Obstetric Hemorrhage Abike James MD Assistant Clinical Prof. Obstetrics and Gynecology University of Pennsylvania

Third Trimester Bleeding A 32 yo G2P1 presents at 36 weeks complaining of bright red vaginal bleeding. Upon further questioning she does admit to having had some light bleeding on 1 to 2 occasions last week. Her previous pregnancy was delivered at term by a Classical Cesarean Section for footling breech presentation.

Differential Diagnosis? Placenta Previa Uterine Rupture Placental Abruption Vasa Previa Laceration Vaginal mass

Placenta Previa Painless third-trimester bleeding Complicates 4-6% pregnancies between 10 and 20 wks, 0.5% pregnancies >20 weeks Risk factors –Increasing parity, maternal age, prior c/s, curettages for sab’s/tab’s Placental tissue overlying the internal os. Types? –Complete previa (20-30%) –Partial previa (does not completely cover) –Marginal (proximate to os) Management: pelvic rest, u/s, IV, T+S, C/S

Associated Conditions Placenta accreta, increta, percreta –Risk inc w/ inc no. of prior c/s (50% risk in pt w/ previa and 2 prior c/s) Vasa Previa –Vessels traverse the membranes in the lower uterine segment in advance of the fetal head. –Rupture can lead to fetal exsanguination

Uterine Rupture Associated with Prior c/s Rates of uterine rupture? –Spontaneous rupture (no c/s history): 1/2000 (0.05%) –Low Transverse: 0.5%-1%risk rupture, VBAC 80% success rate –Classical C/s: 10% risk rupture, schedule amnio/c/s ~37 weeks.

Placental Abruption Premature separation of placenta Painful third-trimester bleeding Risk Factors – smoking, trauma, HTN cocaine, pprom, polyhydramnios, multiples Trauma evaluation – bleeding, contractions, abdominal pain and NRFHT in 4hrs U/s misses up to 50% of abruptions Management: IV, T+X, Continuous monitoring, c/s vs. vag delivery

Case Cont’d U/s reveals active, vertex fetus. Placenta anterior and free of os. Pt having contractions q 2-3 minuters. Bleeding increases. BP drops from 110/60 to palpable systolic pressure of 70. FHT drops from 120 to 90 bpm. What do you do???

Post Partum Hemorrhage A 34yo G6P6 patient at term has just delivered a 4000gm infant after second stage of labor lasting 3 ½ hours. The placenta delivered spontaneously and the patient is bleeding briskly. What is average EBL w/ SVD? –500cc What is average EBL w/ C/S? –1000cc

Classes of Hemorrhage Class 1 –<900cc –Minimal symptoms Class 2 – cc –Tachycardia, tachypnea Class 3 – cc –Overt Hypotension, cold, clammy skin Class 4 –2400cc –Shock, absent BP

Management Fluids –Crystalloid, open wide/bolus Labs –Cbc, coags, fibrinogen Transfuse PRPC’s FFP –Larger vol (250cc/unit, all coagulation factors) Cryopercipitate –Smaller volume (20cc/unit, many coagulation factors)

Differential Diagnosis Atony Uterine inversion Laceration (cervical, vaginal) Retained Placenta

Uterine Atony Risk factors – multiparity, multiple gestation, macrosomia, abruption, retained POC’s, placenta previa, induction (prolonged pitocin) Management –Bimanual exam/massage –IV acess/fluids –Oxytocin, methergine 0.2mg IM, Hemabate 250mcg IM, misoprostol 800 to 1000mcg rectally Laparotomy –Uterine artery ligation –B Lynch –Hysterectomy UAE

Uterine Inversion Inverted fundus extends beyond cervix (looks beefy red) Stop pitocin if infusing Replace uterus Relaxants if necessary (terbutaline, MgSo4, Nitrogylcerin) Anesthesia Laparotomy