International

Obstetrical
Hemorrhage

Obstetrical
Hemorrhage

International

Obstetrical
Hemorrhage
Obstetrical Hemorrhage

Principles
Prompt diagnosis
Recognize reserve and ability to
compensate
Resuscitate vigorously
Identify underlying cause
Treat underlying cause

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Obstetrical
Hemorrhage

A 25 year- old G3 woman presents to the

maternity unit with vaginal bleeding.
Fetal heart rate is 140/mnt and her BP is
110/60mmHg and her HR 85/mnt. Fundal height
is 28cm. She has been given nothing.
What are the possible diagnosis ?
--------------------------------------------------------------How would you distinguish between the
diagnosis ? ----------------------------------------------

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Obstetrical
Hemorrhage

International

Obstetrical
Hemorrhage

Antepartum
Hemorrhage

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Obstetrical
Hemorrhage

Objectives

Definitions and Incidence

Etiology and Risk Factors
Diagnosis
Management
- maternal and fetal assessment
- appropriate resuscitation
- no vaginal exam prior to determining
placental location
Individual Causes

International

Obstetrical
Hemorrhage

Definition
vaginal bleeding between 20 weeks and delivery

Incidence
2% to 5% of all pregnancies
various causes of antepartum haemorrhage
- abruptio placenta
40% - 1% of
pregnancies
- unclassified
35%
- placenta previa
20% - % of
pregnancies
- lower genital tract lesion 5%
- other

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Obstetrical
Hemorrhage

Etiology of APH

Cervical
contact bleeding (e.g. intercourse, pap, neoplasia, examination
inflammation (e.g. infection)
effacement and dilatation (e.g. labour, cervical incompetence)
Placental
abruptio
previa
marginal sinus rupture
Vasa previa
Other - abnormal coagulation

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Obstetrical
Hemorrhage

Diagnostic Procedures
History and physical - No digital pelvic exam
Ultrasound
definitive test for previa
less useful in abruptio
Electronic Fetal Monitoring
for fetal compromise and uterine tone
Speculum
do ultrasound first if possible
No digital pelvic exam

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Obstetrical
Hemorrhage

Laboratory
CBC, blood type, Rh, Coombs
coagulation status
INR, PTT, fibrinogen
2 - 4 units of PRBC cross matched as
appropriate
bedside clot test
Kleihauer-Betke or Neirhaus test
vaginal and/or maternal blood
fetal lung maturity indices if appropriate

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Obstetrical
Hemorrhage

Vaginal Bleeding
Risk Factors Tests (No vaginal exam)
Fetal / Maternal Assessment
Mother or fetus unstable
Hemodynamic Resuscitation
Mother or fetus unstable
Delivery

Mother and fetus stable

Labs / Fetal Monitoring
U/S vaginal exam
Expectant
consider ongoing loss, etiology,
gestation

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Obstetrical
Hemorrhage

Management - ABC s
talk to and observe mother and fetus
large bore IV access
crystalloid (N/S)
CBC and coagulation status
cross-match and type
get HELP!

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Obstetrical
Hemorrhage

Hemodynamic Resuscitation
early aggressive resuscitation to protect fetus and
maternal organs from hypoperfusion and to prevent
DIC
stabilize vital signs
large bore IV crystalloid infusion, plasma expanders
follow hemoglobin and coagulation status
oxygen
consumption is up 20% in pregnancy

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Obstetrical
Hemorrhage

Fetal Considerations
lateral position increases cardiac output up to
30%
consider amniocentesis for lung indices
external fetal and labor monitoring
Kleihauer-Betke if suspected abruption
post-trauma monitor at least 4 hours for
evidence of fetal insult, abruptio, fetal
maternal transfusion

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Obstetrical
Hemorrhage

Abruptio Placenta - Definition

premature separation of normally implanted
placenta

Abruptio Placenta - Classification

Total fetal death
Partial fetus may tolerate up to 30-50%
abruption

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Obstetrical
Hemorrhage

Risk Factors for Abruption

hypertension: gestational and pre-existing

abdominal trauma
cocaine or crack abuse
previous abruption
overdistended uterus
multiple gestation, polyhydramnios
smoking, especially >1 pack/day

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Obstetrical
Hemorrhage

Clinical Presentation of Abruption

vaginal bleeding usually painful, unremitting
presence of risk factor
hemodynamic status may not correlate with amount
of vaginal blood loss concealed abruptio
may be evidence of fetal compromise
uterus - tender, irritable, contracting or tetanic
ultrasound rules out previa and may show clot

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Obstetrical
Hemorrhage

ABRUPTION
Live Fetus

Dead Fetus
coagulopathy
Delivery
(watch for DIC)
Assess Maturity

Maturity
Vaginal delivery or C/S

Immaturity
Steroids plus expectancy
Transfusion? Transfer?

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Obstetrical
Hemorrhage

Placenta Previa - Definition

placenta covers or lies near the cervix

Placenta Previa - Classification

total
- entirely covers the os
partial
- partially covers the os
marginal - close enough to the os to increase risk
of bleeding as cervical effacement and dilatation
occur

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Obstetrical
Hemorrhage

Risk Factors for Previa

previous placenta previa
previous caesarian section or uterine surgery
multiparity (5% in grand multiparous patients)
advanced maternal age
multiple gestation
smoking

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Obstetrical
Hemorrhage

Clinical Presentation of Previa

vaginal bleeding usually painless (unless in labour)
maternal hemodynamic status corresponds to
amount of vaginal blood loss
well tolerated by fetus unless maternal instability
uterus - non-tender, not irritable, soft
may have abnormal lie
ultrasound shows previa !

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Obstetrical
Hemorrhage

PREVIA
Assess maturity

Maturity

Immaturity

Delivery by C/S (consider accreta)

May try vaginal if marginal

Steroids plus expectancy

Transfusion? Transfer?

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Obstetrical
Hemorrhage

Vasa Previa - Definition

blood vessels in the membranes run across the cervix

requires a vellamentous insertion or succenturiate lobe

Complication

ex-sanguination following amniotomy or ROM

Diagnosis

Apt test or Kleihauer test on vaginal blood

terminal fetal bradycardia initial tachycardia or
sinusoidal FH

Prognosis

fetal mortality as high as 50-70%

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Obstetrical
Hemorrhage

Conclusions

assess maternal status and stability

assess fetal well-being
resuscitate appropriately
assess cause of bleeding - avoid vaginal exam
expectant management if appropriate
deliver if indicated based on maternal or fetal
status

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Obstetrical
Hemorrhage

Postpartum Hemorrhage

International

Obstetrical
Hemorrhage

You have just delivered a 37 week twin

pregnancy per vagina. The third stage is
complicated by post partum hemorrhage
unresponsive to uterine message and the
use of oxytocin.
What would your next management
steps be ---------------------------------- ?

International

Obstetrical
Hemorrhage

Objectives
Definition
Etiology
Risk Factors
Prevention
Management

International

Obstetrical
Hemorrhage

Traditional Definition
blood loss of > 500 mL following vaginal delivery
blood loss of > 1000 mL following cesarean
delivery

Functional Definition
any blood loss that has the potential to produce or
produces hemodynamic instability

Incidence
about 5% of all deliveries

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Obstetrical
Hemorrhage

Etiology of Postpartum Hemorrhage

Tone

- uterine atony

Tissue

- retained tissue/clots

Trauma

- laceration, rupture, inversion

Thrombin

- coagulopathy

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Obstetrical
Hemorrhage

Risk Factors for PPH - Antepartum

previous PPH or manual removal
placental abruption, especially if concealed
intrauterine fetal demise
placenta previa
gestational hypertension with proteinuria
overdistended uterus (e.g. twins, polyhydramnios)
pre-existing maternal bleeding disorder (e.g. ITP)

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Obstetrical
Hemorrhage

Risk Factors for PPH - Intrapartum

Operative delivery - cesarean or assisted vaginal

Prolonged labour
Rapid labour
Induction or augmentation
Chorioamnionitis
Shoulder dystocia
Internal podalic version and extraction of second
twin
Acquired coagulopathy (e.G. Hellp, dic)

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Obstetrical
Hemorrhage

Risk Factors for PPH - Postpartum

Lacerations or episiotomy
Retained placenta/placental
abnormalities
Uterine rupture
Uterine inversion
Acquired coagulopathy (e.G. Dic)

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Obstetrical
Hemorrhage

Prevention

be prepared
active management of the third stage
prophylactic oxytocin with delivery or with
delivery of anterior shoulder
- 10 U IM or 5 U IV bolus
- 20 U/L N/S IV run rapidly
early cord clamping and cutting
gentle cord traction with suprapubic
countertraction

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Obstetrical
Hemorrhage

Active v.s Expectant Third Stage

Management
Outcome

(subjects)

PPH > 500 mL (n=4636)

PPH > 1000 mL (n=4636)
Maternal Hb < 91 (n=4256)
Blood transfusion (n=4829)
Therapeutic oxytocin (n=4829)
Nausea (n=3407)
Manual removal (n=4829)
0.1

1
Odds Ratio (95% Confidence Interval)

Cochrane Library
Issue 1, 2000

10

International

Obstetrical
Hemorrhage
Postpartum
Hemorrhage

Diagnosis - Is this a PPH?

consider risk factors
observe vaginal loss
express blood from vagina following C/S
REMEMBER
- blood loss is consistently underestimated
- ongoing trickling can lead to significant blood loss
- blood loss is generally well tolerated to a point

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Obstetrical
Hemorrhage

Diagnosis - What is the cause?

Assess the fundus
Inspect the lower genital tract
Explore the uterus
Retained placental fragments
Uterine rupture
Uterine inversion

Assess coagulation

International

Obstetrical
Hemorrhage
Postpartum
Hemorrhage

C
B
A
A = airway
B = breathing
C = circulation

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Obstetrical
Hemorrhage

Management - ABC s
talk to and observe patient
large bore IV access ( Nr.16 gauge)
crystalloid - lots!
CBC
cross-match and type
get HELP!

International

Obstetrical
Hemorrhage
Postpartum
Hemorrhage

Management - Assess the fundus

simultaneous with ABC s
atony is the leading cause of PPH
if boggy bimanual massage
- rules out uterine inversion
- may feel lower tract injury
- evacuate clot from vagina and/or cervix
- may consider manual exploration at this
time

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Obstetrical
Hemorrhage
Postpartum
Hemorrhage

Management - Bimanual Massage

International

Obstetrical
Hemorrhage
Postpartum
Hemorrhage

Management - Oxytocin
5 units IV bolus
20 units per L N/S IV wide open
10 units directly into the uterus if no
I.V access

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Obstetrical
Hemorrhage

Management - Manual Exploration

if no response to bimanual massage and
oxytocin then proceed to exploration
manual exploration will:
- rule out uterine inversion
- palpate cervical injury
- remove retained placenta or clot from
uterus
- rule out uterine rupture or dehiscence

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Obstetrical
Hemorrhage

Replacement of Inverted Uterus

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Obstetrical
Hemorrhage

Replacement of Inverted Uterus

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Obstetrical
Hemorrhage

Management - Additional Uterotonics

ergotamine - caution in hypertension
- 0,2 mg IM / IV, interval 15
- maximum dose 1 mg
Hemabate (carboprost) - asthma is relative
contraindication
- 15 methyl-prostaglandin F2
- 0,25 mg IM or intramyometrial
- Maximum dose 2 mg
Cytotec (misoprostol) - caution in asthma
- 400 g pr or po

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Obstetrical
Hemorrhage

Management - Bleeding with firm uterus

explore the lower genital tract
requirements appropriate analgesia
- good exposure and lighting
appropriate surgical repair
- may temporize with packing

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Obstetrical
Hemorrhage
Postpartum
Hemorrhage

Management - Continued uterine bleeding

possible coagulopathy - INR, PTT, TCT, fibrinogen
if coagulation is abnormal:
- correct with clotting factors, platelets
if coagulation is normal:
- prepare for O.R. (may consider embolization)
- rule out uterine rupture, inadequate incision repair
- consider uterine/hypogastric ligation, hysterectomy

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Obstetrical
Hemorrhage

Management - ABC s

ENSURE that you are always

ahead with your
resuscitation!!!
consider need for Foley catheter, CVP, arterial line, etc
consider need for more expert help

Obstetrical
Hemorrhage

International

Conclusions

be prepared
practice prevention
assess the loss
assess maternal status
resuscitate vigorously and appropriately
diagnose the cause
treat the cause

International

Obstetrical
Hemorrhage
Postpartum
Hemorrhage

Management - Evolution
Panic
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness

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Obstetrical
Hemorrhage

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Obstetrical
Hemorrhage

Kleihauer-Betke
Indications
Measures fetal cells in maternal circulation
Used in assessing for Rh Sensitization
Maternal blood Rh negative
Large antepartum bleed
Mechanism
Blood Film stained with acid elution
Fetal HbF more acid resistant
Fetal RBC darkly stained, Maternal RBC "ghosts"
Technique
Count Fetal cells per 50 low power fields
Five cells per 50 (lpf) = 0.5 ml bleed

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Obstetrical
Hemorrhage

Interpretation
Calculate Maternal Blood Volume (ml) =
(Pre-pregnant weight in kg) x 70 ml/kg x (1.0 +
(0.5 x weeks gestation/36)) Estimated Blood loss (ml) at time of test
Calculate Fetal Whole Blood (ml) =
(Fetal Cell Count/Maternal Cell Count) x
Maternal Blood Volume
Rh Immune Globulin (RhoGAM) Dose
Give 300 g per 30 mL fetal whole blood or 15
mL PRBC

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B-Lynch
methode

Obstetrical
Hemorrhage

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Obstetrical
Hemorrhage

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Obstetrical
Hemorrhage

Medical Anti Schock Trouser &

Penekan Infus

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Obstetrical
Hemorrhage
Postpartum
Hemorrhage

Keep your bloody fingers off

the cervix!