Postpartum Hemorrhage Dr B Khani MD Postpartum Hemorrhage

Postpartum Hemorrhage Dr. B Khani MD

Postpartum Hemorrhage u EBL > 500 cc u 10% of deliveries u If within 24 hrs. pp = 1 pp hemorrhage u If 24 hrs. - 6 wks. pp = 2 pp hemorrhage u Causes – uterine atony – genital trauma – retained placenta – placenta accreta – uterine inversion

Uterine Atony u Most common cause of pp hemorrhage u Contraction of uterus is 1 mechanism for controlling blood loss at delivery – oxytocin and prostaglandins u Risk factors – multiple gestation – chorioamnionitis – macrosomia – precipitous labor – polyhydramnios – tocolytics – high parity – halogenated agents – prolonged labor

Uterine Atony: Treatment u uterine massage u oxytocin: – produced by posterior pituitary – causes peripheral vasodilation, reflex tachycardia – administered diluted in IV fluid, not IV push – metabolized/excreted by liver, kidney, oxytocinase u ergot derivatives u prostaglandins u If drugs fail, embolization of arterial supply, ligation, or hysterectomy

Uterine Atony: Ergot Derivatives u ergonovine and methylergonovine (methergine) – act via -adrenergic mechanism – adverse effects: nausea/vomiting, vasoconstriction (including coronary), HTN, PAP – relative contraindications: chronic HTN, PIH, PVD, CAD – dose: 0. 2 mg IM (not IV), last 2 -3 hrs.

Uterine Atony: Prostaglandins u myometrial intracellular free Ca++, enhance action of other oxytocics u Side effects: fever, nausea/vomiting, diarrhea u 15 -methyl PG F 2 (Carboprost, Hemabate) – may cause bronchospasm, altered VQ, shunt, hypoxemia, HTN – 250 g IM or intramyometrially q 15 -30 min, up to max 2 mg. – contraindications: asthma, hypoxemia

Genital Trauma u Vaginal: associated with forceps, vacuum, prolonged 2 nd stage, multiple gestation, PIH – Rx: I & D and packing u Vulvar: bleeding from branches of pudendal arteries u Retroperitoneal: least common, most dangerous – laceration of branch of hypogastric during C/S (or uterine rupture) – Dx: CT – Rx: expl. lap. , ligation of hypogastric, hyst

Retained Placenta u Obstetric management: – manual removal, oxytocin u Anesthetic management: – epidural or spinal anesthesia, if not hypovolemic – or MAC – or GA (ketamine, RSI, intubate, 50% nitrous, fentanyl) – Uterine relaxation may be requested (NTG)

Placenta Accreta u Definitions: – accreta vera: adherence of placenta to myometrium – increta: invasion of placenta into myometrium – percreta: invasion of placenta to/thru the serosa u Risk factors: – prior uterine trauma + placenta previa

Placenta Accreta II u Placenta previa + prior C/S v. accreta risk: Number of prior C/S 0 1 2 3 4 u Rx: Incidence of accreta 5% 24% 47% 40% 67% uterine curettage, oversewing of plac. bed, usually hysterectomy (accreta is most common indication for C-hyst)

Uterine Inversion u Low mortality u Risk factors: – uterine atony – inappropriate fundal pressure – unbilical cord traction – uterine anomaly u Rx: replace the uterus, oxytocin, Hemabate, methergine – may need uterine relaxation transiently » NTG (50 -100 g IV) vs. halogenated agent » anecdotal reports of other nitrates, terb, Mg

Invasive Treatment Options for Obstetric Hemorrhage u Uterine arteries are branches of internal iliacs (major supply to uterus) u Ovarian arteries also contribute during preg. u Options – angiographic embolization – bil. surgical ligation of uterine, ovarian, internal iliacs (preserves fertility): 42% success – Cesarean or pp hysterectomy » EBL 2500 cc (emergent), 1300 cc (elective)