1. Bleeding in Pregnancy: Antepartum & Postpartum Hemorrhage
OB & GY Dept. First Hospital, Xi’An Jiao Tong University

2. Learning Objectives Definition of Post Partum Hemorrhage
Management of PPH
Risk Factors for PPH
Differential Diagnosis of Third Trimester Bleeding
Management of Placenta Previa and Abruptio Placenta

3. “Worst Case Scenario”
An insulin dependent diabetic was induced for suspect fetal macrosomia and delivered a 4300 gram male infant because of late decelerations. A low forceps delivery was done. An episiotomy was done. Thee was a Shoulder Dystocia. Immediately after delivery of the placenta the patient bled uncontrollably and the anesthesiologist yelled, “The patient is in shock.” There is a 4th degree perineal laceration and the uterus is “boggy” and there is a left side wall laceration as well.

4. Definitions of Postpartum Hemorrhage
Estimated blood loss
a. > 500 mL with vaginal birth
b. > 1000 mL with cesarean delivery
c. > 1500 mL with cesarean hysterectomy
Decline from antepartum to postpartum hematocrit of > 10%
Postpartum hematocrit < 27%
Transfusion of red blood cells

5. Risk Factors of Postpartum Hemorrhage: Results of Logistic Regression
Vaginal Birth
(N=9.598)
Cesarean Deliveries
(N=3.052)
Anesthesia (general vs. epidural) --
2.94
Amnionitis NS
2.69
Episiotomy (mediolateral vs. none/midline)
4.67
Labor abnormalities
Protracted active phase
Arrest of descent (present vs. absent)
2.91
2.40
1.90
Lacerations (cervical/vaginal/perineal vs. none)
2.05
Multiple gestations (twins vs. singletons)
3.31
Preeclampsia (present vs. absent)
5.02
2.18
Prior postpartum hemorrhage (present vs. absent)
3.55
Third stage (>30 minutes vs. <30 minutes)
7.56

6. Postpartum Hemorrhage
An event, not a diagnosis.
Excessive blood loss
Atony
Abnormal Implantation Site
Placenta Accreta
Uterine Inversion
Genital Tract Injury
Cervical or Vaginal Lacerations
Pelvic Hematoma

7. Postpartum Hemorrhage Vaginal Birth Antepartum - postpartum > 10% (Hct)
Risk Factors
Prolonged 3rd stage of labor
Preeclampsia
Mediolateral episiotomy
Combs CA et al, obstet Gnecol. 1991:77:63

8. Postpartum Hemorrhage C/S
Risk Factors
General anesthesia
Amnionitis
Preeclampsia
Combs CA et al, obstet Gynecol 1991:77;77

9. Postpartum Hemorrhage Vaginal Birth Postpartum Hct <27% or Blood Transfusion
Risk Factors
Estimated blood loss > 500 ml
Marginal previa
Placental abruption
Third stage of labor > 30 minutes
Chorioamnionitis
Nicol B et al obstet Gynecol 1997;90:514

10. Postpartum Hemorrhage Antepartum - Postpartum > 10% (Hct)
Risk Factors
Preeclampsia
Disorders of active phase of labor
Native American ethnicity
Previous PPH
Maternal weight > 250 lbs

11. Postpartum Hemorrhage
Knowing the risk factors associated with postpartum hemorrhage means the obstetricians can effectively manage at-risk patients.
One can ancticipate those patients where there is a greater likelihood of a postpartum hemorrhage

12. Postpartum Hemorrhage
Medical Management
Atony - Bimanual compression
- 15 methyl PGF 2: 0.25 mg 15’
IM or intra-myometrium
- Methylergonovine : 0.2 mg 1M
No IV => severe hypertension
- Misoprostol (100 mg) rectally

13. Postpartum Hemorrhage
Prevention
Vaginal deliveries
Active Management of 3rd stage of labor
Uterotonic agents
Cesarean deliveries
Spontaneous delivery placenta
Repair uterine incision in situ

14. Management of Postpartum Hemorrhage

15. Postpartum Hemorrhage
Surgical Management
Uterine artery ligation
Hypogastic artery ligation
Ovarian vessels
B-Lynch technique
Selective arterial embolization
Hysterectomy

16. Figure

17. Hematoma
Pelvic Hematoma
Vulvar
Vaginal
Retroperitoneal

18. Risk Factors Episiotomy Primiparity Preeclampsia Multiple gestation
Vulvovaginal varicosities
Prolonged 2nd stage of labor
Clotting abnormalities

19. Hematoma Vulvar hematoma
Laceration of vessels in the superficial fascia of pelvic triangle
Volume support
< 3 cm: observation
> 3 cm: surgical evacuation with suture closure and dressing compression

20. Hematoma Vaginal hematoma
Accumulation of blood above the pelvic diaphragm
More associated with forceps deliveries
Incision and evacuation
Vaginal packing for 12 – 18 hours

21. Hematoma Retroperitoneal hematomas Sudden onset of hypotensive shock
Laceration of a branch of hypogastric artery
Inadequate hemostasis of the uterine arteries (C/S)
Rupture of low transverse scar
Surgical exploration and ligation of the hypogastric vessel

22. Potential Complications of Puerperal Hematomas
Transfusion
Coagulation Defects
Anemia
Fever
Reformation
Deep vein thrombosis
Scarring with resultant dyspareunia
Fistula Formation
Prolonged Hospitalization and Recuperation

23. Placenta Accreta/Increta/Percreta
Accreta: villi attatched to myometrium (85%)
Increta: villi invading the myometrium (15%)
Percreta: villi beneath or through the uterine serosa (5%)

24. Placenta Accreta/Increta/Percreta
Risk factors
Early 30s
Parity (2 or 3 prior births)
Prior C/S
H/O of D& C
Prior manual placental removal
Prior retained placenta
Infection

25. Postpartum Accreta Postpartum hemorrhage 39 – 64%
2600 ml (without previa)
4700 ml (with previa)

26. Placenta Accreta/Increta/Percreta
Postpartum hemorrhage
Conservative Management
Hysterectomy

27. Placenta Accreta/Percreta/Increta
Conservative management
Leaving the placenta in place
Localized resection and repair
Oversewing a defect (esp percreta)
Blunt disection/curretage

28. Uterine Inversion 1/2000  1/6400 Partial delivery of placenta
Rapid onset of maternal shock
Degree
1st (Incomplete)
- Corpus does not pass through the cervix
2nd (Complete)
- Corpus passes through the cervix
3rd (Prolapse)
- Corpus extends through vaginal introitus

29. Uterine Inversion Treatment Fluid therapy Restoration of uterus
Pushing the fundus with a fisted hand along the axis of vagina through cervix back into pelvis
If failed
Terbutaline
Mg SO4
General anesthesia
Laparotomy

30. Uterine Rupture 0.05% for all pregnancies
0.8% after a previous low transverse c/s
75% in prior classical c/s
25% in prior uterine myomectomy

31. Uterine Rupture Risk Factors Surgical procedures of uterus
C/S, myomectomy, perforation, cornual resection, hysteroscopic or laparoscopic injuries, penetrating abdominal wounds
• Grand multiparity
Obstetric trauma
Fetal macrosomia
Malpresentation
Breech extraction
Instrumental vaginal deliveries

32. Uterine Rupture Symptoms and signs Ripping lower abdominal Pain
Referred Shoulder Pain
Vaginal Hemorrhage
Fetal Bradycardia
Loss of fetal presentation part

33. Uterine Rupture Management Hysterectomy
Repair  recurrent rupture: 19%

34. Third Trimester Bleeding: Antepartum Hemorrhage
Placental Abruption
Placental Previa

35. “Real Life Situation”
A patient calls you by telephone and tells you that she has some vaginal bleeding with some crampy lower abdominal pain at 32 weeks gestation. She is hypertensive and has used drugs in the past as well. She has had 2 previous CS and was transfused with the last one. She was told that she had a placenta previa earlier in her pregnancy with her ultrasound exam at 20 weeks.

36. Placental Abruption External hemorrhage Concealed hemorrhage Total
Partial
1/200 – 1/1550 deliveries
Perinatal mortality: 25%
Recurrence: 4 – 12.5%

40. Placental Abruption Increased Maternal age and parity N/A
Risk Factors RR
Increased Maternal age and parity N/A
Preeclampsia – 4.0
Chronic hypertension – 3.0
PROM – 3.0
Smoking – 1.9
Cocaine N/A (13%)
Prior abruption – 25

42. Placental Abruption Symptoms & Signs Frequency (%) Vaginal bleeding 78
Uterine tenderness or back pain
Fetal distress
High frequency of contractions
Hypertonus
Idiopathic preterm labor
IUFD

43. Placental Abruption
DIC
Acute renal failure
Couvelaire uterus

44. Placental Abruption Management Gestational age Maternal status
Fetal status
Correct maternal hypovolemia, anemia, hypoxia
? Tocolysis
Vaginal vs. C/S

46. Placenta Previa Incidence: 0.3- 0.7 % Definitions: Total Partial
Marginal
Low-lying

47. Tubal Occlusion:

51. Placental Previa Risk Factors Increased maternal age Increase parity
Smoking
Prior C/S
One: 2X – 3X ( %)
Two: 1.9%
Three: 4.1%
Diagnosis: U/S (TVU), MRI

52. Placental Previa GA at U/S (wk) Previa or Bleeding at Delivery
< %
20 – %
25 – %
30 – %

53. Placental Previa Management ? Fetal lung maturity ? Labor
? Preterm
? Fetal lung maturity
? Labor
? Severe hemorrhage
Vaginal delivery vs. C/S