CASE 1 : Third Trimester Bleeding

2. A 21-year-old nulliparous patient at 41 weeks’ gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis. After placental separation, profound uterine atony is noted, and the patient be-gins to hemorrhage. The atony is unrespon-sive to bimanual massage, intravenous oxy-tocin, and intramuscular methylergonovine.What can be done to stanch the flow? • 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. • CASE 1 :Third Trimester Bleeding

3. A 21-year-old nulliparous patient at 41 weeks’ gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis. After placental separation, profound uterine atony is noted, and the patient be-gins to hemorrhage. The atony is unrespon-sive to bimanual massage, intravenous oxy-tocin, and intramuscular methylergonovine.What can be done to stanch the flow? • Placenta Previa • Placental Abruption • Uterine Rupture • VasaPrevia • Laceration • Vaginal mass • What is the “Differential Diagnosis”?

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 CS, curettages , myomectomy • Types? • Complete previa (20-30%) • Partial previa (does not completely cover) • Marginal (proximate to os) • Management: • pelvic rest, US, IV, T+S, C/S

5. Associated Conditions • Placenta accreta, increta, percreta • Risk increase w/ inc no. of prior CS • PP+unscarred uterus-5 % risk of accreta • PP+one previous C/D-24% risk of accreta • PP+two previous C/D-47% risk of accreta • PP+three previous C/D-50% risk of accreta • PP+four previous C/D-67% risk of accreta • 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. Associated Conditions • VasaPrevia • Vessels traverse the membranes • in the lower uterine segment in • advance of the fetal head. • Rupture can lead to fetal exsanguination • 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

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. Uterine Rupture • Associated with Prior CS • 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.

10. A 21-year-old nulliparous patient at 41 weeks’ gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis. After placental separation, profound uterine atony is noted, and the patient be-gins to hemorrhage. The atony is unrespon-sive to bimanual massage, intravenous oxy-tocin, and intramuscular methylergonovine.What can be done to stanch the flow? • A 21-year-old nulliparous patient at 41 weeks’ gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis. • After placental separation, profound uterine atony is noted, and the patient begins to hemorrhage. The atony is unresponsive to bimanual massage, intravenous oxytocin, and intramuscular methylergonovine. • CASE 2 Uterine atony leads to heavy bleeding

11. What can be done to stop the flow

12. A stepwise approach to bleeding caused by persistent uterine atony

13. A stepwise approach to bleeding caused by persistent uterine atony

14. CASE3 Postpartum hemorrhage with Hypovolemic shock • A 35 year old womanin her 4th pregnancy, had a history of PPH in her previous pregnancies. • She was diagnosed to have pre eclampsia during this pregnancy and was on oral antihypertensive medication. • At 38 weeks of gestation she was admitted and LABOR was induced with prostaglandins • A 35 year old womanin her 4th pregnancy, had a history of PPH in her previous pregnancies. • She was diagnosed to have pre eclampsia during this pregnancy and was on oral antihypertensive medication. At 38 weeks of gestation she was admitted and LABOR was induced with prostaglandins.

15. The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery. • Exploration did not reveal any retained products. • The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available. • The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery. • Exploration did not reveal any retained products. • The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

16. She was transferred to a general hospital for further resuscitation but arrived in a moribid state and signs of hyovolemic shock was evident • What should be your first step of management? • The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery. • Exploration did not reveal any retained products. • The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

17. At ANE: INITIAL ASSESSMENT AND START BASIC TREATMENT

18. ANE to OT: TEMPORIZING AND TRANSFER INTERVENTION ANE to OT: DRUGS OF CHOICE If not available or bleeding still continue from previous drugs ANE to OT: TORRENTIAL BLEEDING

19. CASE 4: • A 30 year women in her third pregnancy at 38 weeks of gestation came in labour at a district hospital. Her antenatal period had been uneventful. • She delivered vaginally. With active management of 3rd stage and the placenta was delivered by CCT. • A 35 year old womanin her 4th pregnancy, had a history of PPH in her previous pregnancies. • She was diagnosed to have pre eclampsia during this pregnancy and was on oral antihypertensive medication. At 38 weeks of gestation she was admitted and LABOR was induced with prostaglandins.

20. After the placenta was delivered , there was active bleeding from the vagina. A green cannula was inserted and the on-call doctor was informed. • Over the phone the doctor ordered for uterine massage to be done ,IV ergometrine 0.5mg and IV Pitocin 40 unit in 500mls NS . • The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery. • Exploration did not reveal any retained products. • The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

21. Blood pressure was normal but the pulse rate was 96 b/min. • Abdominal examination done showed that the uterus was contracted. Despite that the patient was still actively bleeding. • Another IV line was inserted and blood was sent for CBC, GXM and PT/PTT. She was given NS running fast. • The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery. • Exploration did not reveal any retained products. • The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

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