Obstetrical Hemorrhage InternationalObstetrical HemorrhageObstetrical Hemorrhage International PrinciplesPrompt diagnosisRecognize reserve and ability to compensateResuscitate vigorouslyIdentify underlying causeTreat underlying causeObstetrical HemorrhageObstetrical Hemorrhage International A 25 year- old G3 woman presents to the maternity unitwith vaginal bleeding. Fetal heart rate is 1!"mnt and her #P is11!"$!mm%g and her %& '5"mnt. Fundal height is 2'cm.(he has been given nothing. )hat are the possible diagnosis* --------------------------------------------------------------- %ow would you distinguish between the diagnosis * ----------------------------------------------Obstetrical Hemorrhage InternationalObstetrical Hemorrhage InternationalAntepartum HemorrhageObstetrical Hemorrhage International +b,ectivesDefinitions and IncidenceEtiology and Risk FactorsDiagnosisManagement

maternal and fetal assessment

appropriate resuscitation

no vaginal e!am prior to determining placental locationIndividual "ausesObstetrical Hemorrhage International -e.initionvaginal bleeding bet#een $% #eeks and delivery /ncidence$& to '& of all pregnanciesvarious causes of antepartum (aemorr(age

abruptio placenta )%&*&of pregnancies

unclassified +'&

placenta previa $%&,& of pregnancies

lo#er genital tract lesion '&

ot(erObstetrical Hemorrhage International 0tiology o. AP% 1ervical- contact bleeding 2e.g. intercourse3 pap3 neoplasia3 e4amination5- in.lammation 2e.g. in.ection5- e..acement and dilatation 2e.g. labour3 cervical incompetence5 Placental- abruptio- previa- marginal sinus rupture 6asa previa+ther- abnormal coagulation Obstetrical Hemorrhage International -iagnostic Procedures%istory and physical - .o digital pelvic e!am7ltrasound- de.initive test .or previa- less use.ul in abruptio0lectronic Fetal 8onitoring- .or .etal compromise and uterine tone(peculum- do ultrasound .irst i. possible- .o digital pelvic e!amObstetrical Hemorrhage International 9aboratory1#13 blood type3 &h3 1oombscoagulation status- /:&3 P;;3 .ibrinogen2 -units o. P cross matched as appropriatebedside clot test vaginal e4am-elivery8other or .etus unstable04pectant consider ongoing loss3 etiology3 gestationObstetrical Hemorrhage International 8anagement-A#1 ?stalk to and observe mot(er and fetuslarge bore I/ accesscrystalloid 0.123"4" and coagulation statuscrossmatc( and typeget 5E6P7Obstetrical Hemorrhage International %emodynamic &esuscitationearlyaggressiveresuscitationtoprotectfetusand maternalorgansfrom(ypoperfusionandtoprevent DI"stabilize vital signslarge bore I/ crystalloid infusion8 plasma e!pandersfollo# (emoglobin and coagulation statuso!ygenconsumption is up $%& in pregnancyObstetrical Hemorrhage International Fetal 1onsiderationslateral position increases cardiac output up to +%&consider amniocentesis for lung indicese!ternal fetal and labor monitoring9lei(auer4etke if suspected abruptionposttraumamonitoratleast)(oursfor evidenceoffetalinsult8abruptio8fetal maternal transfusionObstetrical Hemorrhage International Abruptio Placenta - -e.initionpremature separation of normally implanted placenta Abruptio Placenta - 1lassi.icationTotal fetal deat(Partial fetus may tolerate up to +%'%& abruptionObstetrical Hemorrhage International &is= Factors .or Abruption (ypertension: gestational and pree!istingabdominal traumacocaine or crack abuseprevious abruptionoverdistended uterus - multiple gestation8 poly(ydramniossmoking8 especially ;* pack1dayObstetrical Hemorrhage International 1linical Presentation o. Abruption vaginal bleeding usually painful8 unremittingpresence of risk factor(emodynamic status may not correlate #it( amount of vaginal blood loss concealed abruptiomay be evidence of fetal compromiseuterustender8 irritable8 contracting or tetanic ultrasound rules out previa and may s(o# clotObstetrical Hemorrhage International ABRUPTION

Live Fetus Dead Fetus coagulopathyDelivery (watch for DIC)Assess MaturityMaturity Immaturityaginal delivery or C!" "teroids plus e#pectancy$ransfusion%$ransfer% Obstetrical Hemorrhage International Placenta Previa - -e.initionplacenta covers or lies near t(e cervi! Placenta Previa - 1lassi.icationtotal entirely covers t(e ospartial partially covers t(e osmarginalclose enoug( to t(e os to increase riskof bleeding as cervical effacement and dilatation occurObstetrical Hemorrhage International &is= Factors .or Previaprevious placenta previaprevious caesarian section or uterine surgerymultiparity 0'& in grand multiparous patients3advanced maternal agemultiple gestationsmokingObstetrical Hemorrhage International 1linical Presentation o. Previavaginal bleeding usually painless 0unless in labour3maternal (emodynamic status corresponds to amount of vaginal blood loss#ell tolerated by fetus unless maternal instabilityuterusnontender8 not irritable8 soft may (ave abnormal lieultrasound s(o#s previa 7Obstetrical Hemorrhage InternationalPREVIA Assess maturityMaturity ImmaturityDelivery &y C!" (consider accreta) "teroids plus e#pectancy May try vaginal if marginal$ransfusion% $ransfer% Obstetrical Hemorrhage International 6asa Previa - -e.initionblood vessels in t(e membranes run across t(e cervi!rept test or 9lei(auer test on vaginal bloodterminal fetal bradycardia ? initial tac(ycardia or sinusoidal F5 Prognosisfetal mortality as (ig( as '%@%&Obstetrical Hemorrhage International 1onclusionsassess maternal status and stabilityassess fetal #ellbeingresuscitate appropriatelyassess cause of bleedingavoid vaginal e!ame!pectant management if appropriatedeliver if indicated based on maternal or fetal statusObstetrical Hemorrhage InternationalPostpartum HemorrhageObstetrical Hemorrhage International @ou have ,ust delivered a 3A wee= twin pregnancy per vagina. ;he third stage is complicated by post partum hemorrhage unresponsive to uterine message and the use o. o4ytocin. )hat would your ne4t management steps be---------------------------------- *Obstetrical Hemorrhage International +b,ectives-e.inition0tiology&is= FactorsPrevention8anagementObstetrical Hemorrhage International ;raditional -e.initionblood loss of; '%% m6 follo#ing vaginal deliveryblood loss of; *%%% m6 follo#ing cesarean delivery Functional -e.initionany blood loss t(at (as t(e potential to produce or produces (emodynamic instability /ncidenceabout '& of all deliveriesObstetrical Hemorrhage International;one - uterine atony;issue - retained tissue"clots;rauma - laceration3 rupture3 inversion;hrombin - coagulopathyEtiology of Postpartum 5emorr(ageObstetrical Hemorrhage Internationalprevious PP% or manual removal placental abruption3 especially i. concealedintrauterine .etal demiseplacenta previagestational hypertension with proteinuriaoverdistended uterus 2e.g. twins3 polyhydramnios5pre-e4isting maternal bleeding disorder 2e.g. /;P5&is= Factors .or PP% - AntepartumObstetrical Hemorrhage International+perative delivery - cesarean or assisted vaginalProlonged labour&apid labour/nduction or augmentation1horioamnionitis(houlder dystocia/nternal podalic version and e4traction o. second twinAcBuired coagulopathy 2e.G. %ellp3 dic5&is= Factors .or PP% - /ntrapartumObstetrical Hemorrhage International9acerations or episiotomy&etained placenta"placental abnormalities7terine rupture7terine inversionAcBuired coagulopathy 2e.G. -ic5&is= Factors .or PP% - PostpartumObstetrical Hemorrhage Internationalbe preparedactive management o. the third stageprophylactic o4ytocin with delivery or with delivery o. anterior shoulder

1! 7 /8 or 5 7 /6 bolus

2! 7"9 :"( /6 run rapidlyearly cord clamping and cuttinggentle cord traction with suprapubic countertractionPreventionObstetrical Hemorrhage InternationalActive v.s Expectant Third Stage anagementCochrane Li&raryIssue '( )***++, - .** mL (n/0121)++, - '*** mL (n/0121)Maternal ,& 3 4' (n/0).1)5lood transfusion (n/06)4)$herapeutic o#ytocin (n/06)4)7ausea (n/20*8)Manual removal (n/06)4)0.1 1 109dds :atio (4.; Confidence Interval)9utcome(su&4" Dsatony is t(e leading cause of PP5if boggy bimanual massage

rules out uterine inversion

may feel lo#er tract inEury

evacuate clot from vagina and1or cervi!

may consider manual e!ploration at t(is timePostpartum HemorrhageObstetrical Hemorrhage International8anagement-#imanual 8assagePostpartum HemorrhageObstetrical Hemorrhage International 8anagement-+4ytocin' units I/ bolus$% units per 6 .12 I/ #ide open*% units directly into t(e uterus if no IA/ accessPostpartum HemorrhageObstetrical Hemorrhage International 8anagement-8anual 04plorationif no response to bimanual massage and o!ytocin t(en proceed to e!ploration manual e!ploration #ill:

rule out uterine inversion

palpate cervical inEury

remove retained placenta or clot from uterus

rule out uterine rupture or de(iscenceObstetrical Hemorrhage International&eplacement o. /nverted 7terusObstetrical Hemorrhage International&eplacement o. /nverted 7terusObstetrical Hemorrhage International 8anagement-Additional 7terotonicsergotaminecaution in (ypertension

%8$ mg IM 1 I/8 interval *'D

ma!imum dose * mg5emabate 0carboprost3ast(ma is relative contraindication

*' met(ylprostaglandin F$

%8$' mg IM or intramyometrial

Ma!imum dose $ mg"ytotec 0misoprostol3caution in ast(ma

)%% Fg pr or poObstetrical Hemorrhage International 8anagement-#leeding with .irm uteruse!plore t(e lo#er genital tractre