1. Management of Obstetrical Hemorrhage
Jeffrey Stern, M.D.

2. Incidence of Obstetrical Hemorrhage
4% of SVD
6.4 % of C-sections
13% of maternal deaths (1:10,000 to 1:1,000)
10% risk of recurrence

3. Etiology of Obstetrical Hemorrhage: Antepartum
Placenta previa
Abruption
Coagulopathy: ITP/pre-eclampsia, FDIU

4. Etiology of Obstetrical Hemorrhage: Intrapartum
Placenta previa
Abruption
Abnormal placentation
Genital tract lacerations: (2.4 odds ratio)
Uterine rupture
Coagulopathy: infection, abruption, amniotic fluid embolism

5. Etiology of Postpartum Hemorrhage (Primary) (Within 24 hours of delivery)
Uterine atony (3.3 odds ratio)
Induction or Augmentation of labor (1.4 odds ratio)
Retained products of conception (3.5 odds ratio)
Placenta accreta, increta, percreta (3.3 odds ratio)
Coagulopathy
Fetal death in utero
Uterine inversion – may need MgSO4, Halothane, Terbutaline, NTG
Amniotic fluid embolism

6. Etiology of Postpartum Hemorrhage (Secondary) (After 24 hours of delivery to 6 weeks postpartum)
0.5-2% of patients
Infection
Retained products of conception with atony
Placental site involution
Rx: D+C, ABX, uterotonic medications

7. Uterine Atony: 1 in 20 to 1 in 100 deliveries (80% of PPH)
Uterine over distension (Polyhydramnios, Multiple gestations, Macrosomia)
Prolonged labor: “uterine fatigue” (3.4 odd ratio)
Precipitory labor
High parity
Chorioamnionitis
Halogenated anesthetic
Uterine inversion

8. Treatment of Uterine Atony
Message fundus continuously
Uterotonic agents
Foley catheter/Bakri balloon (500cc)
Uterine packing usually ineffective but can temporize
Modified B-Lynch stitch (#2chromic)
Uterine, utero-ovarian, hypogastric artery ligation
Subtotal/Total abdominal hyst.

9. Treatment of Uterine Atony
Oxytocin – 90% success
10-40 units in 1 liter NS or LR rapid infusion
Methylergonovine (Methergine) 90% success
0.2 mg IM q 2-4 hours max. 5 doses; avoid with hypertension
Prostaglandin F2 Alpha (Hemabate) 75% success
250 micrograms IM, intramyometrial, repeat q min. max. 8 doses; Avoid if asthma/Hi BP
Prostaglandin E2 suppositories (Dinoprostone, Prostin E2) 75% success
20 mg per rectum q 2 hours; avoid with hypotension
Prostaglandin PGE 1 Misoprostol (Cytotec) 75% - 100% success
1000 microgram per rectum or sublingual (ten 100 micrograms tabs/five 200 micrograms tabs)

10. Retained Products of Conception: Etiology
Succentiurate lobe
Placenta accreta, increta, percreta
Previous C-section; hysterotomy
Previous puerperal curettage
Previous placenta previa
High parity

11. Management of Retained Products of Conception
Examine placenta carefully
Manual exploration of uterus
Careful curettage-Banjo curret

12. Placenta Accreta, Increta, Percreta: Risk Factors
High Parity
Previous placenta previa
Previous C-section
GTN
Advanced maternal age
Previous uterine abnormal placentation

13. Management of Abnormal Placentation
Placenta will not separate with usual maneuvers
Curettage of uterine cavity
Localized resection and uterine repair: (Vasopressin 1cc/10cc N.S-sub endometrial)
Leave placenta in situ
If not bleeding: Methotrexate
Uterus will not be normal size by 8 weeks
Uterine, utero-ovarian, hypogastric artery ligation
Subtotal/total abdominal hysterectomy

14. Uterine Inversion: 1 in 2500 Deliveries
Risk factors: Abnormal placentation, excessive cord traction
Treatment
Manual replacement
May require halothane/general anesthesia
Remove placenta after re-inversion
Uterine tonics and massage after placenta is removed
May require laparotomy

15. Coagulopathy Hereditary Acquired Preganancy induced hypertension
Abruption
Sepsis
Fetal death in utero
Amniotic fluid embolism
Massive blood loss

16. Genital Tract Laceration and Hematomas: Etiology
Macrosomia
Forceps
Episiotomy
Precipitous delivery
C-section incision extension
Uterine rupture

17. Therapy of Genital Tract Lacerations
Superficial lacerations and small hematomas: expectant
Large laceration
Repair in layers
Consider a drain

18. Hematomas
Below pelvic diaphragm: (vulva, paracolpos, ischiorectal fossa)
Leave alone if possible
Legate bleeder - often difficult to find
Pack open
Drain
May need combined abdominal/perineal approach
Above the pelvic diaphragm
Laparotomy- especially if expanding
Combined abdominal/perineal approach

19. Selective Artertial Embolization by Angiography
Clinically stable patient – Try to correct coagulopathy
Takes approximately 1-6 hours to work
Often close to shock, unstable, require close attention
Can be used for expanding hematomas
Can be used preoperatively, prophylactically for patients with accreta
Analgesics, anti-nausea medications, antibiotics

20. Selective Artertial Embolization by Angiography
Real time X-Ray (Fluoroscopy)
Access right common iliac artery
Single blood vessel best
Embolize both uterine or hypogastric arteries
Sometimes need a small catheter distally to prevent reflux into non-target vessels
May need to treat entire anteriordivision or even all of the internal iliac artery.
Risks: Can embolize nearby organs and presacral tissue, resulting in necrosis
Technique
Gelfoam pads – Temporary, allows recanalization
Autologous blood clot or tissue
Vasopressin, dopamine, Norepinephrine
Balloons, steel coils

22. Evaluate for Ovarian Collaterals
May need to embolize

23. Mid-Embolization “Pruned Tree Vessels”

24. Post Embolization

25. Post Embolization
Pre Embo
Post Embo

26. Uterine Rupture Scarred versus scarless uterus
Uterine scar dehiscence: separation of scar without rupture of membranes
2-4% of deliveries after previous transverse uterine incision
Morbidity is usually minimal unless placenta is underneath or it tears into the uterine vessels
Diagnosis after vaginal delivery
Often asymptomatic, incidental finding
Difficult to diagnose because lower uterine segment is very thin
Therapy is expectant if small and asymptomatic
Diagnosed at C-section: Simple debridement and layered closure

27. Uterine Rupture Etiology
Previous uterine surgery - 50% of cases
C-section, Hysterotomy, Myomectomy
Spontaneous (1/1900 deliveries)
Version-external and internal
Fundal pressure
Blunt trauma
Operative vaginal delivery
Penetrating wounds

28. Uterine Rupture Etiology
Oxytocics
Grand multiparity
Obstructed labor
Fetal abnormalities-macrosomia, malposition, anomalies
Placenta percreta
Tumors: GTN, cervical cancer
Extra-tubal ectopics

29. Classic Symptoms of Uterine Rupture
Fetal distress
Vaginal bleeding
Cessation of labor
Shock
Easily palpable fetal parts
Loss of uterine catheter pressure

30. Uterine Rupture
Myth: Uterine incisions which do not enter the endometrial cavity will not
subsequently rupture
Type of closure: no relation to tensile strength
Continuous or interrupted sutures: chromic, vicryl, Maxon
Inverted or everted endometrial closure
Degree of complications
Inciting event- spontaneous, traumatic
Gestational age
Placental site in relation to rupture site
Presence or absence of uterine scar
Scar: 0.8 mortality rate
No scar: 13% mortality rate
Location of scar
Classical scar- majority of catastrophic ruptures
Transverse scar- less vascular; less likely to involve placenta
Extent of rupture

31. Management of Uterine Rupture
Laparotomy
Debride and repair in 2-3 layers of Maxon/PDS
Subtotal Hysterectomy
Total Hysterectomy

32. Pregnancy After Repair of Uterine Rupture
Not possible to predict rupture by HSG/Sono/MRI
Repair location
Classical %
Low transverse %
Not recorded %
Re-rupture %
Maternal death %
Perinatal death %
(Plauche, W.C 1993)

33. Modified Smead-Jones Closure
Running looped #1 PDS/Maxon
Contaminated wounds/under tension
Additional Interruptured sutures - 2 cm apart
Fascial edges should be approximated
No tension