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OBSTETRICAL HEMORRHAGE

Obstetrics is "bloody business." hemorrhage still remains a leading

cause of maternal mortality. 12 %of maternal deaths were

caused by obstetrical hemorrhage. hemorrhage is the single most

important cause of maternal death worldwide.

Obstetrical hemorrhage accounts for almost half of all postpartum deaths in developing countries

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most maternal deaths from hemorrhage is associated with substandard care.many hemorrhage-related maternal deaths were preventable and were associated with inadequate facilities

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خونریزی در طی حاملگی باید بدون تاخیر د ارزیابی شوبیمارستاندر .

خونریزی مامایی نیاز به ارزیابی سریع دارد زیرا بدون توجه به منشاء خونریزی،

هر خونریزی مامایی می تواند سریعاً شودتبدیل به خونریزی شدید .

غیر ممکن وقتی خونریزی شروع می شود کرد که کی و چه پیشگوییاست بتوان

.مقدار شدید می شود

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بایست می اورژانسی های مراقبت چهو شدید خونریزی دچار که زنانی برای

گیرد؟ انجام اند شده آمیز مخاطره

بیمار وضعیت Stable کردن

خونریزی محل تعیین

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کمک بخواهیدبرای stable کردن بیمار Volume expansion .بدهیم

یا بزرگتر)گاهی اوقات 18ایجاد راه وریدی با سوزن شماره خونریزی بحدی است که باید چند رگ گرفته و با سرعت

مناسب مایع را جایگزین کردرینگر الکتات- انفوزیون سریع سالن

انفوزیون سریع خونانجام آزمایشات الزم

ارسال نمونه برای گروه خونی و کراس مچ حداقل چهار واحد شمارش پالکت، سطح PTT وfDP CBC، PT ،خون

،فیبرینوژنمیلی لیتر خون در داخل لوله فاقد مواد آنتی کواگوالنت 5تهیه

دقیقه بعد ازنظر ایجاد لخته10- 15و مشاهده آن کنترل حجم ادرار

ارزیابی سالمت جنین و سن حاملگی

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اگر خونریزی متوقف نشد و زایمان شروع .نشدسریع ختم حاملگی داده شود

در صورتی که بیمار بتواند جراحی را تحمل کند باید سریع سزارین گردد

اگر زایمان شروع شده باشد در حالتdouble set-up بیمار را معاینه می کنیم

برای تعیین علت خونریزیاگر خونریزی متوقف شد و یا کم شد و بیمار

و ضربان قلب جنین خوبست اقدام الزم را برای تعیین محل خونریزی انجام دهید

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اثر جنین روی تواند می مامائی خونریزیبه باعث یا باشد جنین داشته افتادن ، مخاطره

. در بنابراین شود نوزاد بیماری و جنین مرگزایمان برای تیمحین در احیاءمناسب نوزاد

اتاقباشد آماده .زایمان

با بیمار وضعیت مورد صحبت در می� فامیلش کنیم

منفی درصورت خونی بودن گروه مثبت مادروکرد توجه باید رگام تجویز به نوزاد خونی .گروه

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ANTEPARTUM HEMORRHAGE

Placental Abruption Placenta Previa

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Causes of Obstetrical HemorrhagePlacental Abruption:Placental separation from its implantation site before delivery variously called placental abruption, abruptio placentae, accidental hemorrhage , abruptioplacentae

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COMPLICATIONS Shock Consumptive Coagulopathy Renal Failure Sheehan Syndrome

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Shockshock sometimes seen with placental abruption was disproportionate to the amount of hemorrhage. because placental thromboplastin enters the maternal circulation and incites intravascular coagulation hypovolemic shock is directly due to maternal blood loss.

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Consumptive Coagulopathy

Placental abruption is one of the most common causes of

clinically significant consumptive coagulopathy in

obstetrics.

In approximately a third of women with an abruption severe

enough to kill the fetus

there are measurable changes in coagulation factors.

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Renal Failureit is more common if treatment of hypovolemia is delayed or incomplete. most cases of acute kidney injury are reversible, however,

acute cortical necrosis, when it occurs, is usually caused by

placental abruption. Seriously impaired renal perfusion is the consequence of

massive hemorrhage. Because preeclampsia frequently coexists with placental

abruption, renal vasospasm and hypoperfusion are likely

intensified.

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Sheehan SyndromeSevere intrapartum or early postpartum hemorrhage rarely is followed by pituitary failure or Sheehan syndrome. characterized by :

failure of lactation, amenorrhea, breast atrophy, loss of pubic and axillary hair, hypothyroidism, adrenal cortical insufficiency.

exact pathogenesis is not understood,

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DIAGNOSIS

sonography confirmes clinical diagnosis in only 25 % of women

negative findings with sonographic examination do not exclude placental abruption

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MANAGEMENT with massive external bleeding, intensive

resuscitation with blood plus crystalloid and prompt delivery to control hemorrhage are lifesaving for mother and hopefully, for fetus.

If the diagnosis is uncertain and the fetus is alive but without evidence of compromise, then close observation can be practiced in facilities capable of immediate intervention.

for the welfare of the distressed fetus, steps should be initiated immediately to correct maternal hypovolemia, anemia, and hypoxia to restore and maintain function of any placenta that is still implanted.

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PLACENTA PREVIA Placenta previa is used to

describe a placenta that is implanted over or very near the internal cervical os.

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Kinds:• Total placenta previa — internal os is

covered completely by placenta • Partial placenta previa —internal os is

partially covered by placenta • Marginal placenta previa —edge of the

placenta is at the margin of internal os • Low-lying placenta —placenta is implanted

in lower uterine segment such that the placental edge does not reach the internal os, but is in close proximity to it

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CLINICAL FINDINGS The most characteristic event is painless

hemorrhage usually appear near the end of the

second trimester and without warning bleeding maybe appear in the onset of

labor. it may vary from slight to profuse clinically may mimic placental abruption. Hemorrhage from the implantation site in

the lower uterine segment may continue after placental delivery because the lower uterine segment contracts poorly.

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DIAGNOSIS The simplest, safest, and most accurate

method of placental localization is provided by transabdominal sonography. (average accuracy is 96 %(

False-positive results are often a result of bladder distension , placenta is large and extended downward all the way to the internal cervical os.

transvaginal sonography Magnetic Resonance (MR( Imaging

(useful for diagnosis of placenta accreta (

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MANAGEMENTCesarean delivery is necessary

in practically all women with placenta previa

if fetus is reasonably mature :c/s The fetus is preterm and there

are no other indications for delivery :close observation

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POSTPARTUM HEMORRHAGE

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The single most significant cause of maternal death worldwide

One of the top three causes of maternal mortality in all of countries

Serious morbidity may follow PPH: ARDS, coagulopathy, shock, loss of fertility, sheehan syn.

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Incidence 

 The incidence varies widely: 1-5% of deliveries

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DefinitionThere is no single, satisfactory definition of PPH. PPH is excessive bleeding that makes the patient symptomatic

Most common definition: Excess blood loss (>500ml in NVD or >1000ml in C/S(

Decline in Hct of 10%(not a clinically useful definition(

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Types of PPH Primary PPH(early(: in the first 24 hours, 4-6% of pregnancies Secondary PPH(late(: between 24h to 6-12 weeks,(0.5-2% of pregnancies(

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Atony  The most common cause of PPH is uterine atony

Complicates 1 in 20 births

Responsible for at least 80 % of cases of PPH

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only a small proportion of women with any risk factors for PPH develop the disorder and many women without risk factors experience hemorrhage after delivery; thus,

knowledge of risk factors is not very useful clinically

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کاهش یا کننده پیشگیری اقداماتزایمان از بعد خونریزی دهنده

یوتروتونیک داروهای از استفادهجفت مشاهده

زایمانی کانال مشاهدهزایمان از بعد اول ساعت یک در دقیق کنترل

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Planning & prevention training team

Protocol for management of PPH

equipments of medications and instruments are readily available in Labor and delivery units

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DIAGNOSIS The differentiation between bleeding

from uterine atony and genital tract lacerations is tentatively determined by predisposing risk factors and the condition of 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.

careful inspection of the vagina, cervix, and uterus is essential.

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Management management of PPH is multifaceted and can involve many teams (obstetricians, nurses, anesthesiologists, blood bank personnel, laboratory medicine, surgical subspecialists, interventional radiology(. These teams are often required to work together under great stress and time pressures Coordination is essential and can be facilitated by protocols and flow diagrams that anticipate how these teams will communicate and function together.

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Management of postpartum hemorrhage at vaginal delivery

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Initial Interventions

Fundal massage  Massage should be maintained while other interventions are being initiated Intravenous access Laboratory tests  CBC, fibrinogen concentration , platelet count, PT, activated PTT, typed and crossed for multiple units of packed red blood cells.

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Fluid resuscitation and transfusion 

Monitoring vital signs Bladder catheter A large volume of crystalloid is

infused Replacement of blood

components

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Uterotonic drugsOxytocin • 40 units in 1 liter of normal saline • 10 units IM (including directly into the myometrium(.• Higher doses of oxytocin (up to 80 units in 1000 mL for a short duration (eg, over 30 minutesMethylergonovine • 0.2 mg IM (or directly into the myometrium( (never IV(. • May repeat at 2-4h intervals, as needed. If there has not been a good response to the first

dose, quickly move on to a different uterotonic agent.

Carboprost tromethamine (15 methyl-PGF2α((Hemabate( 250 mcg IM (or directly into the myometrium( every 15-90 min, [a total dose of 2 mg (8 doses(], no asthma.(75 % respond to a single dose(

move on to a different uterotonic agent if no response after one or two doses.  

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Uterotonic drugs(con(

Misoprostol (PGE1( Is most useful for reducing blood loss in settings where injectable uterotonics are unavailable. The optimum dose and route of administration are unclear. A dose of 400 mcg with the sublingual route is probably the optimal route of administration Can be given to women with hypertension or asthma. Maternal temperature should be monitored closely

Dinoprostone (PGE2( 20 mg vaginal or rectal suppository is an alternative PGE to misoprostol (PGE1(. Can be repeated at 2-4h intervals.

Carbetocin,

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Secondary Interventions

Provide adequate anesthesia Inspect for and repair cervical

and vaginal lacerations Exclude uterine rupture  Remove retained products of

conception Uterine tamponade   

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Uterine tamponade  Uterine tamponade is effective in many patients with atony or lower segment bleeding Balloons  Packs

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INDICATIONS FOR LAPAROTOMY 

If vital signs are worse than expected for the estimated blood loss,

the possibility of internal hemorrhage should be considered

When a vaginal laceration has extended above the fornix

Management of uterine atony unresponsive to the conservative interventions described

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ثبت دقیق مدارک پزشکی

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HYPOVOLEMIC SHOCK

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DEFINITIONS

Hypovolemic Shock :there is an inadequate circulating blood volume resulting from hemorrhage or acute volume depletion.

Class IV Class III Class II Class I  

>2,000 1,500- 2,000 750- 1,500 <750 Blood loss (mL)

>40 30- 40 15- 30 <15 Blood volum(%)

>140 >120 >100 <100 Heart rate (beats/m)

Decreased Decreased (mean arterial pressure

<60 mm Hg)

Normal (+ tilt)

Normal or increased

Blood pressure

Decreased Decreased Decreased Normal Pulse pressureAlways delayed Usually delayed May be

delayedNormal Capillary refill

Marked tachypnea; respiratory

collapse

Moderate to marked tachypnea

Mildly increased

Normal Respirations (breaths/m)

>35 30-40 20- 30 14- 20  Essentially anuric 5- 15 20- 30 >30 Urinary output

(mL/h)Lethargic, obtunded Confused Anxious Normal or

anxiousMental status

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Management of Shock

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A team approach staff trained in intensive care medicine

O R D E ROxygenate

Restore circulatory volume

Drug therapy

Evaluate response to therapy Remedy the underlying cause

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RESTORE CIRCULATING VOLUME Rapid volume repletion is indicated . Delayed therapy can lead to ischemic injury

and possibly to irreversible shock and multiorgan system failure.

1- to 2-liter fluid challenge with an isotonic electrolyte solution, preferably Ringer's lactate.

Fluid repletion continues at the initial rapid rate as long as the systemic blood pressure remains low.

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Clinical signs, BP, urine output,

mental status, and peripheral

perfusion guide resuscitation.

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inserting one or two large-bore (14- or 16-gauge) angiocatheters for volume replacement.

Trendelenburg position.

initial laboratory assessment CBC

differential and platelets, electrolytes,

BUN, Cr, calcium, magnesium, glucose,

phosphate, and, where indicated, liver

function studies, clotting profiles, serum

lactate, and blood cultures.

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whole blood transfusion is standard .

Packed red blood cells (PRBC) have a

volume of 200 to 250 mL and a hematocrit of 70%.

normal saline+ PRBCs are the component of choice for hemorrhagic shock.

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oxygen-carrying capacity is met in most healthy patients with a hemoglobin of 7 g/dL, then transfusion for moderate anemia (8 to 10 mg/dL) is no recommended. but, correction of anemia is important .

In critically ill patients and those with significant underlying cardiac disease, RBC transfuse to maintain hemoglobin levels between 10 and 12 g/dL

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For avoid the risks of hemolysis, agglutination, and clotting, all blood products should be administered through filtered lines with normal saline without electrolyte or drug additives.

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PREVENTION OF HYPOTHERMIA

Rapid transfusion of multiple units of

chilled blood may reduce the core

temperature abruptly and can lead to

cardiac arrhythmias . hypothermia interfere with the normal

functioning of the coagulation system.

A blood warmer should be used whenever

more than three units are transfused.

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Massive blood transfusion Massive transfusion, defined as the

replacement by transfusion of more than 50 percent of a patient's blood volume in 12 to 24 hours

Massive transfusion involves: the selection of the appropriate

amounts and types of blood componentsmanagement of bleeding and

coagulation abnormalitieschanges in ionized calcium, potassium,

and acid-base balance.

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RED CELL AND VOLUME REPLACEMENT  Correction of the deficit in blood volume with

crystalloid volume expanders will generally maintain

hemodynamic stability, while transfusion of red cells is

used to improve and maintain tissue oxygenation .

Each unit of packed cells contains 200 mL of red cells,

will raise the hematocrit by 3-4 % unless there is

continued bleeding.

At rest, oxygen delivery is normally four times oxygen

consumption. if intravascular volume is maintained

during bleeding oxygen delivery will be adequate until

the hematocrit falls below 10 percent.

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COAGULATION PROTEINS  there will be 10 percent decrease in the

concentration of clotting proteins for each 500 mL of blood loss .

Additional bleeding based solely on dilution can occur when the level of coagulation proteins falls to 25 percent of normal. This usually requires 8 to 10 units of red cells in an adult.

Thus, the PT, aPTT, and fibrinogen should be monitored in patients receiving massive blood transfusions of this magnitude.

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Two units of FFP should be given if the values exceed 1.5 times control.

Each unit will increase the clotting protein levels by 10 percent.

Cryoprecipitate may be used when fibrinogen levels are critically low (<100 mg/dL)

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PLATELET COUNT  A similar dilutional effect on the platelet

concentration can be seen with massive transfusion .

each 10 to 12 units of transfused red cells can produce a 50 percent fall in the platelet count; thus, significant thrombocytopenia can be seen after 10 to 20 units of blood.

with platelet counts below 50,000/microL. six units of random donor platelets, or one unit of apheresis platelets, should be given.

each unit should increase the platelet count by 5000 to 10,000/microL.

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