Management of Obstetrical Hemorrhage

Jeffrey L. Stern, M.D.

Management of Obstetrical Hemorrhage

• VS q 15 minutes, oxygen by mask 10 liter/min. – to keep O2 saturation > 94%

• 1st IV: LR w/ Pitocin 20-40 units at 1000 ml/ 30 minutes• Start 2nd, 18 G IV: warm LR - administer wide open• CBC, fibrinogen, PT/PTT, platelets, T&C 4u PRBCs• Monitor I&O, urinary Foley catheter• Get help

– Anesthesia,Interventional Radiology, GYN ONC, Intensivist, etc.

Management of Obstetrical Hemorrhage

• LR or NS replaces blood loss at 3:1• Volume expander 1:1 (albumin, hetastarch, dextran)• Administer uterotonic medications• Anticipate disseminated Intravascular coagulapathy (DIC)• Verify complete removal of placenta, may need ultrasound• Inspect for bleeding

– episiotomy, laceration, hematomas, inversion, rupture

• Emperic transfusion– 2 u PRBC; FFP 1-2 u/4-5 u PRBC – Cryo 10 u, uncrossed (O neg.) PRBC

• Warm blood products and I.V.infusions – prevent hypothermia, coagulopathy, arrhythmias

Target Values

• Invasive monitoring: central/ arterial lines• Maintain systolic BP>90 mmHg• Maintain urine output > 0.5 ml per kg per hour• Hct > 21%• Platelets > 50,000/ul• Fibrinogen > 100 mg/dl• PT/PTT < 1.5 times control• Repeat labs as needed – every 30 minutes

Blood Component Therapy

• Fresh Frozen Plasma (45 minutes to thaw)– INR > 1.5 - 2u FFP– INR 2-2.5 - 4u FFP– INR > 2.5 - 6u FFP

• Cryoprecipitate (1 hour to thaw) – Fibrinogen < 100 mg/dl – 10u cryo – Fibrinogen < 50 mg/dl – 20u cryo

• Platelets (5 minutes when in stock)– Platelet. count. < 100,000 – 1u plateletpheresis– Platelet. count. < 50,000 – 2u plateletpheresis

Blood Component Therapy

Blood Comp Contents Volume(ml)

Effect

Packed RBCs RBC, Plasma 300 Inc. Hgb by 1 g/dl

Platelets Platelets, Plasma 250 Inc. count by 25,000

FFPFibrinogen, antithrombin III,

clotting factors, plasma250 Inc. Fibrinogen 10 mg/dl

CryoprecipitateFibrinogen, antithrombin III,

clotting factors, plasma40 Inc. Fibrinogen 10 mg/dl

Uterine Atony: 1 in 20 to 1 in 100 deliveries (80% of PPH)

• Uterine over distension – Polyhydramnios, Multiple gestations, Macrosomia

• Prolonged labor: “uterine fatigue” (3.4 odds ratio)• Precipitory labor• High parity• Chorioamnionitis• Halogenated anesthetic• Uterine inversion

Treatment of Uterine Atony

• Message fundus continuously• Uterotonic agents• Foley catheter/ Bakri balloon (500cc)• Uterine packing usually ineffective- can temporize• Modified B-Lynch stitch (#2chromic)• Uterine/ utero-ovarian artery ligation Hypogastric artery ligation Subtotal or Total abdominal hysterectomy

Treatment of Uterine Atony

• Oxytocin – 90% success– 10-40 units in 1 liter NS or LR rapid infusion

• Methylergonovine (Methergine) - 90% success– 0.2 mg IM q 2-4 hours max. 5 doses; avoid with hypertension

• Prostaglandin F2 Alpha (Hemabate) - 75% success– 250 mcg IM; intramyometrial, repeat q 20-90 min; max 8 doses.– Avoid if asthma/Hi BP.

• Prostaglandin E2 suppositories (Dinoprostone, Prostin E2) - 75% success– 20 mg per rectum q 2 hours; avoid with hypotension

• Prostaglandin E1 Misoprostol (Cytotec): 75 -100% success– 1000 mcg per rectum or sublingual (100 or 200 mcg tabs)

Uterine Inversion: 1 in 2500 Deliveries

• Risk factors: Abnormal placentation, excessive cord traction

• Treatment– Manual replacement– May require halothane/ general anesthesia– Remove placenta after re-inversion– Uterine tonics and massage after placenta is removed– May require laparotomy

Uterine Rupture Etiology

• Previous uterine surgery - 50% of cases– C-section, Hysterotomy, Myomectomy

• Spontaneous (1/1900 deliveries)• Version-external and internal• Fundal pressure• Blunt trauma• Operative vaginal delivery• Penetrating wounds

Uterine Rupture Etiology

• Oxytocics• Grand multiparity• Obstructed labor• Fetal abnormalities-macrosomia, malposition,

anomalies• Placenta percreta• Tumors: Trophoblastic disease, cervical cancer• Extra-tubal ectopic pregnancy

Classic Symptoms of Uterine Rupture

• Fetal distress• Vaginal bleeding• Cessation of labor• Shock• Easily palpable fetal parts• Loss of uterine catheter pressure

Uterine Rupture• Myth: Uterine incisions that do not enter the endometrial

cavity will not rupture in the future• Type of closure: no relation to tensile strength

– Continuous or interrupted sutures: chromic, Vicryl, Maxon– Inverted or everted endometrial closure

• Degree of complications– Inciting event- spontaneous, traumatic– Gestational age– Placental site in relation to rupture site– Presence or absence of uterine scar

• Scar: 0.8 mortality rate• No scar: 13% mortality rate

– Location of scar• Classical scar- majority of catastrophic ruptures• Transverse scar- less vascular; less likely to involve placenta

– Extent of rupture

Uterine Scar Dehiscence

• Separation of scar without rupture of membranes– 2-4% of deliveries after previous transverse uterine

incision– Morbidity is usually minimal unless placenta is

underneath or it tears into the uterine vessels– Diagnosis after vaginal delivery

• Often asymptomatic, incidental finding• Difficult to diagnose- lower uterine segment is very thin• Therapy is expectant if defect small and asymptomatic

– Diagnosed at C-section: • Simple debridement and layered closure

Management of Uterine Rupture

• Laparotomy– Debride and repair in 2-3 layers of Maxon/PDS– Subtotal Hysterectomy– Total Hysterectomy

Pregnancy After Repair of Uterine Rupture

• Not possible to predict rupture by HSG/Sono/MRI• Repair location

– Classical -------------------------48%– Low transverse------------------16%– Not recorded---------------------36%

• Re-rupture-------------------12%• Maternal death--------------1%• Perinatal death--------------6%

Plauce WC, 1993

Prepare for Laparotomy

• General anesthesia usually best • Allen or Yellowfin stirrups• Uterine cavity manual exploration for retained placenta

with ultrasound present/ uterine rupture • Uterine inversion• Uterine packing (treatment vs. temporizing)

– 4” gauze (Kerlex) soaked in 5000 u of thrombin in 5ml of sterile saline

– 24 Fr. Foley with 30ml balloon filled with 30-80 ml of saline (may need more than one)

– Bakri (intrauterine) balloon - 500 cc– Antibiotics– Remove in 24-48 hours

Intraoperatively

• Consider vertical abdominal incision • General anesthesia usually best• Get Help!• Avoid compounding problems by making major mistakes• Direct manual uterine compression / uterotonics• Direct aortic compression• Modified B-Lynch Suture for atony: #2 chromic • Ligation of uterine and utero-ovarian vessels: #1 chromic

Intraoperatively

• Internal iliac (hypogastric) artery ligation ( 50% success)– Desirous of children – Experience of surgeon– Palpate common iliac bifurcation– Ligate at least 2-3 cm from bifurcation– #1 silk. Do not divide vessel

• Interventional Radiology: uterine artery embolization (catheters placed pre-op)

• Hysterectomy/ subtotal hysterectomy (put ring forceps on anterior lip of dilated cervix, to help identify it)

• Cell saver: investigational (amniotic fluid problems)

Modified B-Lynch Suture

Artery Ligation

Management of Abnormal Placentation

• Placenta will not separate with usual maneuvers• Curettage of uterine cavity• Localized resection and uterine repair:

(Vasopressin 1cc/10cc N.S-sub endometrial)• Leave placenta in situ

– If not bleeding: Methotrexate– Uterus will not be normal size by 8 weeks

• Uterine, utero-ovarian, hypogastric artery ligation• Subtotal/ total abdominal hysterectomy

Post-Hysterectomy Bleeding

• Patient usually has DIC – Rx with whole blood, FFP, platelets, etc.

• Military Anti-Shock Trousers (MAST)– Increases pelvic and abdominal pressure to reduce bleeding– Can use at any point in the procedure

• Transvaginal or transabdominal (pelvic) pressure pack– Bowel bag with opening pulled through vagina cuff/ abd. wall– Stuff with 4 inch gauze tied end-to-end until pelvis packed tight– Tie to 10-20 lbs. Weight and hang over edge of bed to help keep

constant pressure

• May have to leave clamps or accept ligation of ureter or a major side wall vessel

• Interventional Radiology

Selective Artertial Embolization by Angiography

• Clinically stable patient – Try to correct coagulopathy

• Takes approximately 1-6 hours to work• Often close to shock, unstable, require close

attention• Can be used for expanding hematomas• Can be used preoperatively, prophylactically for

patients with placenta accreta• Analgesics, anti-nausea medications, antibiotics

Selective Artertial Embolization by Angiography

• Real time X-Ray (Fluoroscopy)• Access right femoral artery• Single bleeding blood vessel is best• Embolize: - Both uterine or hypogastric arteries - May need to treat entire anterior division or all of internal iliac artery - Sometimes need a small catheter distally to prevent reflux into non-target vessel • Risks: Can embolize nearby organs and presacral tissue, resulting in

tissue necrosis• Technique:

– Gelfoam pads/slurry – Temporary, allows recanalization– Autologous blood clot or tissue– Vasopressin, dopamine, Norepinephrine– Balloons, steel coils

Evaluate for Ovarian Collaterals

May need to embolize

Mid-Embolization “Pruned Tree Vessels”

Post Embolization

Post Embolization

Pre Embo Post Embo