OBSTETRIC Hemorrhage (APH &PPH)

1. OBSTETRICHemorrhage (APH &PPH) DR.A.SAMSAMI DEPARTMENT OF OB GYN SHIRAZ UNIVERSITY

2. Antepartum & Postpartum Hemorrhage • Obstetrics is "bloody business." • Death from hemorrhage still remains a leading cause of maternal mortality. • preventable

3. ANTEPARTUM HEMORRHAGE • Complicates about 4% of all pregnancies and is a MEDICAL EMERGENCY! • Is one of the leading causes of antepartum hospitalization, maternal morbidity, and operative intervention.

4. Time of bleeding ( 3rd trimester) • Deffinition • Significance • Amount of bleeding (estimation) • Pregnancy outcome

5. Key point to Remember • The pregnancy in which such bleeding occurs remains at increased risk for a poor outcome even though the bleeding soon stops and placenta previa appears to have been excluded by sonography.

6. The Four “T” Tone Tissue Trauma Thrombin

7. PPH Risk Factors

8. PPH Risk Factors

9. PPH Risk Factors

10. PPH Risk Factors

11. What are the most common causes of obstetric Hemorrhage ?

12. COMMON CAUSES • Bloody Show • Placenta Previa • Uterine Rupture • Vasa Previa • Coagulation Disorder • Vaginal Lesion/Injury • Cervical Lesion/Injury

13. Abruptio Placenta • Placental abruption occurs when all or part of the placenta separates from the underlying uterine attachment • Incidence- approx 1/100 - 1/200 deliveries • Common cause of intrauterine fetal demise

14. Placental Abruption • Defined as the premature separation of the normally implanted placenta. • The Latin abruptio placentae, means “ accidental and sudden sepration of the placenta • Occurs in 1-2% of all pregnancies • Perinatal mortality rate associated with placental abruption was 119 per 1000 births compared with 8.2 per 1000 for all others.

15. Placental Abruption • external hemorrhage • concealed hemorrhage • Total • Partial

16. Placental Abruption • What are the risk factors for placental abruption?

17. Placental Abruption The primary cause of placental abruption is unknown, but there are several associated conditions. • Increased age and parity • Preeclampsia • Chronic hypertension • Preterm ruptured membranes • Multifetal gestation • Hydramnios • Cigarette smoking • Thrombophilias • Cocaine use • Prior abruption • Uterine leiomyoma • External trauma

18. Abruptio Placenta- Associating Factors • Hypertension- 1/2 of abruptions were associated with HTN • PPROM- abruptio may be a manifestation of rapid decompression of uterus or from subacute villitis • Smoking (and/or ethanol consumption) linked to abruptio

19. Abruptio Placenta- Associating Factors (2) • Cocaine abuse- 2-15% rate of abruption in patients using cocaine • Uterine leiomyoma- risk increased if fibroid is behind implantation site • Trauma- relatively minor trauma can predispose (association with bleeding. Contractions, or abnormal FHT)

20. Placental Abruption • Pathology • Placental abruption is initiated by hemorrhage into the decidua basalis. • The decidua then splits, leaving a thin layer adherent to the myometrium. • development of a decidual hematoma that leads to separation, compression, and the ultimate destruction of the placenta adjacent to it.

21. Placental Abruption • Bleeding with placental abruption is almost always maternal. • Significant fetal bleeding is more likely to be seen with traumatic abruption. • In this circumstance, fetal bleeding results from a tear in the placenta rather than from the placental separation itself.

22. 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. • The amount of external bleeding may not accurately reflect the amount of blood loss.

23. Placental Abruption • Shock • Consumptive Coagulopathy • Renal Failure • Fetal Death • Couvelaire Uterus

25. Abruptio Placenta- Concealed Hemorrhage • Bleeding from abruption may be all intrauterine- vaginally detected bleeding may be much less • DIC occurs as a consequence of hypofibrinogenemia- in chronic abruption, this process may be indolent

26. Occult Hemorrhage in Abruption Abruption Placenta

27. Abruption- Other Complications • Shock- now thought to be in proportion to blood loss • Labor- 1/5 initially present with diagnosis of “labor”- abruption may no be immediately apparent • Ultrasound may not diagnose abruption

28. Abruption- Other Complications (2) • Renal failure- may be pre-renal, due to underlying process (preeclampsia) or due to DIC • Uteroplacental apoplexy (Couvelaire uterus)- widespread extravasation of blood into the myometrium and serosa

29. Abruptio Placenta- Recurrence • Recurrence rate may be as high as 1 in 8 pregnancies • Antenatal testing is indicated (albeit predictive value may be poor- numerous examples of normal testing with subsequent serious or fatal event

30. 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

31. Abruption- Management • Management is influenced by gestational age and degree of abruption • Indicators for delivery- • Fetal intolerance • DIC sever bleeding • Labor

32. Abruption Management (2) • Vaginal delivery is acceptable (and generally preferred with DIC) • Tocolysis: • Betasympathomimetics contraindicated in hemodynamically compromised • Magnesium possibly indicated in special circumstances

33. Placenta Previa • Defined as a placenta implanted in the lower segment of the uterus, presenting ahead of the leading pole of the fetus. • Total placenta previa. The internal cervical os is covered completely by placenta. • Partial placenta previa. The internal os is partially covered by placenta. • Marginal placenta previa. The edge of the placenta is at the margin of the internal os. • Low-lying placenta. The placenta is implanted in the lower uterine segment such that the placenta edge actually does not reach the internal os but is in close proximity to it.

34. Types of Placenta Previa Complete Partial Marginal Low Lying

35. Placenta Previa • Bleeding results from small disruptions in the placental attachment during normal development and thinning of the lower uterine segment

36. Placenta Previa • Incidence about 1 in 300 • Perinatal morbidity and mortality are primarily related to the complications of prematurity, because the hemorrhage is maternal.

37. Placenta Previa • Etiology: • Advancing maternal age • Multiparity • Multifetal gestations • Prior cesarean delivery • Smoking • Prior placenta previa

38. Placenta Previa • The most characteristic event in placenta previa is painless hemorrhage. • This usually occurs near the end of or after the second trimester. • The initial bleeding is rarely so profuse as to prove fatal. • It usually ceases spontaneously, only to recur.

39. Clinical Findings- Previa (1) • Most common symptom is painless bleeding • Some degree of placental separation is inevitable with previa = bleeding • Bleeding increases with labor, direct trauma, or digital examination

40. Clinical Findings- Previa (2) • Initial bleeding is usually not catastrophic • Uterine bleeding may persist postpartum because of overdistention of the poorly contractile lower uterine segment • Coagulopathy is uncommon with previa unless due to massive bleeding

41. Placenta Previa • Diagnosis. • Placenta previa or abruption should always be suspected in women with uterine bleeding during the latter half of pregnancy. • The diagnosis of placenta previa can seldom be established firmly by clinical examination. Such examination of the cervix is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean delivery, because even the gentlest examination of this sort can cause torrential hemorrhage. • The possibility of placenta previa should not be dismissed until appropriate evaluation, including sonography, has clearly proved its absence

42. Placenta Previa- Accreta • Placenta previa is associated with increased risk of placenta accreta • Risk of accreta is 5% with unscarred uterus • Previous C-section and previa portends a 25% risk of accreta

44. Placenta Previa- Diagnosis • DO NOT DIAGNOSE via vaginal exam! (Exception-”double setup”) • Ultrasound is the easiest, most reliable way to diagnose (95-98+% accuracy) • False positive- ultrasound with distended bladder • Transvaginal or transperineal often superior to transabdominal methods

45. Placenta Previa • The simplest and safest method of placental localization is provided by transabdominal sonography. • Transvaginal ultrasonography has substantively improved diagnostic accuracy of placenta previa. • MRI • At 18 weeks, 5-10% of placentas are low lying. Most ‘migrate’ with development of the lower uterine segment.

46. Migration is a misnomer- the placental attachment does not change, the relative growth of the lower segment does

47. Placenta Previa- Placental Migration • Placental location may “change” during pregnancy • 25% of placentas implant as “low lying” before 20 weeks of pregnancy • Of those 25%, up to 98% are not classified as placenta previa at term • Complete or partial previas do not appear to resolve as often (if at all)

48. Management - Placenta Previa (3) • Delivery should depend upon type of previa • Complete previa = c/section • Low lying = (probable attempted vaginal delivery • Marginal/partial = (it depends!) Consider “double setup” for uncertain cases

49. Placenta PreviaManagement • Admit to hospital • NO VAGINAL EXAMINATION • IV access • Placental localization

50. Placenta PreviaManagement Severe bleeding Caesarean section Resuscitate >34 Moderate bleeding Gestation <34 Unstable Resuscitate Steroids Stable Mild bleeding preterm Gestation Conservative care term