third trimester bleeding, postpartum hemorrhage, & shock management
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Third Trimester Bleeding, Postpartum Hemorrhage, & Shock Management. UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series. Objectives for Third Trimester Bleeding. List the causes of third trimester bleeding - PowerPoint PPT PresentationTRANSCRIPT
Third Trimester Bleeding, Postpartum Hemorrhage, & Shock Management
UNC School of MedicineObstetrics and Gynecology Clerkship
Case Based Seminar Series
Objectives for Third Trimester Bleeding
List the causes of third trimester bleeding Describe the initial evaluation of a patient with third
trimester bleeding Differentiate the signs and symptoms of third trimester
bleeding Describe the maternal and fetal complications of placenta
previa and abruption placenta Describe the initial evaluation and management plan for
acute blood loss List the indications and potential complications of blood
product transfusion
Objectives for Postpartum Hemorrhage
Identify the risk factors for postpartum hemorrhage Construct a differential diagnosis for immediate and
delayed postpartum hemorrhage Develop an evaluation and management plan for the
patient with postpartum hemorrhage
4-5% of pregnancies complicated by 3rd trimester bleeding
Immediate evaluation needed Significant threat to mother & fetus (consider
physiologic increase in uterine blood flow) Consider causes of maternal & fetal death Priorities in management (triage!)
Rationale (why we care….)
Common: Abruption, previa, preterm labor, labor
Less common: Uterine rupture, fetal vessel rupture, lacerations/lesions,
cervical ectropion, polyps, vasa previa, bleeding disorders Unknown NOT vaginal bleeding!!!
(happens more than you think!)
Vaginal Bleeding: Differential Diagnosis
Stabilize patient – two large bore IVs if bleeding is heavy, EBL is significant or patient is clearly unstable
Auscultate fetal heart rate - Confirm reassuring pattern Focused history PE
Vitals Brief inspection for petechiae, bruising Careful inspection of vulva Speculum exam of vagina and cervix – NO DIGITAL EXAM until r/o
previa Labs – CBC, coag profile, type and cross match Ultrasound exam to assess placental location and fetal condition
Initial Management for Third Trimester Bleeding
Separation of placenta from uterine wall Incidence
0.5-1.5% of all pregnancies Recurrence risk
10% after 1st episode 25% after 2nd episode
Placental Abruption: Definition
Cocaine Maternal hypertension Abdominal trauma Smoking Prior abruption Preeclampsia Multiple gestation
Prolonged PROM Uterine decompression Short umbilical cord Chorioamnionitis Multiparity
Placental abruption: Risk factors and associations
Vaginal bleeding Abdominal or back pain Uterine contractions Uterine tenderness
Placental Abruption: Symptoms
Vaginal bleeding Uterine contractions Hypertonus Tetanic contractions Non-reassuring fetal status or demise
Can be concealed hemorrhage
Placental Abruption: Physical Findings
Anemia May be out of proportion to observed blood loss
DIC Can occur in up to 10% (30% if “severe”) First, increase in fibrin split products Followed by decrease in fibrinogen
Placental Abruption: Laboratory Findings
Clinical scenario Physical exam
NOT DIGITAL PELVIC EXAMS UNTIL RULE OUT PREVIA Careful speculum exam
Ultrasound Can evaluate previa Not accurate to diagnose abruption
Placental Abruption: Diagnosis
Physical exam Continuous electronic fetal monitoring Ultrasound
Assess viability, gestational age, previa, fetal position/lie Expectant mgmt
vaginal vs cesarean delivery Available anesthesia, OR team for stat cesarean
delivery
Placental Abruption: Management
Placental tissue covers cervical os Types:
Complete - covers os Partial Marginal - placental edge at margin of internal os Low-lying
placenta within 2 cm of os
Placenta Previa: Definition
Most common abnormal placentation Accounts for 20% of all antepartum hemorrhage Often resolves as uterus grows
~ 1:20 at 24 wk. 1:200 at 40 wk.
Nulliparous - 0.2% Multiparous - 0.5%
Placenta Previa: Incidence
Prior cesarean delivery/myomectomy Prior previa (4-8% recurrence risk) Previous abortion Increased parity Multifetal gestation Advanced maternal age Abnormal presentation Smoking
Placenta Previa: Risk factors and associations
Painless vaginal bleeding Spontaneous After coitus
Contractions No symptoms
Routine ultrasound finding Avg gestational age of 1st bleed, 30 wks 1/3 before 30 weeks
Placenta Previa: Symptoms
Bleeding on speculum exam Cervical dilation
Bleeding a sx related to PTL/normal labor Abnormal position/lie Non-reassuring fetal status If significant bleeding:
Tachycardia Postural hypertension Shock
Placenta Previa: Physical Findings
Ultrasound Abdominal 95% accurate to detect Transvaginal (TVUS) will detect almost all
Consider what placental location a TVUS may find that was missed on abdominal
Physical/speculum exam remember: no digital exams unless previa RULED OUT!
Placenta Previa: Diagnosis
Initial evaluation/diagnosis Observe/admit to L&D IV access, routine (maybe serial) labs Continuous electronic fetal monitoring
Continuous at least initially May re-evaluate later if stable, no further bleeding
Delivery???
Placenta Previa: Management
Less than 36 wks gestation - expectant management if stable, reassuring Bed rest (negotiable) No vaginal exams (not negotiable) Steroids for lung maturation (<32 wks) Possible mgmt at home after 1st bleed
70% will have recurrent vaginal bleeding before 36 completed weeks requiring emergent cesarean
Placenta Previa: Management
36+ weeks gestation Cesarean delivery if positive fetal lung maturity by
amniocentesis Delivery vs expectant mgmt if fetal lung immaturity Schedule cesarean delivery @ 37 weeks Discussion/counseling regarding cesarean hysterectomy
Note: given stable maternal and reassuring fetal status, none of these management guidelines are absolute (this is why OB is so much fun!)
Placenta Previa: Management
Placenta accreta, increta, percreta Cesarean delivery may be necessary History of uterine surgery increases risk Must consider these diagnoses if previa present Could require further evaluation, imaging (MRI
considered now)
NOT the delivery you want to do at 2 am
Placenta Previa: Other considerations
In cases of velamentous cord insertion fetal vessels cover cervical os
Vasa Previa: Definition
0.1-1.0% Greater in multiple gestations Singleton - 0.2% Twins - 6-11% Triplets - 95%
Vasa Previa: Incidence
Painless vaginal bleeding Fetal bleeding
Positive Kleihauer Betke test Ultrasound
Routine vs at time of symptoms
Vasa Previa: Symptoms, Findings, Diagnosis
If bleeding, plan for emergent delivery If persistent bleeding, nonreassuring fetal status,
STAT cesarean… not a time for conservative mgmt!
Fetal blood loss NOT tolerated
Vasa Previa: Management
Cervicitis Infection Cervical erosion Trauma Cervical cancer Foreign body Bloody show/labor
Third Trimester Bleeding: Other Etiologies
Previa Decreased mortality from 30% to 1% over last 60 years Now emergent cesarean delivery often possible Risk of preterm delivery
Abruption Perinatal mortality rate 35% Accounts for 15% of 3rd trimester stillbirths Risk of preterm delivery Most common cause of DIC in pregnancy
Massive hemorrhage --> risk of ARF, Sheehan’s, etc.
Perinatal Morbidity and Mortality
EBL >500 cc, vaginal delivery EBL >1000 cc, cesarean delivery
Differential Diagnosis: Uterine atony Lacerations Uterine inversion Amniotic fluid embolism Coagulopathy
Postpartum Hemorrhage: Definition and Differential Diagnosis
Prolonged labor Augmented labor Rapid labor h/o prior PPH Episiotomy Preeclampsia Overdistended uterus (macrosomia, twins, hydramnios) Operative delivery Asian or Hispanic ethnicity Chorioamnionitis
Risk Factors for Postpartum Hemorrhage
Uterine Atony(same overall mgmt regardless of delivery type)
Recognition Uterine exploration Uterine massage Medical mgmt:
Pitocin (20-80 u in 1 L NS) Methergine (ergonovine maleate 0.2 mg IM)
Not advised for use if hypertension
Hemabate (prostaglandin F2 mg IM or intrauterine)
B-lynch suture (to compress uterus) Uterine artery ligation
Must understand anatomy Risk of ureteral injury
Uterine artery embolization Typically an IR procedure Plan “ahead” and let them know you may need them
Hysterectomy (last resort) Anesthesia involved
Whether in L&D room or the OR!!!
Uterine Atony
Recognition Perineal, vaginal, cervical All can be rather bloody!
Assistance Lighting Appropriate repair
Control of bleeding Identify apex for initial stitch placement
Lacerations
Uncommon, but can be serious, especially if unrecognized
Consider if difficult placental delivery Consider if cannot recognize bleeding source Consider… always! Delayed recognition is bad news Patient can have shock out of proportion to EBL
(though not all sources will agree on this)
Uterine Inversion
Management Call for help Manual replacement of uterus Uterotonics to necessary to relax uterus & allow
thorough manual exploration of uterine cavity IV nitroglycerin (100 g)
Appropriate anesthesia to allow YOU to manually explore uterine cavity Concern for shock… to be discussed (and managed by
the help you’ve called into the room!) Exploratory laparotomy may be necessary
Uterine Inversion
High index of suspicion Recognition Again… call for help! Supportive treatment Replete blood, coagulation factors as able Plan for delivery (if diagnose antepartum) if able to
stabilize mom first
Amniotic Fluid Embolism
Stabilize mother Large-bore IV x 2 Place patient in Trendelenburg position Crossmatch for pRBCs (2, 4, more units) Rapidly infuse 5% dextrose in lactated Ringer’s
Monitor urine output Ins/Outs very important
(and often not well-recorded prior to emergency situation -- how many times did she really void while in labor??? How dehydrated was she when presented???)
By the way… get help (calling for help works quickly on L&D!)
Management of Shock
Serial labs CBC and platelets Prothrombin time (factors II, V, VII, X {extrinsic}) Partial thromboplastin time (factors II, V, XIII, IX, X,
XI {intrinsic})
Management of Shock
Transfusion products
Product Content VolumeWhole blood RBCs, 2,3 DPG, coagulation factors (50
V, VIII), plasma proteins 500 cc
Packed RBCs RBCs 240cc
Platelets 55 x 106 platelets/unit 50cc
Fresh frozen plasma Clotting factors V, VIII, fibrinogen 200-250cc
Cryoprecipitate Factor VIII; 25% fibrinogen, von Willebrand’s factor
10-40cc
Management of Shock
No universally accepted guidelines for replacement of blood components
If lab data available, most providers will transfuse patients with hemoglobin values less than 7.5 to 8 g/dL
If no labs, it is reasonable to transfuse 2 units of packed red blood cells (pRBCs) if hemodynamics do not improve after the administration of 2 to 3 liters of normal saline and continued bleeding is likely.
Indications for Transfusion
Risks of blood transfusion
Infectious Disease Risk FactorHepatitis B 1/200,000
Hepatitis C 1/3,300
HIV 1/225,000
CMV 1/20
MTLV-1/11 1/50,000
Management of Shock
Risks of blood transfusion Immunologic reactions
Fever - 1/100 Hemolysis - 1/25,000 Fatal hemolytic reaction - 1/1,000,000
Management of Shock
Delivery Vaginally unless other obstetrical indication, i.e.
fetal distress, herpes, etc. Best to stabilize mother before initiating labor or
going to delivery
Management of Shock
Bottom Line Concepts
Common causes of third trimester bleeding - Abruption, previa, preterm labor, labor
NO DIGITAL EXAMS until placenta previa has been ruled out
Ultrasound – can use to evaluate previa but not accurate to diagnose abruption
Postpartum hemorrhage refers to EBL >500 cc, vaginal delivery or EBL >1000 cc, cesarean delivery
Most common cause of PPH – uterine atony No universal rule for when to transfuse – decision made with
clinical judgment and based on each patient’s individual circumstance and presentation
References and Resources
APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 23, 27 (p48-49, 56-57).
Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 12, 21 (p133-39, 207-11).
Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 10 (p128-136).
Baron F, Hill WC. “Placenta previa, placenta abruption”, Clinical Obstetrics and Gynecology, Sep 1998 41(3) pp527-532.
Benedetti T. Obstetric hemorrhage, in obstetrics: normal and problem pregnancies, Gabbe S, Niebyl J, Simpson J, 3rd ed. New York: Churchill Livingston 1996, pp161-184.
Hertzberg B. “Ultrasound evaluation of third trimester bleeding,” The Radiologist, July 1997 4(4) pp227-234.
Sheiner E, Shohan-Vardi I. “Placenta previa: obstetric risk factors and pregnancy outcome,” Journal of Maternal-Fetal Medicine, December 2001 10(6) pp414-418.
Jacobs, Allan J. “Management of postpartum hemorrhage at vaginal delivery.” UpToDate. May 2011