000;14:1-18
3. Miller’s clinical anesthesia 8th edition, 2015
4. Morgan and Mikhaili’s clinical anesthesiology 5th edition, 2013
5. ATOTW 257, management of obstetrics hemorrhage, 2012
6. WHO, management of obstetrics hemorrhage and retained
placenta,2009
7. PubMed database
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