MANAGEMENT MANAGEMENT

OF OF

OBSTETRICOBSTETRIC

HAEMORRHAGEHAEMORRHAGE

Dr Amir M. SafaDr Amir M. Safa

CAUSESCAUSES

ANTEPARTUMANTEPARTUM POSTPARTUMPOSTPARTUM

Placenta Previa Uterine Atony

Placental Abruption Genital Trauma

Uterine Rupture Retained Placenta

Vasa Previa Placenta Accreta

Uterine Inversion

ANTEPARTUM BLEEDINGANTEPARTUM BLEEDING

Incidence: 4%

Aetiology:

Benign lesions: Cervicitis

Placentation abnormalities:

Placenta Previa

Placental Abruption

PLACENTA PREVIAPLACENTA PREVIA

Definition: Placenta implantation over or near internal os

Incidence: 1:200 pregnancies, associated with preterm labour

Types:

Total Previa: complete coverage of the os

Partial Previa: partial coverage of the os

Marginal Previa: lying close w/o covering the os

Aetiology: unclear

Risk factors:

Previous uterine trauma

Multiparity

Advanced maternal age

Previous PP, uterine surgery, & CS

Diagnosis:

Painless vaginal bleed, 2nd & 3rd trimester

No relation w/ contractions

Confirmation w/ US

PLACENTAL ABRUPTION PRESENTATION : BLEEDING W/O PLACENTAL ABRUPTION PRESENTATION : BLEEDING W/O PAIN 10%PAIN 10%

1st episode: mostly spontaneous resolution w/o foetal distress

Obstetric management:

Related to bleeding severity & foetal distress

Vaginal examination: usually avoided

double set up room

Goal: Delaying delivery until foetus is mature

Bed rest & tocolytic drugs

MgSO4

Terbuteline

Mature foetus or bleeding: CS

Anaesthetic management:

Related to indication & urgency

Always greater risk of bleeding during uterine incision

Adequate IV access, urine catheter, > 2units of blood

Stable patient: consider regional anaesthesia

Unstable patient: GA + RSI + fluid warmer + >4 units of blood +/- invasive monitoring

PLACENTAL ABRUPTIONPLACENTAL ABRUPTION:

Definition:

Placental separation from decidua basalis before delivery

Acute bleeding from decidual vessels

Foetal distress

Incidence: 1%

Aetiology: unknown

Risk factors:

HT PROM

Advance age & parity Trauma

Drugs: tobacco, cocaine Previous abruption

Diagnosis:

Vaginal bleed (retroperitoneal!!)

Uterine contractions & tenderness

Ultrasound

Complications:

Shock

ARF

DIC: most common cause (10%)

Foetal distress

IUGR

Preterm labour

Perinatal death (15-25%)

Obstetric management:

FHR monitoring

IV access

FBC, G&S, XM, clotting screen

Def. Treatment: delivery (related to gest.age, bleeding, & FHR)

Anaesthetic management:

Vaginal delivery: epidural if, no CI

Regional: if no CI to mother or foetus

GA + RSI

Ketamine: <1.5 mg/kg as it increases uterine toneKetamine: <1.5 mg/kg as it increases uterine tone

UTERINE RUPTURE:UTERINE RUPTURE:

Incidence: <1%

Risk factors:

Previous uterine trauma, anomalies

Tumours

CS incision

Forceps delivery

Placenta percreta

Foetal anomalies & malpositions

Oxytocin

Multiparity

Diagnosis:

Vaginal bleeding, Hypotension, Cessation of labour, Foetal

distress, Abdominal pain

Obstetric management:

Reparable: repairing

Non repairable: arterial ligation

hysterectomy

Anaesthetic management:

EPIDURAL: controversy in the past

good pain relief

could be used for CS

VASA PREVIAVASA PREVIA::

Definition: foetal vessels traverse the foetal membrane in front of the presenting part

DOES NOT AFFECT PARTURIANT BUT ASSOCIATED WITH DOES NOT AFFECT PARTURIANT BUT ASSOCIATED WITH HIGH FETAL MORTALITYHIGH FETAL MORTALITY

Incidence: 1:2-3000

Diagnosis:

Associated w/ multiple births

Haemorrhage w/ intact membrane

Palpation or observation of foetal vessels in the cervix

Prolonged bleeding after membrane rupture

Umbilical vessels traversing the cervical opening w/o bleeding

Obstetric management:

Primary concern: neonatal resuscitation

CS

Anaesthetic management:

GA + RSI vs. regional related to the degree of emergency

POSTPARTUM BLEEDINGPOSTPARTUM BLEEDING

Definition:

Vaginal delivery: >500ml

CS: >1000ml

Incidence:

Vaginal delivery: 4%

CS: 6-7%

Types:

Primary: 0 - 24 hr

Secondary: 24 hr - 6 weeks

RETAINED PLACENTARETAINED PLACENTA:

Could cause early & delayed haemorrhage

Obstetric management:

Manual removal of Placenta & inspection

Anaesthetic management:

Epidural: could be used when placed

Spinal: if no CI

GA: If unstable (RSI)

PLACENTA ACCRETAPLACENTA ACCRETA:

Definition: abnormally adherent placenta

Types: PA Vera: adhesion to myometrium

PA Increta: adhesion & invasion of myometrium

PA Percreta: invasion to the serosa or other pelvic structures

Risk factors: Prior uterine trauma

Multiple CS w/ low-lying Placenta or PP

PRESENT EVEN W/O ANTEPARTUM HAEMORRAGE (PP)PRESENT EVEN W/O ANTEPARTUM HAEMORRAGE (PP)

Diagnosis: Usually at delivery Difficulty to separate Placenta

Def. diagnosis: laparotomy

US: may predict. MRI, TVCD: more sensitive

Obstetric management:

Hysterectomy

Anaesthetic management:

Regional: could be done

GA + RSI: recommended

Blood should be ready

Risk factors:

Multiple gestation

Macrosomia, Polyhydramnios

Chorioamnionitis

Labour abnormalities

Diagnosis:

Soft uterus with vaginal bleeding

UTERINE ATONYUTERINE ATONY::

Most common cause of postpartum:

Haemorrhage, Hysterectomy & Transfusion

Obstetric management:

Bimanual compression

Uterine massage

Drugs

Drugs:

Oxytocin: 1st line

Ergot Alkaloids: 2nd line

Prostaglandins

GENITAL TRAUMAGENITAL TRAUMA:

Types:

Vaginal haemorrhage: soft tissue injury

Vulval haemorrhage: Pudendal artery

Retroperitoneal haematoma: Hypogastric artery

Anaesthetic & Obstetric management:

Vulval & vaginal:

mostly I + D under local or regional anaesthesia

Retroperitoneal haematoma:

Laparotomy under GA + RSI

UTERINE INVERSIONUTERINE INVERSION:

Incidence: 1:500-10000

Risk factors:

Uterine atony or anomalies

Umbilical cord traction

Inappropriate fundal pressure

Diagnosis:

Haemorrhage + vaginal mass

Obstetric management:

Early replacement + uterotonic drugs

Anaesthetic management:

Goal: rapid & short relaxation

GA + volatile: if no CI to GA

IV TNG: if CI to GA