Hemorrhage Flashcards
Postpartum hemorrhage is defined as loss of blood of
> 500 ml after third stage of labor
Class 1 Blood loss
1000 ml
15%
Dizziness, palpitations
Class 2 blood loss
1500 20-25% Tachycardia Tachypnea Sweating, weakness and narrowed pulse pressure
Class 3 blood loss
2000 ml 30-35% Significant tachycardia and tachypnea Restlessness Pallor Cool extremities
Class 4 blood loss
> /= 2500
40%
Shock
Air hunger
Hemodynamic adaptations in pregnant
Inc BV 40-50% by 30th week Inc RBC mass by 20-30th with good stores Inc CO by 30-50% in 3rd trimester Dec vascular resistance Inc in fibrinogen and procoagulant factors
Anatomical change that promotes hemostasis at 3rd stage labor/post partum
Interlacing myometrial fibers
Dry lap sponges 18 x 18
25 ml - 50% saturation
50 ml - 75% saturation
75 ml - entire surface
100 ml - saturate and drip
Massive transfusion protocol
6 units pRBC: 4 FFP: 1 unit platelet
Position that improves hemodynamic status
Inc SV
Inc CO
dec HR
Trendelenburg
Left lateral decubitus
Common causes of hemorrhage in the antepartum period (maternal + fetal concerns)
Ectopic pregnancy Abortion GTN - before 20 weeks Abruptio placenta - most common Placenta previa Vasa previa
Most common cause of hemorrhage in antepartum period
Abruptio placenta
Causes of hemorrhage in post-partum period
Uterine atony Genital tract laceration Hematoma Uterine inversion Adherent placenta Accreta, increta, percreta Retained placenta, placental fragment Coagulopathy
Most common significant post-partum cause of hemorrhage
Uterine atony
Genital tract laceration
Most frequent cause of obstetrical hemorrhage
Failure of uterus to contract sufficiently
Premature separation of normally implanted placenta from uterus prior to delivery after 20 weeks AOG
Placenta abruption initiated by hemorrhage into the decidua basalis
Decidua splits leaving a thin layer adhered to myometrium
Decidual hematoma expands and causes separation and compression of adjacent placenta
Abruptio placenta
40-60% of abruptio occur
prior to 37 weeks AOG
Abruptio is difficult to diagnose because
Concealed
Tetanic contraction of uterus
Hematoma formation from abruptio can
go inside sinuses and go into circulation releasing thrombin, thromboplastin material and cause DIC
Abruptio Dx
UTZ (retroplacental hematoma)
MRI
Histopath confirmation
Based on clinical picture
Vaginal bleeding with or without tetanic contractions
Sudden pain: trauma, vehicular accident, amniotomy (rapid change in pressure)
Sudden onset ABDOMINAL PAIN
uterine tenderness
Pallor
Baby tachycardic, bradycardic and no FTH
Abruptio placenta
PainLESS bleeding
Placenta previa
Separation of placenta, blood seeped into myometrium explaining bluish discoloration of the placenta
This uterus will not contract anymore because of blood in between which affects the contractility of muscles
Couvelaire uterus
Abruptio Mx
Amniotomy - to release the pressure and blood will not be pushed to sinuses and thombin and thromboplastin will not be released and will not proceed into DIC
If near delivery, expedite quickly (vaginal)
If not in labor, proceed to CS or else DIC
Degrees of abruptio
Mild
Moderate - baby fead
Severe - DIC
Presence of placental tissue over or near internal cervical os
Placenta previa
Restriction of activity in previa is only required if the condition persists more than
28 weeks
or if bleeding or contraction develops before this time
Placenta previa resolves if detected in 2nd trimester due to formation of
lower uterine segment
placental migration
PAINLESS vaginal bleeding appearing near end of 2nd trimester
10% if lowlying no bleeding
Placenta previa
Total - completely covering Os
Marginal - portion of placenta near os
Low-lying - edge of placenta quite close but does not overlap
Placenta previa risk factors
Inc parity Advanced age Maternal cigarette smoking - carbon monoxide hypoxemia causing placental hypertrophy Placenta previa In vitro fertilization Cocaine Infertility Multiple gestation Malpresentation IUGR Preterm labor Congenital anomalies Previous history of previa Prior uterine surgeries
Cigarette smoking causes placental hypertrophy because
Carbon monoxide hypoxia promotes hypertrophy
Placenta edge may reach the lower part of the uterus ans cover the entire cervical canal
Atrophy or inflammation of decidua may cause defective vascularization
CI in Placenta previa
IE
TVS is not because it doesn’t touch cervix
Placenta previa Dx
Transabdominal UTZ - identifies implantation site, confirms the
diagnosis of placenta previa
TVS - accurate in assessing distance, measures how much of the placenta overlaps
MRI
Placenta previa Tx
CS Preterm: Steroids (lung maturity) MgSO4 (neuroprotection) Tocolytic Bed rest No coitus Repeat UTZ 32-35 weeks Deliver 36-37 w
Presence of fetal vessels (velamentous cord insertiong over cervical os
Prone to compression leading to anoxia and laceration leading to fetal hemorrhage
Fetal death instantaneous hence warrants immediate CS
Vasa previa
Vasa Previa risk factors
Bilobed or succenturiate-lobed placenta Vilamentous insertion of umbilical cord Placenta succenturiata IVF pregnancy Multiple gestation Second tri placenta previa or low-lying placenta
Branching off of umbilical cord before reaching the placenta therefore exposed within the membrane
The cord and vessels go upright up to surface of the placenta before branching off
Velamentous insertion of umbilical cord
Velamentous insertion Dx
Color Doppler Ultrasound
Blue - flow away from sonologist
Red - flow towards sonologist
Yellow - turbulent flow
Placenta consists of large lobe and smaller one connected together by a membrane
Umbilical cord is inserted into the large lobe branches of its vessels cross the membrane to the small succenturiate (accessory lobe)
Accessory lobe may be retained in the uterus after delivery leading to postpartum hemorrhage
There could be fetal hemorrhage
Placenta succenturiata
Placenta previa Dx
UTZ with Doppler flow
History of vaginal bleeding after rupture of the membrane due to laceration of thr fetal vessels
IE: pulsations of fetal vessels in the membrane that overlie the cervical OS
Vasa Previa Tx
If prior term and not bleeding: NST to check for cord compression
CS at 34-35 weeks
If during labor: Immediate CS
Most important and most preventable cause of postpartum hemorrhage
Disseminated intravascular coagulation
Hemostatic mechanisms to prevent hemorrhage
Platelet aggregation and platelet plug formation Local vasoconstriction Clot polymerization Fibrous tissue fortification of clot Uterine contraction
Most common cause of postpartum hemorrhage (80%)
Uterine atony
If atony is prior to placental delivery
manually extract placental
If atony is after placental delivery
medical management + bimanual compression of uterus
If pure atony but stable patient,
tamponade (uterine packing) with gauze or balloon
selective embolization
surgical intervention
Uterine atony sx
Ligation of uterine and internal iliac artery
Hysterectomy
Medical Management (Uterotonic)
Oxytocin
Carbetocin -long acting oxytocin agonist
Ergot derivatives (Methylergometrine maleate, Methergine, Ergonavine) - rapid if oxytocin not working
PGE1 (Misoprostol) - transrectal
PGEF2a (Carboprost) - not given in asthmatics
PGE2 (Dinoprostone)
Uterine atony ligation is done in
Internal iliac/hypogastric artery Uterine artery (branch) at isthmus for lateral laceration
Abnormal attachment of placenta to the uterine lining due to absence of decidua basalis and an incomplete development of fibrinoid layer
Placenta accreta
Placenta on myometrium
Accreta
Penetrates deep into myometrium
Increta
Beyond the myometrium and possibly in neighboring structures
Percreta
Risk factor for Placenta Accreta
Placenta previa and prior CS Increased parity and age Myoma uteri (submucous) Previous uterine surgery Previous curettage leading to endometrial defects
Placenta accreta Tx
CS Hysterectomy at 34-35 weeks
If uterine preservation is requested with focal accrete, give
methotrexate
