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CLINICAL SCIENCE SESSION (CSS)OBSTETRICAL HEMORRHAGE

DISUSUN OLEHANITA MUBAROKAH, S.Ked

PEMBIMBINGDr. Firmansyah, Sp. OGObstetrics is bloody business. Although medical advances have dramatically reduced the dangers of childbirth, death from hemorrhage still remains a leading cause of maternal mortality.

Hemorrhage was a direct cause of more than 17 percent of 4200 pregnancy-related maternal deaths in the United States as ascertained from the Pregnancy Mortality Surveillance System of the Centers for Disease Control and Prevention (Gerberding, 2003).

OVERVIEWIMPLICATIONS ANDCLASSIFICATIONFatal hemorrhage is most likely in circumstances in which blood or components are not available immediately.Generally speaking, obstetrical hemorrhage may be antepartumsuch as with placenta previa or placental abruption, or more commonly it is postpartumfrom uterine atony or genital tract lacerations.

Incidence and Predisposing ConditionsThe exact incidence of obstetrical hemorrhage is not known because of its imprecise definition as well as difficulty in its recognition and thus its diagnosis.

Antepartum HemorrhageSlight vaginal bleeding is common during active labor. This bloody show is the consequence of effacement and dilatation of the cervix, with tearing of small vessels. Uterine bleeding, however, coming from above the cervix, is cause for concern.8CONT.... It may follow some separation of a placenta implanted in the immediate vicinity of the cervical canal-placenta previa.

It may come from separation of a placenta located elsewhere in the uterine cavity-placental abruption

Rarely, there may be velamentous insertion of the umbilical cord, and involved placental vessels may overlie the cervix-vasa previa

CONT....The source of uterine bleeding is not always identified. In that circumstance, antepartum bleeding typically begins with few, if any, symptoms and then stops.

Postpartum HemorrhageCommon causes include bleeding from the placental implantation site, trauma to the genital tract and adjacent structures, or both.

1. DefinitionTraditionally, postpartum hemorrhage has been defined as the loss of 500 mL of blood or more after completion of the third stage of labor. This is problematic because half of all women delivered vaginally shed that amount of blood or more when losses are measured quantitatively.

2. Hemostasis at the Placental Site

Near term, it is estimated that at least 600 mL/min of blood flows through the intervillous space. This flow is carried by the spiral arteries. With separation of the placenta, these vessels are avulsed. Hemostasis at the placental implantation site is achieved first by contraction of the myometrium that compresses this formidable number of relatively large vessels. This is followed by subsequent clotting and obliteration of their lumens. Thus, adhered pieces of placenta or large blood clots that prevent effective myometrial contraction can impair hemostasis at the implantation site.

3. Clinical Characteristics

Postpartum bleeding may begin before or after placental separation. Instead of sudden massive hemorrhage, there usually is steady bleeding. At any given instant, it appears to be only moderate, but may persist until serious hypovolemia develops. Especially with hemorrhage after placental delivery, constant seepage can lead to enormous blood loss.

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4. DiagnosisThe differentiation between bleeding from uterine atony and that from genital tract lacerations is tentatively determined by predisposing risk factors and the condition of the uterus. If bleeding persists despite a firm, well-contracted uterus, the cause of the hemorrhage most likely is from lacerations. Bright red blood also suggests arterial blood from lacerations. To confirm that lacerations are a cause of bleeding, careful inspection of the vagina, cervix, and uterus is essential. CAUSES OF OBSTETRICAL HEMORRHAGEPlacental Abruption Placental separation from its implantation site before delivery has been variously called placental abruption, abruptio placentae, and in Great Britain, accidental hemorrhage.

The bleeding of placental abruption typically insinuates itself between the membranes and uterus, ultimately escaping through the cervix, causing external hemorrhage

ContLess often, the blood does not escape externally but is retained between the detached placenta and the uterus, leading to concealed hemorrhage

1. Significance and Frequency

Abruption severity often depends on how quickly the woman is seen following symptom onset. With delay, the likelihood of extensive separation causing fetal death is increased remarkably.The frequency with which placental abruption is diagnosed varies because of different criteria, but the reported frequency averages 1 in 200 deliveries.282. Perinatal Morbidity and Mortality

Although the rates of fetal death from abruption have declined, they remain especially prominent as stillbirth rates from other causes have decreased.

3. Etiology and Associated Factors

Age, Parity, Race, and Familial FactorsHypertensionPrematurely Ruptured Membranes and Preterm DeliverySmokingCocaine.Thrombophilias.Traumatic Abruption.Leiomyomas

4. Recurrent Abruption

A woman who has suffered a placental abruptionespecially that caused fetal deathhas a high recurrence rate.Management of a pregnancy subsequent to an abruption is thus difficult because another separation may suddenly recur, even remote from term. 5. Pathology

Placental abruption is initiated by hemorrhage into the decidua basalis. The decidua then splits, leaving a thin layer adhered to the myometrium. Consequently, the process in its earliest stages consists of the development of a decidual hematoma that leads to separation, compression, and ultimate destruction of the placenta adjacent to it.a. Concealed Hemorrhage

There is an effusion of blood behind the placenta, but its margins still remain adheredThe placenta is completely separated, yet the membranes retain their attachment to the uterine wallBlood gains access to the amnionic cavity after breaking through the membranesThe fetal head is so closely applied to the lower uterine segment that blood cannot make its way past.

b. Chronic Placental Abruptionc. Fetal-to-Maternal Hemorrhage

Bleeding with placental abruption is almost always maternal. This is logical because the separation is within the maternal decidua.

In this circumstance, fetal bleeding results from a tear or fracture in the placenta rather than from the placental separation itself.

6. Clinical Diagnosis

The signs and symptoms of placental abruption can vary considerably. Sonography infrequently confirms the diagnosis of placental abruption at least acutely, because the placenta and fresh clot have similar sonographic appearances.ContSyokKoagulopati KonsumtifGagal GinjalSindrom SheehanUterus Couvelaire

7. Management Treatment for placental abruption varies depending on gestational age and the status of the mother and fetus. With a fetus of viable age, and if vaginal delivery is not imminent, then emergency cesarean delivery is chosen by most clinicians.

a. Expectant Management in Preterm Pregnancy. Delayingb. Tocolysisc. Cesarean Deliveryd. Vaginal Delivery- Labor- Amniotomy- Oxytocinh. Timing of Delivery after Severe Placental Abruption.

TERIMA KASIH