Postpartum Hemorrhage Dr.B Khani MD

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

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

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

Uterine Atony: Ergot Derivatives 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  myometrial intracellular free Ca++, enhance action of other oxytocics Side effects: fever, nausea/vomiting, diarrhea 15-methyl PG F2 (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 Vaginal: associated with forceps, vacuum, prolonged 2nd stage, multiple gestation, PIH Rx: I & D and packing Vulvar: bleeding from branches of pudendal arteries 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 Obstetric management: manual removal, oxytocin 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 Definitions: Risk factors: accreta vera: adherence of placenta to myometrium increta: invasion of placenta into myometrium percreta: invasion of placenta to/thru the serosa Risk factors: prior uterine trauma + placenta previa

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

Uterine Inversion Low mortality Risk factors: uterine atony inappropriate fundal pressure unbilical cord traction uterine anomaly 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 Uterine arteries are branches of internal iliacs (major supply to uterus) Ovarian arteries also contribute during preg. 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)