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Obstetric Hemorrhage

Obstetric Hemorrhage

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Obstetric Hemorrhage

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  1. Obstetric Hemorrhage Abike James MD Assistant Clinical Prof. Obstetrics and Gynecology University of Pennsylvania

  2. Third Trimester Bleeding A 32 yo G2P1 presents at 36 weeks complaining of bright red vaginal bleeding. Upon further questioning she does admit to having had some light bleeding on 1 to 2 occasions last week. Her previous pregnancy was delivered at term by a Classical Cesarean Section for footling breech presentation.

  3. Differential Diagnosis? • Placenta Previa • Uterine Rupture • Placental Abruption • Vasa Previa • Laceration • Vaginal mass

  4. Placenta Previa • Painless third-trimester bleeding • Complicates 4-6% pregnancies between 10 and 20 wks, 0.5% pregnancies >20 weeks • Risk factors • Increasing parity, maternal age, prior c/s, curettages for sab’s/tab’s • Placental tissue overlying the internal os. Types? • Complete previa (20-30%) • Partial previa (does not completely cover) • Marginal (proximate to os) • Management: pelvic rest, u/s, IV, T+S, C/S

  5. Associated Conditions • Placenta accreta, increta, percreta • Risk inc w/ inc no. of prior c/s (50% risk in pt w/ previa and 2 prior c/s) • Vasa Previa • Vessels traverse the membranes in the lower uterine segment in advance of the fetal head. • Rupture can lead to fetal exsanguination

  6. Uterine Rupture • Associated with Prior c/s • Rates of uterine rupture? • Spontaneous rupture (no c/s history): 1/2000 (0.05%) • Low Transverse: 0.5%-1%risk rupture, VBAC 80% success rate • Classical C/s: 10% risk rupture, schedule amnio/c/s ~37 weeks.

  7. Placental Abruption • Premature separation of placenta • Painful third-trimester bleeding • Risk Factors • smoking, trauma, HTN cocaine, pprom, polyhydramnios, multiples • Trauma evaluation • bleeding, contractions, abdominal pain and NRFHT in 4hrs • U/s misses up to 50% of abruptions • Management: IV, T+X, Continuous monitoring, c/s vs. vag delivery

  8. Case Cont’d U/s reveals active, vertex fetus. Placenta anterior and free of os. Pt having contractions q 2-3 minuters. Bleeding increases. BP drops from 110/60 to palpable systolic pressure of 70. FHT drops from 120 to 90 bpm. What do you do???

  9. Post Partum Hemorrhage A 34yo G6P6 patient at term has just delivered a 4000gm infant after second stage of labor lasting 3 ½ hours. The placenta delivered spontaneously and the patient is bleeding briskly. • What is average EBL w/ SVD? • 500cc • What is average EBL w/ C/S? • 1000cc

  10. Classes of Hemorrhage • Class 1 • <900cc • Minimal symptoms • Class 2 • 1200-1500cc • Tachycardia, tachypnea • Class 3 • 1800-2100cc • Overt Hypotension, cold, clammy skin • Class 4 • 2400cc • Shock, absent BP

  11. Management • Fluids • Crystalloid, open wide/bolus • Labs • Cbc, coags, fibrinogen • Transfuse PRPC’s • FFP • Larger vol (250cc/unit, all coagulation factors) • Cryopercipitate • Smaller volume (20cc/unit, many coagulation factors)

  12. Differential Diagnosis • Atony • Uterine inversion • Laceration (cervical, vaginal) • Retained Placenta

  13. Uterine Atony • Risk factors • multiparity, multiple gestation, macrosomia, abruption, retained POC’s, placenta previa, induction (prolonged pitocin) • Management • Bimanual exam/massage • IV acess/fluids • Oxytocin, methergine 0.2mg IM, Hemabate 250mcg IM, misoprostol 800 to 1000mcg rectally • Laparotomy • Uterine artery ligation • B Lynch • Hysterectomy • UAE

  14. Uterine Inversion • Inverted fundus extends beyond cervix (looks beefy red) • Stop pitocin if infusing • Replace uterus • Relaxants if necessary (terbutaline, MgSo4, Nitrogylcerin) • Anesthesia • Laparotomy