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 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

Rationale (why we care….) 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!)

Vaginal Bleeding: Differential Diagnosis 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!)

Initial Management for Third Trimester Bleeding 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

Placental Abruption: Definition 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: Risk factors and associations Cocaine Maternal hypertension Abdominal trauma Smoking Prior abruption Preeclampsia Multiple gestation Prolonged PROM Uterine decompression Short umbilical cord Chorioamnionitis Multiparity

Placental Abruption: Symptoms Vaginal bleeding Abdominal or back pain Uterine contractions Uterine tenderness

Placental Abruption: Physical Findings Vaginal bleeding Uterine contractions Hypertonus Tetanic contractions Non-reassuring fetal status or demise Can be concealed hemorrhage

Placental Abruption: Laboratory 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: Diagnosis 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: Management 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

Placenta Previa: Definition 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: Incidence 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: Risk factors and associations Prior cesarean delivery/myomectomy Prior previa (4-8% recurrence risk) Previous abortion Increased parity Multifetal gestation Advanced maternal age Abnormal presentation Smoking

Placenta Previa: Symptoms 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: Physical Findings 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: Diagnosis 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: Management 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: Other considerations 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

Vasa Previa: Definition In cases of velamentous cord insertion fetal vessels cover cervical os

Vasa Previa: Incidence 0.1-1.0% Greater in multiple gestations Singleton - 0.2% Twins - 6-11% Triplets - 95%

Vasa Previa: Symptoms, Findings, Diagnosis Painless vaginal bleeding Fetal bleeding Positive Kleihauer Betke test Ultrasound Routine vs at time of symptoms

Vasa Previa: Management 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

Third Trimester Bleeding: Other Etiologies Cervicitis Infection Cervical erosion Trauma Cervical cancer Foreign body Bloody show/labor

Perinatal Morbidity and Mortality 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 Most common cause of DIC in pregnancy Massive hemorrhage --> risk of ARF, Sheehan’s, etc.

Postpartum Hemorrhage: Definition and Differential Diagnosis EBL >500 cc, vaginal delivery EBL >1000 cc, cesarean delivery Differential Diagnosis: Uterine atony Lacerations Uterine inversion Amniotic fluid embolism Coagulopathy

Risk Factors for Postpartum Hemorrhage Prolonged labor Augmented labor Rapid labor h/o prior PPH Episiotomy Preeclampsia Overdistended uterus (macrosomia, twins, hydramnios) Operative delivery Asian or Hispanic ethnicity Chorioamnionitis

(same overall mgmt regardless of delivery type) 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)

Uterine Atony 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!!!

Lacerations Recognition Perineal, vaginal, cervical All can be rather bloody! Assistance Lighting Appropriate repair Control of bleeding Identify apex for initial stitch placement

Uterine Inversion 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

Amniotic Fluid Embolism 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

Management of Shock Stabilize mother Monitor urine output 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 Volume Whole 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

Indications for Transfusion 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.

Management of Shock Risks of blood transfusion Infectious Disease Risk Factor Hepatitis 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

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