Management of Obstetrical Hemorrhage

Jeffrey Stern, M.D.

Incidence of Obstetrical Hemorrhage

• 4% of SVD• 6.4 % of C-sections• 13% of maternal deaths (1:10,000 to 1:1,000)• 10% risk of recurrence

Etiology of Obstetrical Hemorrhage: Antepartum

• Placenta previa• Abruption• Coagulopathy: ITP/pre-eclampsia, FDIU

Etiology of Obstetrical Hemorrhage: Intrapartum

• Placenta previa• Abruption• Abnormal placentation• Genital tract lacerations: (2.4 odds ratio)• Uterine rupture• Coagulopathy: infection, abruption, amniotic fluid

embolism

Etiology of Postpartum Hemorrhage (Primary)(Within 24 hours of delivery)

• Uterine atony (3.3 odds ratio) • Induction or Augmentation of labor (1.4 odds

ratio)• Retained products of conception (3.5 odds ratio)• Placenta accreta, increta, percreta (3.3 odds

ratio)• Coagulopathy • Fetal death in utero• Uterine inversion – may need MgSO4,

Halothane, Terbutaline, NTG• Amniotic fluid embolism

Etiology of Postpartum Hemorrhage (Secondary)(After 24 hours of delivery to 6 weeks postpartum)

• 0.5-2% of patients• Infection• Retained products of conception with atony• Placental site involution• Rx: D+C, ABX, uterotonic medications

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 odd 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 but can

temporize• Modified B-Lynch stitch (#2chromic)

– Uterine, utero-ovarian, hypogastric artery ligation– Subtotal/Total abdominal hyst.

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 micrograms 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 PGE 1 Misoprostol (Cytotec) 75% - 100% success– 1000 microgram per rectum or sublingual (ten 100 micrograms

tabs/five 200 micrograms tabs)

Retained Products of Conception: Etiology

• Succentiurate lobe• Placenta accreta, increta, percreta• Previous C-section; hysterotomy• Previous puerperal curettage• Previous placenta previa• High parity

Management of Retained Products of Conception

• Examine placenta carefully• Manual exploration of uterus• Careful curettage-Banjo curret

Placenta Accreta, Increta, Percreta: Risk Factors

• High Parity• Previous placenta previa• Previous C-section• GTN• Advanced maternal age• Previous uterine abnormal placentation

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

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

Coagulopathy

• Hereditary• Acquired

– Preganancy induced hypertension– Abruption– Sepsis– Fetal death in utero– Amniotic fluid embolism– Massive blood loss

Genital Tract Laceration and Hematomas: Etiology

• Macrosomia• Forceps• Episiotomy• Precipitous delivery• C-section incision extension• Uterine rupture

Therapy of Genital Tract Lacerations

• Superficial lacerations and small hematomas: expectant

• Large laceration– Repair in layers– Consider a drain

Hematomas

• Below pelvic diaphragm: (vulva, paracolpos, ischiorectal fossa)– Leave alone if possible– Legate bleeder - often difficult to find– Pack open– Drain– May need combined abdominal/perineal approach

• Above the pelvic diaphragm– Laparotomy- especially if expanding– Combined abdominal/perineal approach

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 accreta• Analgesics, anti-nausea medications, antibiotics

Selective Artertial Embolization by Angiography

• Real time X-Ray (Fluoroscopy)• Access right common iliac artery• Single blood vessel best• Embolize both uterine or hypogastric arteries• Sometimes need a small catheter distally to prevent reflux into non-

target vessels• May need to treat entire anteriordivision or even all of the internal

iliac artery.• Risks: Can embolize nearby organs and presacral tissue, resulting

in necrosis• Technique

– Gelfoam pads – 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

Uterine Rupture

• Scarred versus scarless uterus• 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 because lower uterine segment is very thin

• Therapy is expectant if small and asymptomatic

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

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: GTN, cervical cancer• Extra-tubal ectopics

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 which do not enter the endometrial cavity will not

• subsequently rupture• 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

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%• (Plauche, W.C 1993)

Modified Smead-Jones Closure

• Running looped #1 PDS/Maxon– Contaminated wounds/under tension

• Additional Interruptured sutures - 2 cm apart

– Fascial edges should be approximated– No tension