james w. van hook, m.d. department of obstetrics and ... downloads for website/ob... · department...
TRANSCRIPT
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Obstetric Hemorrhage
James W. Van Hook, M.D.Department of Obstetrics and GynecologyThe University of Texas Medical Branch
Galveston, Texas, U.S.
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Lecture Organization
• Antepartum hemorrhage– Placenta previa– Vasa previa– Abruptio placentae
• Postpartum bleeding– Uterine atony– Laceration– Uterine inversion– Other
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Placenta Previa Definition
• Total - Internal os covered by placenta• Partial - Internal os partially covered
by placenta• Marginal - The edge of placenta is at
the margin of the internal os• Low lying - Near the internal os
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Types of Placenta Previa
Complete Partial
Marginal Low Lying
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Placenta Previa - Factoids
• Incidence at approximately 0.3%-0.5%• Occurs as consequence of zygote
implantation• Risk increased with:
– Advanced maternal age– Prior C/S (at least 1.5 times higher)– Defective decidualization– Smoking (risk doubled)
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Placenta Previa - Accreta
• Placenta previa is associated with increased risk of placenta accreta (discussed subsequently)
• Risk of accreta is 5% with unscarred uterus• Previous C-section and previa portends a 25%
risk of accreta
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Clinical Findings - Previa (1)
• Most common symptom is painless bleeding• Some degree of placental separation is
inevitable with previa = bleeding• Bleeding increases with labor, direct trauma,
or digital examination
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Clinical Findings - Previa (2)
• Initial bleeding is usually not catastrophic• Uterine bleeding may persist postpartum
because of overdistention of the poorly contractile lower uterine segment
• Coagulopathy is uncommon with previa unless due to massive bleeding
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Overdistended Lower Uterine Segment - Previa
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Placenta Previa - Diagnosis
• DO NOT DIAGNOSE via vaginal exam! (Exception – “double setup”)
• Ultrasound is the easiest, most reliable way to diagnose (95%-98+% accuracy)
• False positive - ultrasound with distended bladder
• Transvaginal or transperineal often superior to transabdominal methods
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Placenta Previa –Placental Migration
• Placental location may “change” during pregnancy
• 25% of placentas implant as “low lying”before 20 weeks of pregnancy
• Of those 25%, up to 98% are not classified as placenta previa at term
• Complete or partial previas do not appear to resolve as often (if at all)
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Placenta Previa –Placental Migration (2)
• Clinically important bleeding is not likely before 24-26 weeks gestation
• The clinically important diagnosis of placenta previa is therefore a late second or early third trimester diagnosis
• Migration is a misnomer - the placental attachment does not change, the relative growth of the lower segment does
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Management - Placenta Previa
• The clinical relevance of the diagnosis is in the late second and/or third trimester
• Bedrest probably indicated• Antenatal testing probably indicated• Recent data suggests, if environment ideal,
home care is acceptable
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Management - Placenta Previa (2)
• Evaluation for possibility of accreta needs to be considered
• Consideration for RHIG in Rh-negative patients with bleeding
• Episodic AFS testing with bleeding events• Vigilance regarding fetal growth• Follow-up ultrasound if indicated
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Management - Placenta Previa (3)
• Delivery should depend on type of previa– Complete previa = c/section– Low lying = probable attempted vaginal
delivery– Marginal/partial = it depends!
Consider “double setup” for uncertain cases
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Tamponade Of Previa By Presenting Part
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Placenta Accreta
• Placenta accreta– Accreta = adherent to endometrial cavity– Increta = placental tissue invades myometrium– Percreta = placental tissue grows through uterine wall
Accreta caused by faulty development of NITABUCH’S LAYER
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Placenta Accreta
• Incidence = approximately 1/2500• Related to abnormal decidual formation• 1/3 coexisted with placenta previa• 1/4 with previous curettage• Grandmultiparity can be risk factor• If diagnosed microscopically, 1/2 women
with C/S have some evidence of abnormal implantation
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Clinical Course - Accreta
• Association with elevated MSAFP• Antepartum bleeding usually related to
coexistent placenta previa• Main problem is at delivery with
adherent placenta– Association with inversion– Bleeding of placental bed– Increta/percreta consequences
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Clinical Course - Accreta(2)
• Attempted manual removal is often unsuccessful
• Conservative management suggested (albeit with high M/M)
• May require radical surgery if invasion is extrauterine
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Vasa Previa
• Associated with velamentous insertion of the umbilical cord (1% of deliveries)
• Bleeding occurs with rupture of the amniotic membranes (the umbilical vessels are only supported by amnion)
• Bleeding is FETAL (not maternal as with placenta previa)
• Fetal death may occur with trivial symptoms
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Vasa Previa
Placental disk
Umbilical cord
Membranes
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Abruptio Placentae
• Placental abruption occurs when all or part of the placenta separates from the underlying uterine attachment
• Incidence - approximately 1/100-1/200 deliveries
• Common cause of intrauterine fetal demise
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Abruptio Placentae -Associating Factors
• Hypertension - Half of fatal fetal abruptions were associated with HTN
• PPROM - abruptio may be a manifestation of rapid decompression of uterus or from subacute villitis
• Smoking (and/or ethanol consumption) linked to abruptio
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Abruptio Placentae -Associating Factors (2)
• Cocaine abuse - 2%-15% rate of abruption in patients using cocaine
• Uterine leiomyoma - risk increased if fibroid is behind implantation site
• Trauma - relatively minor trauma can predispose (association with bleeding, contractions, or abnormal FHT)
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Abruptio Placentae - Recurrence
• Recurrence rate may be as high as 1 in 8 pregnancies
• Antenatal testing is indicated (albeit predictive value may be poor - numerous examples of normal testing with subsequent serious or fatal event)
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Abruptio Placentae –Concealed Hemorrhage
• Bleeding from abruption may be all intrauterine -vaginally detected bleeding may be much less than with placenta previa
• DIC occurs as a consequence of hypofibrinogenemia - in chronic abruption, this process may be indolent
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Occult Hemorrhage in Abruption
Abruption
Placenta
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Abruption - Other Complications
• Shock - now thought to be in proportion to blood loss
• Labor - 1/5 initially present with diagnosis of “labor” - abruption may not be immediately apparent
• Ultrasound may not diagnose abruption in up to 14% of cases
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Abruption - Other Complications (2)
• Renal failure - may be pre-renal, due to underlying process (preeclampsia), or due to DIC
• Uteroplacental apoplexy (Couvelaire uterus) -widespread extravasation of blood into the myometrium and serosa
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Abruption Management
• Management is influenced by gestational age and degree of abruption
• Indicators for delivery -– Fetal intolerance– DIC– Labor
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Abruption Management (2)
• Vaginal delivery is acceptable (and generally preferred with DIC)
• Tocolysis:– Betasympathomimetics contraindicated in
hemodynamically compromised– Magnesium possibly indicated in special
circumstances– NSAID’s contraindicated
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Postpartum Hemorrhage
• Traditional definition = >500 ml blood loss• Normally seen blood losses:
– Vaginal delivery - 50% >500 ml– C/section - 1000 ml– Elective C-hys - 1500 ml– Emergent C-hys - 3000 ml
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Postpartum Hemorrhage (2)
• Pregnancy is normally a state of hypervolemia and increased RBC mass
• Blood volume normally increased by 30%-60% (1-2 L)
• Pregnant patients are therefore able to tolerate some degree of blood loss
• Estimated blood loss is usually about 1/2 of actual loss!
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Postpartum Hemorrhage (3)
• Early postpartum hemorrhage is within 1st 24 hours (also may be referred to as “postpartum hemorrhage”)
• Late postpartum hemorrhage (not addressed in this talk) is less common and occurs after the 1st 24 hours postpartum
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Postpartum Hemorrhage - Causes
• Genital tract laceration• Coagulopathy• Uterine
– Uterine atony– Uterine inversion– Uterine rupture– Retained POC
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Postpartum Hemorrhage - Genital Tract Laceration
• May be cervix, vaginal sidewall, rectal (example = hemorrhoid), or episiotomy
• Genital tract needs thorough inspection after any delivery– Cervix needs to be seen– Vagina needs to be inspected
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Repairing Lacerations
• Be sure to suture above internal apex of laceration
• Forceps may be used as vaginal retractors• Cervical lacerations >2.0 cm in length need to
be repaired. The cervix is grasped with ringed forceps and retracted to allow repair (starting at or above apex).
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Cervical Laceration
Begin repairat apex
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Puerperal Hematomas
• Incidence = 1/300 to 1/1500 deliveries• Episiotomy is most commonly associated risk
factor• Considerable bleeding may occur with
dissection above pelvic diaphragm• Drainage usually indicated (source often not
evident?)
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Uterine Rupture
• 1%-2% of previous lower segment C/S TOL patients (more with classical C/S)
• Other causes include:– Instrumented deliveries/versions/operative– Curettage– Macrosomia– Prolonged labor– Oxytocin
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Uterine Rupture (2)
• Rupture = separation of whole scar with rupture of membranes and bleeding
• Dehiscence = partial separation of previous uterine scar that is usually associated with less bleeding
• Dehiscence may be occult
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Uterine Rupture (3)
• Uterine rupture may be associated with antepartum or postpartum events
• Repair may require simple closure or hysterectomy
• Consider uterine rupture in patient with firm uterus (no atony), negative laceration survey, and continued bleeding
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Hemostatic Disorders
• Thrombocytopenia and DIC may predispose to continued vaginal bleeding after delivery
• Occasionally, a patient with von Willebrand’s disease (or other inherited disorder) will be diagnosed at or after delivery
• Bleeding from hemostatic disorder is usually not brisk, but it is persistent
• Amniotic fluid embolism may present with DIC
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Uterine Atony
• Most common cause of postpartum hemorrhage• Should be default diagnosis in patients with
postpartum bleeding (albeit always exclude other causes)
• Can be suspected by uterine palpation exam
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Uterine Atony (2)
• A prolonged third stage of labor (>30 min) is associated with postpartum hemorrhage
• Other associations with postpartum hemorrhage include:– Enlarged uterus (macrosomia or twins)– Prolonged labor or oxytocin (tachyphylaxis)– High parity– Maneuvers that hasten placental removal
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Uterine Atony Presentation
• Bleeding may be indolent and not easily recognized
• Postpartum patients may not exhibit dramatic hemodynamic changes until blood loss is pronounced
• Patients with pregnancy induced hypertension may fare poorly (MgSO4+ volume contraction)
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Uterine Atony Treatment
• Make sure uterus is evacuated (manual exploration)
• Rule out other causes• Resuscitation• Uterine contractile agents
– Oxytocin– Ergonovine– Prostaglandin
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Uterine Inversion
• May occur spontaneously, as a consequence of placental removal, or in association with connective tissue disorder (Marfan’s, Ehlers-Danlos)
• Risk of inversion increased with higher parity• May occur with accreta
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Uterine Inversion (2)
• Treatment is to reduce inversion before contraction of uterus
• If accreta-associated, DO NOT REMOVE THE PLACENTA (BLEEDING)
• May require uterine relaxants (TNG, halothane)
• Rarely, surgical reduction necessary (with constriction band)
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Postpartum Hemorrhage -Unified Approach
• Always examine systematically• Uterine atony most common, but other
causes may be overlooked• Get help!• Remember the hemodynamic
implications of the bleeding
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Postpartum Hemorrhage
Hemorrhage suspected
Exploration of uterus
Retained placenta (Accreta?)
Empty uterus(Next Slide)
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Postpartum Hemorrhage (2)Empty Uterus
OxytocinAtony?
Yes - Secondary medical tx.Consider surgery for failure
No - Inspect vaginaand cervix (next slide)
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Postpartum Hemorrhage (3)
Consider DIC, AFE, factordisorder, uterine rupture
Laceration
Yes = Repair No = other clues?