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OBSTETRICS & GYNECOLOGY

POSTPARTUM HEMORRHAGE
POSTPARTUM HEMORRHAGE (OB) It is an event rather than a diagnosis, and when
DR. FAV =
encountered, its etiology must be determined.
NOVEMBER 5, 2018 O
Traditionally, any blood loss greater than normal is
-

PPT, Lecture notes, Williams 25th edition considered postpartum hemorrhage. (blood loss of
more than 500 cc after NSD and more than 1000
cc after CS delivery.)
3 Major Causes of Maternal Mortality
ooo
Hemorrhage- single most important cause
Hypertension
Manner of Delivery Normal Blood Loss
Infection NSD 500 mL
CS 1000 mL

: : : ::
"
÷÷ Bleeding within the first 24 hours is designated
o postpartum hemorrhage and after 24 hours
early
is designated as late o postpartum haemorrhage
But the estimated blood loss is commonly
underestimated
Tai wit da 90
,

A treacherous feature of ostpartum hemorrhage is


the failure of the pulse and blood pressure to
undergo more than moderate alterations until
large amounts of blood have been lost
O a-
According to the ACOG, postpartum hemorrhage
is defined as cumulative blood loss >1000 mL
accompanied by signs and symptoms of
-

hypovolemia
-

Normal Pregnancy Induced Hypervolemia


30-60% of the blood volume
1500-2000 ml
This is different for hypertensive mothers, where
the blood loss is only 10%
-

* More Accurate Estimate of Blood Loss

0-0-7
* Blood Loss = Calculated Hypervolemia = 500mL
(For each 3% volume drop in Hct)
Whenever the postpartum hematocrit is lower
than one obtained on admission or delivery, blood
loss can be estimated as the sum of the calculated
pregnancy-added volume plus 500 mL for each 3
volume percent decline of the hematocrit.
-

Example:
Hct on Admission: 0.34
Hct on Postpartum: 0.28 0.06

@
Volume that is dropped = 0.34-0.28 = 0.6 drop in
hct
Then you compute for each 3% volume drop so

*
you divide: 6/3 = 2
Blood loss = 1500mL + 500 ml (x2)
=1500 + 1000 = 2500mL
For some, they will just look at the os, on how
much it was soaked then they will just multiply it

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o -

-
O -
I
When excessive hemorrhage is suspected in high- Enlarged, boggy uterus –
risk women, crystalloid and blood are promptly
-
pathognomonic sign
administered or suspected hypovolemia. above the umbilicus
not soft (just like water balloons)
Hemostasis at The Placental Site
Most important for activating hemostasis, Risk Factors:
contraction and retraction of the myometrium to Overdistended Uterus Macrosomia
compress large vessels and obliterate their C to hypotonia after delivery)
(prone Polyhydramnios
lumens
- -

Multiple fetuses
Cells that invade the decidua and the Uterine activity Uterine
myometrium, coming from the outer cell Hypertonus
trophoblast (inner cell – blastocyst) Uterine Hypotonus
Trophoblast invades the myometrium as well as HighOparity (more than 4)
-

the spiral arterioles, so maternal vessels are History of a prior postpartum


opened which are now called sinuses hemorrhage (prior history of

e-
These vessels have no muscular layer because of delivery with blood
their remodeling by trophoblasts, which creates transfusion)
a low-pressure system.

EE
Attempts to hasten placental
With placental separation, these vessels at the delivery (such as manual

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implantation site are avulsed, and hemostasis is
* achieved first by myometrial contraction, which
compresses these large vessels.
traction and if done abruptly
may cause uterine inversion;
administration of
Compression is followed by clotting and prostaglandins or oxytocin)
obliteration of vessel lumens.
If, after delivery, the myometrium contracts

EE
Duncan mechanism of placental separation - blood
vigorously, fatal hemorrhage from the placental from the implantation site may escape into the
implantation site is unlikely. vagina immediately
Importantly, an intact coagulation system is not Schultze mechanism – blood remains concealed
necessary for postpartum hemostasis unless behind the placenta and membranes until the
there are lacerations in the uterus, birth canal, placenta is delivered
or perineum. -

Separation and delivery of the placenta by cord


- Uterus: should be in the
Well Contracted traction, especially when the uterus is atonic, may
hypogastric area, slightly below the umbilicus, cause uterine inversion.
-

has to be stone hard, uterus has to be -

tetanically =contracted or else the patient will


Management After Delivery of the Placenta
suffer from hemorrhage.

Adherent pieces of placenta or large blood clots


prevent effective contraction and retraction of
the myometrium, impairs hemostasis at the
implantation site postpartum hemorrhage
- fragments - one of the
Retained placental
causes of postpartum haemorrhage; so after
delivery, make sure that the uterine cavity is
clear of any placental fragements or blood clot

UTERINE ATONY

Failure ofothe uterus to contract properly after


-

delivery
Most⇐ common cause of obstetrical hemorrhage
Typical Findings:

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The fundus should always be palpated to make - Side effects: diarrhea, hypertension, vomiting,
certain that the uterus is well contracted. If it’s not,
-
fever, flushing, and tachycardia, pulmonary
then fundal massage is indicated.
-
airway and vascular constriction
- should not be used for asthmatic women and
If heavy bleeding persists after delivery of the those with suspected amnionic fluid embolism
newborn and while the placenta remains partially or - Relative contraindications: renal, liver, and
totally attached, then manual placental removal is cardiac disease
indicated.
4. o
Carbetocin
Manual removal of placenta. - Oxytocin derivative
- the fundus. The other hand is
-

A. One hand grasps -


- Very, very potent; more potent than oxytocin
inserted into the uterine cavity, and the fingers
-
- Given IV
are swept from side to side as they are
advanced. 5. o
Dinoprostone (PGE2)-

B. When the placenta has become detached, it is - 20 mg suppository


grasped and removed. - Typically causes diarrhea or vigorous vaginal
bleeding
Uterotonic Agents - Another IV PGE2 is suprostone
Medications to cause the postpartum uterus to
contract 6. T (PGE1) - Cytotec
Misoprostol -

400 ug tablet (2 tablets) trans rectus moved


'
- goody
.

1. O
Oxytocin - Unfortunately has already been banned but it’s
- 20U of Oxytocin in 1000 mL of lactated Ringer or very effective, now it’s a restricted drug
normal saline proves effective when - administered rectally to avoid being washed out
administered intravenously at approximately by blood
10mL/min (200mU of oxytocin per minute)
simultaneously with effective uterine massage. Bleeding Unresponsive to Oxytocins * fun dal massage
- Oxytocin is never given as an undiluted bolus 1. Initiate bimanual uterine compression (posterior
-

dose because serious hypotension or cardiac uterine wall is massaged by one hand on the
arrhythmias can develop. abdomen, while the other hand is made into a fist
- IV or IM and placed into the vagina. Fist kneads the anterior
- In normal labor, we only use 10U of oxytocin or uterine wall through the anterior vaginal wall and
1 ampule the uterus is also compressed between the 2 hands)
- With uterine atony, you add another ampule so 2. Call for help (obstetrical and anesthesia team; call
20U or 2 ampules in 1 L of D5LR or NSS for whole blood or packed RBCs)
- Usually we do is fast drip of 100cc 3. Establish 2 IV lines
4. Begin blood transfusion
2. O Derivatives
Ergot 5. Explore the uterine cavity manually for retained
- 0.2 mg methyergonovine, IM placental fragments or lacerations
- avoid at women with hypertension
-
6. Thoroughly inspect the cervix and vagina for
- Second-line treatment lacerationsurine oath
.

- If given IV, may cause dangerous hypertension, 7. Insert IFC to monitor urine output
especially in women with pre-eclampsia. 8. Begin volume resuscitation
in Methergine Toi

① 3. Carboprost- PGhiw
6*0×9100 F2A (Hemabate)
- 250 ug IM q15-90 minutes. Maximum of 8 doses
- Widely available especially in public
-
hospitals B
- If you have the risk factors mentioned earlier,
you give the 125ug IM as prophylaxis but if
-

uterine atony is already present, you give 250ug


-
dose. If it did not succeed, give another IM up to
8 doses but do not wait for 8 doses, move on to
another option

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- give the appearance of suspenders, they are
also called braces
- Possible complications: uterine ischemic
necrosis with peritonitis, uterine wall defects,
uterine cavity synechiae

Step 1. Beginning below the incision, the needle pierces


the lower uterine segment to enter the uterine cavity.
Step 2. The needle exits the cavity above the incision.
The suture then loops up and around the fundus to the
posterior uterine surface.
Step 3. The need le pierces the posterior uterine wall to
reenter the uterine cavity. The suture then traverses to
the opposite side within the cavity.
Step 4. The needle exits the uterine cavity through the
- posterior uterine wall. From the back of the uterus, the
suture loops up and around the fundus to the front of
the uterus.
Step5. The needle pierces the myometrium above the
incision to reenter the uterine cavity.
Surgical Management of Uterine Atony Step 6. The needle exits below the incision and the
Uterine artery ligation sutures at points 1 and 6 are tied below the incision. The
hysterotomy incision is then closed in the usual fashion.

÷÷::÷
o'clock
'

d
'

use Absorbable suture


-
-
uterus 8 uterine & ovarian

anastomosis

- The uterus has 2 major blood supply coming


from the Uterine artery and Ovarian artery
- Cutting the blood supply going to the uterus to
lessen the blood loss After CS
- used primarily for lacerations at the lateral part
of a hysterotomy incision
- less helpful for hemorrhage from uterine atony Uterine Packing
Internal iliac artery ligation call subspecialist very hard sur
, - For significant bleeding refractory to suture or
- source of uterine artery, the goal is also to
-

topical hemostats
lessen the blood supply and blood loss -
-

Rolls of gauze are packed to provide constant local


Uterine Compression Suture (B-lynch) MB OU Boser globe pressure and may serve as a temporizing step
- uses a no. 2 chromic suture to compress the prior to interventional embolization
anterior and posterior uterine walls together (so - may be left for 24-48 hrs.
it uses a thicker, non-absorbable suture)

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- If the patient is stable and bleeding appears to vessel becomes bigger in the periphery, there might
have stopped, packing is removed. be an accessory lobe. Do manual curettage and if
you were able to palpate the accessory lobe
-
Bakri- Postpartum Balloon attached, then you do incision curettage

PLACENTA ACCRETA, INCRETA, PERCRETA


RETAINED
Accreta - placentalPLACENTAL FRAGMENTS
villi are attached to the
myometrium
Increta - placental villi invade the myometrium
Percreta - placental villi penetrate the myometrium
*

T.im
hysterectomy . . .
.
.im#.......:::::
Total Placenta Accreta- involves all lobules do

Partial Pacenta Accreta- involves few to several


lobules
Focal Placenta Accreta- involves only a single lobule
- inserted and inflated to tamponade the 00
Total and Partial: Hysterectomy
endometrial cavity and stop bleeding
Risk Factors:
- Insertion requires 2-3 team members: 1st
performs abdominal US during the procedure. The
- -
Previous cs delivery - MC
- Placenta previa Defective decidua
2nd places the deflated balloon into the uterus
- Precious uterine curettage
and stabilizes it. The 3rd member instills fluid to
- > gravida 6
inflate the balloon, rapidly infusing at least 150 mL
- maternal age >35
followed by further instillation over a few minutes
- elevated MSAFP and B-HCG levels
for a total of 300 to 500 mL to arrest hemorrhage
- remove the balloon after approx. 12 hrs.
Clinical Course:
- non-invasive, similar to IFC but the balloon is
- Cesarean scar pregnancy
bigger, aim of this procedure is compression from
- Uterine rupture
inside the uterus
- Antepartum hemorrhage and Placenta Previa
- Postpartum hemorrhage
If all does not work, the endpoint is do Hysterectomy
How long should you wait before deciding to open Diagnosis:
the uterus? Medications should work within 10 - mins. Sensitivity
If not, surgical management is warranted. Do not
Ultrasound 33%
wait long to avoid complications such as
Doppler 100% with 78% positive predictive value
hypovolemic shock. If it reaches irreversible shock,
patient can die.
st
Atony happens usually within the 1 2 hrs. after o
2 Factors Highly Predictive of Myometrial Invasion

:-O
- a diameter of <1mm between the uterine serosa-
placental delivery -
bladder interface and the retroplacental vessels
Lowering bp, signs of hypotension, tachycardia,
- large intraplacental lakes
uterine tenderness do bimanual compression and
call for help

RETAINED PLACENTAL FRAGMENTS

A common cause of lateO postpartum hemorrhage


-
Retention of a succenturiate lobe (accessory lobes)
Management: completion curettage
-
nd
2 most common cause
Role of the clerk after delivery is to inspect the
placenta, the fetal surface which is shiny, umbilical
cord, vessels which becomes smaller and smaller
until it reaches the periphery. If you notice that the
MC : AccxtaGnhnwPor
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* hypervascularity of the uterine serosa-bladder wall How long do you wait for placenta to - separate?
interface had the highest positive- and negative- Average is 5 mins. but as long as the patient is


predictive values for placenta percreta. stable, wait for 5-15 mins.

MRI traction
o
If placenta does not separate, do gentle controlled

- An adjunct to diagnosis when sonography is Upon palpation, there is an indentation above the
inconclusive fundus which suggests an inverted uterus

Management
- Thorough pre-operative assessment better
planning
- ie
BLOOD!!!
- Presence of the following: gyne-oncologist,
surgeon, urogynecologist

#Tovaon9
Placenta Previa- 2 units of blood
& Placenta Accreta- 4 units of blood Hysterectomy

Placenta Percreta- 8 units of blood

Management:
1. Immediate blood replacement therapy


2. Prompt hysterectomy management of choice
In Percreta, it is difficult to perform hysterectomy so
the option is to leave the placenta behind and wait
for it to become small then that’s the time you do
hysterectomy
3. Uterine or internal iliac artery ligation or
angiographic embolization Management:
4. Conservative management: leave the placenta 1. Call for help!!! (Anesthesia and other physicians)
in situ then close the incision 2. Insert double IV for crystalloids and blood
o
5. Methotrexate therapy to resorb the placenta 3. The recently inverted uterus with placenta
already separated from it may often be replaced
UTERINE INVERSION by simply pushing upon the fundus with the palm
RETAINED
Almost PLACENTAL
always the FRAGMENTS
consequence of strong traction on of the hand and finger in the direction of the long
the umbilical cord attached to a placenta implanted axis of the vagina
in the fundus
-
* need thepaoperte.ch#igue- J
4. If still attached, DON’T REMOVE THE PLACENTA
until the infusion systems are operational, fluids
Risk factors include alone or in combination: are being given, and a uterine relaxing agent has
1. fundal placental implantation, been administered (tocolytic - drugs such as
2. uterine atony,
3. cord traction applied bore placental separation,
(
terbutaline, magnesium sulfate, or nitroglycerin)
(fentanyl, oxytocin) notorious pushback Ya
4. abnormally adhered placentation such as with 5. After removing the placenta, steady pressure
the accrete syndromes with the fist is applied to the inverted uterus in
an attempt to push it up into the dilated cervix.
Mechanism of Placental Separation Two fingers are rigidly extended to push the
✓a,;gn
1. Uterus becomes round and globular - uterine sign center of the fundus upward
6. As soon as the uterus is restored to its normal
2. Sudden gush of blood
3. Uterus goes back to the pelvic cavity configuration, the uterine relaxing agent is
4. Lengthening of the cord cord sign
-

stopped. Oxytocin infusion is begun while the


fundus is maintained in its normal anatomical

Ey
Central separation: Schultze position (return the uterus first before giving
=
Peripheral separation: Duncan uterotonics)

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Surgical Intervention PUERPERAL HEMATOMAS
Huntington- procedure - application of RETAINED
One of the PLACENTAL
complications of lacerations -is hematoma
FRAGMENTS
atraumatic clamps to each round ligament and It usually happens when you repair and suture the
upward traction or placing a deep traction laceration but was not able to notice that there is a
suture in the inverted fundus or grasping it with deeper laceration
tissue forceps.
Haultain-incision - sagittal surgical cut made Risk factors:
posteriorly through the muscular ring to release Nulliparity, episiotomy and forceps delivery
constriction ring that prohibits repositioning. Hematomas may develop following injury to a
blood vessel without laceration of the superficial
tissue
GENITAL TRACT LACERATIONS
RETAINED PLACENTAL
Etiology FRAGMENTS
Diagnostic Management Classification of Hematomas: .
Aid
O branches of the pudendal
Vulvar: often involve e

Perineal Injury to the Thorough Suturing artery, including posterior rectal, transverse

O
-
-

Lacerations lower portion examination


-
perineal, or posterior labial artery
of the vagina Vulvovaginal
and the Paravaginal: involve the descending branch of the
perineal body uterine artery
Vaginal Laceration Thorough Extensive Retroperitoneal- you have to do surgical
lacerations involving the inspection of repair of the laparotomy

O= ÷:÷÷÷÷÷÷÷
middle or the upper laceration
upper third of vagina Diagnosis: . .
the vagina

O
Severe perineal pain and rapid appearance of a
Injuries to Difficult Cervical Laparotomy tense, fluctuant tumor covered by discolored skin
the
cervix
forceps
rotation or
inspection
=
Intrauterine
exploration
Symptoms of pressure or inability to void should
prompt a vaginal examination
deliveries Surgical
When the hematoma extends upward between
performed =
repair
the folds of the broad ligament, it may escape
incompletely
detection unless a portion of the tumor can be felt
e-
Colporrhexis - cervix entirely or partially avulsed on abdominal palpation or unless hypovolemia
from the vagina in the anterior, posterior, or lateral develops
fornices tense, tender swelling of varying size rapidly
Annular or circular detachment- rare injury; entire develops, encroaches on the vaginal lumen, and
vaginal portion of the cervix is avulsed causes overlying skin or epithelium to become
Blood vessels are located in the 3 o’clock and 9 * ecchymotic
o’clock so there is more hemorrhage pelvic pressure, pain, or inability to void
O
Most common symptom: Severe Perineal Pain
-

Treatment
Smaller hematomas (and do not expand)-
observation, ice pack
Expanding/large hematomas, and pain is severe –
O
you have to open up, look for the bleeders, ligate,
then suture ± . .

The cavity may be obliterated by mattress sutures

UTERINE RUPTURE
RETAINED
o
Complete PLACENTAL
Uterine FRAGMENTS
Rupture- all layers of the uterine
wall separated (if you can already see the arm in the
cervix, meaning the serosa has been traversed so

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therefore, it’s complete rupture); (perinatal
mortality is 75%)
o
Incomplete Uterine Rupture (Uterine dehiscence) -
First sign

e
Electronic fetal monitoring finding tends to be
sudden, severe heart rate decelerations that may
evolve into late decelerations, bradycardia, and
uterine muscle separated but visceral peritoneum is undetectable fetal heart action
intact. (serosa is still intact); (recoverable, baby can Cessation of contraction following uterine rupture
survive) Maternal hypovolemia from concealed

-
The most common cause of uterine rupture is hemorrhage
separation of a previous cesarean scar (cl Signs of Uterine rupture: pain, vaginal bleeding,
primary, defined as occurring in a previously intact changes in FHR, Diaphragmatic irritation,
or unscarred uterus, or may be secondary and continuous uterine contraction, hypovolemia
associated with a preexisting incision, injury, or * First0sign of uterine rupture is Abnormal fetal
anomaly of the myometrium heart rate pattern then followed by pain, maternal
hypovolemia – blood loss is strictly concealed.
Classification of Causes of Uterine Rupture: •
Loss of fetal head station

Management:
In cases of scar separation without bleeding
following VBAC, exploratory laparotomy is not
indicated Vaginal Birth after CIS
With frank rupture during a trial of labor,
however, hysterectomy may be required
In selected cases, suture repair with uterine
preservation may be performed

rupture 6 To
Black – PPT purim as a

Red – Lecture -

CS parian rupture o mptms


Blue – Book pun or t

269 o

-END-

Diagnosis of Uterine Rupture:


Hemoperitoneum from a ruptured uterus may
result in irritation of the diaphragm with pain
referred to the chest

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