7-obstetric Hrrge Copy

Obstetric Haemorrhage Dr. Majda Komaikh; FRCOG, Reproductive Medicine Associate Professor, Obstetrics & Gynaecology Faculty of Medicine

Obstetric Haemorrhage: 1. Bleeding in early pregnancy (< 24 weeks): * Abortion * Ectopic pregnancy •Gestational trophoblastic disease 2. Bleeding late in pregnancy (≥ 24 weeks) * Antepartum haemorrhage (24 wks till delivery) * Postpartum haemorrhage (after delivery) Significance: * ↑ Maternal Morbidity * ↑ Maternal mortality * ↑ Fetal loss

ANTEPARTUM HAEMORRHAGE (APH) Definition Bleeding from the genital tract after 24 weeks and before delivery

Classification: * Placental Abruption * Placenta Praevia * Incidental APH

Placental Abruption

UUS

LUS

Placenta Praevia

Placental Abruption: Definition: separation of a normal situated placenta (upper segment of the uterus) before delivery Incidence: 1/80 to 1/200 Recurrence rate 6-10%

Types: *Revealed Hrrge: Blood escape by dissecting between the membranes and uterine wall leading to vaginal bleeding and sometimes getting into the amniotic sac giving blood stained liquor. * Concealed Hrrge: Blood extends into uterine wall with little or no external bleeding. Clinical condition is out of proportion of the loss

Placental Abruption:

Placental separation → Intravasation of the blood through the myometrium to serosal Surface → Couvelaire uterus

Precipitating factors: Trauma; External cephalic version; Amniocentesis; Smoking; Uterine decompression (PROM) in polyhydramnios; H/O Pl. abruption (rec.6-10%); Grandparity (x3); ?Hypertensive disorders (Cause or consequence); Folic acid deficiency.

Clinical Features: Symptoms: Bleeding per vagina (revealed)

Pain: esp in concealed type where the bleed occur through the myometrium (couvelaire uterus) increasing uterine tone Signs: * General signs of shock; (Concealed type: out of proportion of external loss); BP is poor guide to the extent of bleeding because of association with hypertension.

Abdominal exam: tenderness; uterus is hard wooden in consistency (esp. in concealed)

Uterus size:> dates (in concealed) or =dates (in revealed) Fetal parts difficult to palpate FSH: +(fetal bradycardia)/ - fetal death) Avoid P/V exam if placental site bec Placenta praevia is a D.D

Complications: * Coagulopathy: Thromboplastin released from the damaged myometrium cause consumption coagulopathy * Hypovolemic shock→ Renal insufficiency

Management: Admission Initial assestment: mild/moderate/severe Mild bleeding: * Ultrasound to localize the placenta and to rule out retroplacental clots. * Expectant management till maturity: If no retroplacental clots, CTG reactive, and non-progressive. * Rule out local causes by speculum exam

Moderate/severe: * Resuscitation: ABC (Airways/Breathing/Circulation)

Establish intravenous: CBC, Blood group, cross matching, Coagulation profile CVP Urinary catheter for output measurement(>30 ml/hour indicate adequate renal perfusion) CTG monitoring

Mode of delivery Depend on : fetal maturity, fetal heart trace fetal presentation severity of bleeding ARM / Syntocinon: - If CTG is reactive / reasonable fetal maturity / cephalic; if fetus dead allow vaginal delivery -Shorten second stage VE/forceps -Active management of third stage: high risk of PPH Immediate C.S: - If fetus alive and CTG show fetal Bradycardia - Breech - Premature fetus EUA: Severe bleeding / Placental site is unknown

Management of complications: • Consumption coagulopathy: adequate blood transfusion/ FFP/ avoid epidural • PPH: Avoid by active management of third stage • Renal failure: due to inadequate perfusion/rarely from fibrin deposit in DIC Usually recover after adequate blood and fluid replacement. Rarely permanent →seek nephrologist`s help Maternal / Perinatal Mortality: MM <1% PNM 30% to → 15%

Placenta Praevia: Definition The placenta is partly or wholly inserted in the lower uterine segment Types: Partial (minor) Total (major) Incidence: 0.8-1%

Placenta Praevia

Etiology ↑Surface area of placenta:Twins, succenturate lobe - Age / parity: placenta praevia ↑ with age and parity - Previous C/S: Implantation on the scar Clinical feature: Symptoms: Painless vaginal bleeding; usually in trimester / unprovoked / recurrent Signs: general → depend on amount of loss Abd.

→ soft not tender High presenting part FSH usually normal

Vaginal exam. Is C/I in placenta praevia

third

Diagnosis

Ultrasound

Management: Depend on If severe

: Fetal maturity / severity of bleeding : resuscitate and deliver by CS

If mild/moderate: conservative till reasonable maturity. keep patient in hospital. Two units of blood always ready. serial fetal surviellence At 38 weeks: Elective CS Postpartum: Watch for PPH. Active Mg. Of third stage

Prognosis: MM

→ Low

PNM

→ 2% depend on gestational age at delivery

Vasa Praevia: Definition Velamentous insertion of the cord and the fetal vessels lies on the membranes covering the internal os. The blood is fetal in origin. A small amount of bleeding is serious. Diagnosis Kleihauer test Management CS

Velamentous insertion of cord, Vasa praevia

Incidental APH: Bleeding from local causes e.g. Cervical erosion; cervical polyp;cervical varicosities; Cervical cancer Management: Treat cause

POSTPARTUM HAEMORRHAGE

Definition Primary PPH: Blood loss from genital tract in excess of 500 ml in the first 24 hours after delivery of the baby. Secondary PPH: Excessive bleeding from the genital tract after 24 hours postpartum until 6 weeks after the birth. Causes of primary PPH: 1. Uterine Atony

→ 90% of PPH

2. Retained placenta/Morbidity adherent placenta (accrete, increta,percreta) → include in atonic uterus 3. Trauma to genital tract → 7% 4. Coagulation disorders

→ 3%

Uterine Atony: * Uterine overdistention : Polyhydramnios, multiple pregnancy (large placental bed), large baby * Past obstetric history : 15% risk of recurrence * Multiparity: increased fibrous tissue in myometrim * Antepartum haemorrhage: Both abruptio and placenta praevia increase risk of PPH. In abruptio due to coagulation defect or couvelaire uterus which interfer with uterine contraction * Poor uterine contraction due to fibroid or retained products of conception Others:Operative delivery & Anaesthesia: Halothene Prolonged labour Mismanagement of third stage

Retained placenta/Morbidity adherent placenta

Trauma: Unsutured episiotomy, multiple laceration, cervical tear

Coagulation disorders: Chronic: Von Willebrand’s disease, idiopathic thrombocytopenia Acute: Amniotic fluid embolism

Prevention of PPH: • Identification of high risk patients; multiparity; multiple pregnancy; HO PPH; Anaemic patient tolerate blood loss poorly so ensure good Hb level at labour and treat anaemia •Proper management of third stage: * Delivery of placenta (CCT) * Drugs 0.5 mg ergometrine I.m Syntometrine (0.5mg ergometrine+5 units syntocinone) Syntocinone

Management of PPH: IF MAJOR PPH INVOLVE: Senior Anaesthetist Obstetric Consultant Haematologist

1. RESUSCITATE * Adequate venous access * CBC * X match 6 units minimum * Clotting / FDPs * Insert urinary catheter * If hypotensive: Head down tilt Oxygen IV fluid hartmann’s haemaccel unless crossmatched blood available If unavailable uncrossmatched blood (patient’s group) As a last resort group O Rh negative

2. Diagnosis and Treatment: Is the placenta complete? If placenta is retained or incomplete ..

Manual removal of placenta under G.A

succenturate lobe

Atonic uterus: Uterine massage/Bimanual compression Oxytocin 5U IV OR Ergometrine 500 mg IV caution in: PIH, cardiac disease, hypertension If no response: IV Oxytocin infusion (20u in 500ml Hartmann’s)

If no response PGF2 ∝(Hemabate) 250 µ I.M 1.5 hrly to max. of 5 doses Caution in : Asthma

If bleeding persist: Arrange theatre Prepare for EUA: check cervix / vagina / perineum / products Uterine packing/Balloon - B-lynch suture Uterine devascularisation Internal iliac ligation Hysterectomy

retained

Bakri Postpartum Balloon

B-Lynch stitch

*** always check for DIC coagulopathy and correct it *** Watch for complication after acute event: DIC,renal failure, Anaemia, Sheehan syndrome ……………………………………………….

Secondary PPH: Causes: Retained product of placenta/ Endometritis Treatment of secondary PPH: If retained product --- → evacuation under antibiotics If endometritis -------- → Triple antibiotics