Obstetric haemorrage

1. MANAGEMENTMANAGEMENT
OFOF
OBSTETRICOBSTETRIC
HAEMORRHAGEHAEMORRHAGE
Dr Amir M. SafaDr Amir M. Safa

2. CAUSESCAUSES
ANTEPARTUMANTEPARTUM POSTPARTUMPOSTPARTUM
Placenta Previa Uterine Atony
Placental Abruption Genital Trauma
Uterine Rupture Retained Placenta
Vasa Previa Placenta Accreta
Uterine Inversion

3. ANTEPARTUM BLEEDINGANTEPARTUM BLEEDING
Incidence: 4%
Aetiology:
Benign lesions: Cervicitis
Placentation abnormalities:
Placenta Previa
Placental Abruption
PLACENTA PREVIAPLACENTA PREVIA
Definition: Placenta implantation over or near internal os
Incidence: 1:200 pregnancies, associated with preterm labour

4. Types:
Total Previa: complete coverage of the os
Partial Previa: partial coverage of the os
Marginal Previa: lying close w/o covering the os
Aetiology: unclear
Risk factors:
Previous uterine trauma
Multiparity
Advanced maternal age
Previous PP, uterine surgery, & CS

5. Diagnosis:
Painless vaginal bleed, 2nd
& 3rd
trimester
No relation w/ contractions
Confirmation w/ US
PLACENTAL ABRUPTION PRESENTATION : BLEEDING W/OPLACENTAL ABRUPTION PRESENTATION : BLEEDING W/O
PAIN 10%PAIN 10%
1st
episode: mostly spontaneous resolution w/o foetal distress
Obstetric management:
Related to bleeding severity & foetal distress
Vaginal examination: usually avoided
double set up room
Goal: Delaying delivery until foetus is mature

6. Bed rest & tocolytic drugs
MgSO4
Terbuteline
Mature foetus or bleeding: CS
Anaesthetic management:
Related to indication & urgency
Always greater risk of bleeding during uterine incision
Adequate IV access, urine catheter, > 2units of blood
Stable patient: consider regional anaesthesia
Unstable patient: GA + RSI + fluid warmer + >4 units of
blood +/- invasive monitoring

7. PLACENTAL ABRUPTIONPLACENTAL ABRUPTION:
Definition:
Placental separation from decidua basalis before delivery
Acute bleeding from decidual vessels
Foetal distress
Incidence: 1%
Aetiology: unknown
Risk factors:
HT PROM
Advance age & parity Trauma
Drugs: tobacco, cocaine Previous abruption

8. Diagnosis:
Vaginal bleed (retroperitoneal!!)
Uterine contractions & tenderness
Ultrasound
Complications:
Shock
ARF
DIC: most common cause (10%)
Foetal distress
IUGR
Preterm labour
Perinatal death (15-25%)

9. Obstetric management:
FHR monitoring
IV access
FBC, G&S, XM, clotting screen
Def. Treatment: delivery (related to gest.age, bleeding, & FHR)
Anaesthetic management:
Vaginal delivery: epidural if, no CI
Regional: if no CI to mother or foetus
GA + RSI
Ketamine: <1.5 mg/kg as it increases uterine toneKetamine: <1.5 mg/kg as it increases uterine tone

10. UTERINE RUPTURE:UTERINE RUPTURE:
Incidence: <1%
Risk factors:
Previous uterine trauma, anomalies
Tumours
CS incision
Forceps delivery
Placenta percreta
Foetal anomalies & malpositions
Oxytocin
Multiparity

11. Diagnosis:
Vaginal bleeding, Hypotension, Cessation of labour, Foetal
distress, Abdominal pain
Obstetric management:
Reparable: repairing
Non repairable: arterial ligation
hysterectomy
Anaesthetic management:
EPIDURAL: controversy in the past
good pain relief
could be used for CS

12. VASA PREVIAVASA PREVIA::
Definition: foetal vessels traverse the foetal membrane in front of
the presenting part
DOES NOT AFFECT PARTURIANT BUT ASSOCIATED WITHDOES NOT AFFECT PARTURIANT BUT ASSOCIATED WITH
HIGH FETAL MORTALITYHIGH FETAL MORTALITY
Incidence: 1:2-3000
Diagnosis:
Associated w/ multiple births
Haemorrhage w/ intact membrane
Palpation or observation of foetal vessels in the cervix
Prolonged bleeding after membrane rupture
Umbilical vessels traversing the cervical opening w/o bleeding

13. Obstetric management:
Primary concern: neonatal resuscitation
CS
Anaesthetic management:
GA + RSI vs. regional related to the degree of emergency

14. POSTPARTUM BLEEDINGPOSTPARTUM BLEEDING
Definition:
Vaginal delivery: >500ml
CS: >1000ml
Incidence:
Vaginal delivery: 4%
CS: 6-7%
Types:
Primary: 0 - 24 hr
Secondary: 24 hr - 6 weeks

15. RETAINED PLACENTARETAINED PLACENTA:
Could cause early & delayed haemorrhage
Obstetric management:
Manual removal of Placenta & inspection
Anaesthetic management:
Epidural: could be used when placed
Spinal: if no CI
GA: If unstable (RSI)

16. PLACENTA ACCRETAPLACENTA ACCRETA:
Definition: abnormally adherent placenta
Types: PA Vera: adhesion to myometrium
PA Increta: adhesion & invasion of myometrium
PA Percreta: invasion to the serosa or other pelvic structures
Risk factors: Prior uterine trauma
Multiple CS w/ low-lying Placenta or PP
PRESENT EVEN W/O ANTEPARTUM HAEMORRAGE (PP)PRESENT EVEN W/O ANTEPARTUM HAEMORRAGE (PP)
Diagnosis: Usually at delivery Difficulty to separate Placenta
Def. diagnosis: laparotomy
US: may predict. MRI, TVCD: more sensitive

17. Obstetric management:
Hysterectomy
Anaesthetic management:
Regional: could be done
GA + RSI: recommended
Blood should be ready

18. Risk factors:
Multiple gestation
Macrosomia, Polyhydramnios
Chorioamnionitis
Labour abnormalities
Diagnosis:
Soft uterus with vaginal bleeding
UTERINE ATONYUTERINE ATONY::
Most common cause of postpartum:
Haemorrhage, Hysterectomy & Transfusion

19. Obstetric management:
Bimanual compression
Uterine massage
Drugs
Drugs:
Oxytocin: 1st
line
Ergot Alkaloids: 2nd
line
Prostaglandins

20. GENITAL TRAUMAGENITAL TRAUMA:
Types:
Vaginal haemorrhage: soft tissue injury
Vulval haemorrhage: Pudendal artery
Retroperitoneal haematoma: Hypogastric artery
Anaesthetic & Obstetric management:
Vulval & vaginal:
mostly I + D under local or regional anaesthesia
Retroperitoneal haematoma:
Laparotomy under GA + RSI

21. UTERINE INVERSIONUTERINE INVERSION:
Incidence: 1:500-10000
Risk factors:
Uterine atony or anomalies
Umbilical cord traction
Inappropriate fundal pressure
Diagnosis:
Haemorrhage + vaginal mass

22. Obstetric management:
Early replacement + uterotonic drugs
Anaesthetic management:
Goal: rapid & short relaxation
GA + volatile: if no CI to GA
IV TNG: if CI to GA