1. Obstetric Haemorrhage Case Illustration
MCQ
DR MANAL Behery ,
Zagazig University 2013

2. CASE 1 :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.
A 21-year-old nulliparous patient at 41 weeks’ gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis. After placental separation, profound uterine atony is noted, and the patient be-gins to hemorrhage. The atony is unrespon-sive to bimanual massage, intravenous oxy-tocin, and intramuscular methylergonovine. What can be done to stanch the flow?

3. Placenta Previa Placental Abruption Uterine Rupture Vasa Previa
What is the “Differential Diagnosis”?
Placenta Previa
Placental Abruption
Uterine Rupture
Vasa Previa
Laceration
Vaginal mass
A 21-year-old nulliparous patient at 41 weeks’ gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis. After placental separation, profound uterine atony is noted, and the patient be-gins to hemorrhage. The atony is unrespon-sive to bimanual massage, intravenous oxy-tocin, and intramuscular methylergonovine. What can be done to stanch the flow?

4. 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 CS, curettages , myomectomy
Types?
Complete previa (20-30%)
Partial previa (does not completely cover)
Marginal (proximate to os)
Management:
pelvic rest, US, IV, T+S, C/S

5. Associated Conditions
Placenta accreta, increta, percreta
Risk increase w/ inc no. of prior CS
PP+unscarred uterus-5 % risk of accreta
PP+one previous C/D-24% risk of accreta
PP+two previous C/D-47% risk of accreta
PP+three previous C/D-50% risk of accreta
PP+four previous C/D-67% risk of accreta
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

6. Associated Conditions
Vasa Previa
Vessels traverse the membranes
in the lower uterine segment in
advance of the fetal head.
Rupture can lead to fetal exsanguination
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

7. 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

8. 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???

9. Uterine Rupture Associated with Prior CS 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.

10. CASE 2 Uterine atony leads to heavy bleeding
A 21-year-old nulliparous patient at 41 weeks’ gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis.
After placental separation, profound uterine atony is noted, and the patient begins to hemorrhage. The atony is unresponsive to bimanual massage, intravenous oxytocin, and intramuscular methylergonovine.
A 21-year-old nulliparous patient at 41 weeks’ gestation delivers vaginally after a prolonged second stage and chorioamnio-nitis. After placental separation, profound uterine atony is noted, and the patient be-gins to hemorrhage. The atony is unrespon-sive to bimanual massage, intravenous oxy-tocin, and intramuscular methylergonovine. What can be done to stanch the flow?

11. What can be done to stop the flow

12. A stepwise approach to bleeding caused by persistent uterine atony
Apply direct pressure
to the uterine cavity
STEP 3
Control the blood supply
to the uterus
STEP 4
Place uterine
compression sutures
STEP 5
Perform hysterectomy
STEP 1
Identify source of bleeding,administer uterotonic drugs

13. A stepwise approach to bleeding caused by persistent uterine atony
Identify source of bleeding
administer
Uterotonic drugs
STEP 2
Apply direct pressure
to the uterine cavity
STEP 3
Control the blood supply
to the uterus
STEP 4
Place uterine
compression sutures
STEP 5
Perform hysterectomy

14. CASE3 Postpartum hemorrhage with Hypovolemic shock
A 35 year old womanin her 4th pregnancy, had a history of PPH in her previous pregnancies.
She was diagnosed to have pre eclampsia during this pregnancy and was on oral antihypertensive medication.
At 38 weeks of gestation she was admitted and LABOR was induced with prostaglandins
A 35 year old womanin her 4th pregnancy, had a history of PPH in her previous pregnancies.
She was diagnosed to have pre eclampsia during this pregnancy and was on oral antihypertensive medication. At 38 weeks of gestation she was admitted and LABOR was induced with prostaglandins.

15. The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.
Exploration did not reveal any retained products.
The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.
The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.
Exploration did not reveal any retained products.
The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

16. She was transferred to a general hospital for further resuscitation but arrived in a moribid state and signs of hyovolemic shock was evident
What should be your first step of management?
The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.
Exploration did not reveal any retained products.
The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

17. At ANE: INITIAL ASSESSMENT AND START BASIC TREATMENT
Call for help
Assess Airway, Breathing, Circulation [ABC]
Provide Supplementary Oxygen
Obtain an intravenous line
Start fluid replacement with IV crystalloid
Monitor Vital Sign
Catheterize bladder and monitor urine output
Assess need for blood transfusion
Lab test
FBC, Coagulation
Blood Group
Cross Match

18. ANE to OT: TEMPORIZING AND TRANSFER INTERVENTION
Ready to refer
Drugs
Uterine Massage
Bimanual Uterine Compression
External Aortic Compression
Intrauterine Balloon / Condom
To OT
ANE to OT: DRUGS OF CHOICE
Oxytocin
Ergometrine
Prostaglandin
Misoprostol
PG F2alpha
Tranexamic acid
If not available or bleeding still continue from previous drugs
ANE to OT: TORRENTIAL BLEEDING
Uterine packing – balloon, tampone, Torpin packer.

19. CASE 4:
A 30 year women in her third pregnancy at 38 weeks of gestation came in labour at a district hospital. Her antenatal period had been uneventful.
She delivered vaginally. With active management of 3rd stage and the placenta was delivered by CCT.
A 35 year old womanin her 4th pregnancy, had a history of PPH in her previous pregnancies.
She was diagnosed to have pre eclampsia during this pregnancy and was on oral antihypertensive medication. At 38 weeks of gestation she was admitted and LABOR was induced with prostaglandins.

20. After the placenta was delivered , there was active bleeding from the vagina. A green cannula was inserted and the on-call doctor was informed.
Over the phone the doctor ordered for uterine massage to be done ,IV ergometrine 0.5mg and IV Pitocin 40 unit in 500mls NS .
The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.
Exploration did not reveal any retained products.
The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

21. Blood pressure was normal but the pulse rate was 96 b/min.
Abdominal examination done showed that the uterus was contracted. Despite that the patient was still actively bleeding.
Another IV line was inserted and blood was sent for CBC, GXM and PT/PTT. She was given NS running fast.
The labour was uneventful and she delivered The labour was uneventful and she delivered a 3.9kg baby. There was massive bleeding after her delivery.
Exploration did not reveal any retained products.
The uterus remained atonic despite repeated injections of ergometrine and an oxytocin infusion. No blood or blood products were available.

22. Interesting, right?
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