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OB 6
Princinples II antepartum and postpartum hemorrhage
| Question | Answer |
|---|---|
| Causes of Hemorrhage | Previa Accreta Abruption Uterine Rupture Postpartum Hemorrhage Uterine Atony Uterine Inversion |
| What is the leading cause of maternal and fetal morbidity and mortality | Peripartum hemorrhage remains a leading cause of maternal and fetal morbidity and mortality |
| Mechanisms of hemostasis | Coagulation cascade ensues after disruption in vascular integrity Contraction of the uterus represents the primary mechanism for controlling blood loss at parturition Under estimation of peripartum hemorrhage is frequent, and inadequate fluid resus is c |
| Antepartum Hemorrhage | Occurs in about 4% of pregnancies Includes Placenta Previa, Placental Abruption (Abruptio placentae), and Uterine Rupture Perinatal mortality rates are as high as 22% with placenta previa and 37% with abruption |
| Plancenta previa | Present when the placenta implants in advance of the fetal presenting part Three types -Total -Partial -Marginal |
| Total or complete | Placenta completely covers the internal os |
| Partial | Placenta partially covers the internal os |
| Marginal | Placenta just reaches the internal os but does not cover it (aka low-lying) |
| Incidence of Placenta previa is | 1:200 pregnancies |
| What is the common element of placenta previa | Prior uterine trauma is a common element placenta implants in the scarred area, which typically includes the lower uterine segment *** Increases the likelihood that the patient will require a peripartum hysterectomy |
| diagnosis of Placenta previa | -Classic presentation is painless vaginal bleeding during the second or third trimester -Lack of abdominal pain and abnormal uterine tone (often no contractions) helps distinguish from placental abruption -10% have coexisting abruption |
| Obstetric managment | Ultrasonography is mainstay to confirm diagnosis Vaginal exams best avoided, and performed under a “double set-up” Active labor, persistent bleeding, or mature fetus should prompt abdominal delivery |
| Plan a heard. what do you do? for placenta previa | Double set-up (slide 12)- all preparations for hemorrhage and emergency cesarean section set up in OR for direct examination of cervical os (Duke p. 329) |
| Placenta previa risk for fetus | progressive or sudden placental separation causing uteroplacental insufficiency; 2) preterm delivery |
| Goal for placenta previa patient will be | -Goal is to delay delivery until fetus mature |
| What are the decisions regarding tocolytic therapy | -Decisions regarding tocolytic therapy are problematic. because Tocolysis: must balance potential cardiovascular consequences of tocolytic therapy in presence of maternal hemorrhage versus the consequences of preterm delivery. |
| Despite expectant management prematurity remains what? | Despite expectant management, prematurity remains the most common cause of neonatal mortality and morbidity |
| Anesthesia management | All pt should be eval immediately by anesthesia Eval airway & intravascular volume status very carefully Establish 2 large bore IVs, H&H, get Type & Crossmatch (2 Units PRBC available in OR) Initiate volume resusitation with crystalloids C/S depending |
| what would c/c depends on | it will depend on indication/urgency, hypovolemia. possible double set up. including general anesthesia |
| Anesthesia management (the bleeding patient) | Pre-op eval of airway and intravascular volume status Blood administration sets, fluid warmers, invasive monitoring prepared Rapid sequence induction of general anesthesia |
| Oxytocin in anesthesia management for the bleeding patient | Oxytocin (20-30 Units/L) infused immediately after delivery of placenta. Eliminate all uterine relaxants if bleeding continues ½ life of Oxytocin is approx. 3 minutes; causes uterine contractions and letdown reflex |
| Intravenous induction agents for the bleeding patient in anesthesia management | Intravenous induction agents---hypovolemic patients may be better off receiving Ketamine (1 mg/kg) or Etomidate (0.3 mg/kg) for induction Maintenance: 50% N2O/50% O2 with low concentration volatile agent if modest bleeding and no fetal distress; |
| Anesthesia management in placenta accreta | if placenta doesn’t separate easily---expect massive blood loss and need for cesarean hysterectomy Central line, A-line in unstable patients Coagulopathy rare; most common deficit is dilutional thrombocytopenia |
| Placenta Abruption | Defined as separation of the placenta from the decidua basilis (endometrium) before delivery of fetus Acute bleeding from exposed vessels Fetal distress due to loss of large area for maternal-fetal gas exchange |
| Abruption grading (Duke p. 329) | 0-no s/s recognized after delivery; 1- (mild)vag bleeding, abd pain, contractions, uterine tenderness; 2- (mod)same s/s as 1 plus uterine tetany and fetal distress; 3- (severe) maternal shock, uterine tetany, coag. fetal demise, distal organ necrosis DIC |
| Associated risk factor with placenta abruption | Several associated risk factors: hypertension; advanced age and parity; tobacco use; cocaine use; trauma; premature rupture of membranes; history of previous abruption |
| Incidence of plancenta abruption | 1% of pregnancies |
| What is it associated with | Associated with IUGR and fetal malformations—may be a longstanding pathologic process |
| Pathophysiology of placenta abruption | Major complications: hemorrhagic shock, acute renal failure, coagulopathy, fetal distress of demise Major fetal risk—hypoxia; 15-25% of perinatal deaths associated with abruption |
| What is the most common cause of DIC in pregnancy | Abruption is most common cause of DIC in pregnancy—coagulopathies occur in 10% of all cases |
| Major fetal risk-hypoxia | 15-25% of perinatal deaths associated with abruption |
| What is DIC | Activated clotting proteins in blood, get blood clots to organs (can get organ damage); use up clotting proteins then start bleeding, cycle continues; check fibrin degradation products & fibrinogen; have risk of clots and stroke. |
| Obstetric management | Fetal heart rate monitoring Two large bore IV’s Type and cross for PRBC’s Supplemental oxygen Left uterine displacement maintained Apparent blood loss may not reflect true intravascular volume deficit---retroplacental hematoma. Place urethral cathet |
| Is there a true reflection of blood lost. NO. | Apparent blood loss may not reflect true intravascular volume deficit---retroplacental hematoma. Place urethral catheter to gauge adequacy of renal perfusion |
| What is the definitive treatment for placenta abruptor | Delivery of fetus and placenta, In most cases, delivery is prompt. Induction of labor preferred when no evidence of fetal distress and a favorable cervix is present In most other cases, C-section performed without delay Consider Jehovah’s Witness |
| What happen if fetus is preterm and degree of abruption is minimal? | if fetus is preterm, degree of abruption minimal, and no signs of fetal distress, the pt is hospitalized and the pregnancy allowed to continue for fetal lung maturation. |
| Anesthetic management for labor and vag delivery | Epidural analgesia OK if no coagulation abnormalities and no intravascular volume deficit; check labs Continuously monitor for signs of additional bleeding and maintain intravascular volume |
| Cesarean section | GETA preferred in cases of acute fetal distress Ketamine and etomidate better choices in hypovolemia Aggressive volume resuscitation critical—crystalloids and colloids Severe hemorrhage—central and A-lines Oxytocin after delivery (risk of persistent h |
| You want Oxytocin after delivery to cause uterin contraction because. | (risk of persistent hemorrhage from uterine atony or coagulopathy) Coagulation factors in event of coagulopathy Ketamine 1mg/kg or etomidate 0.3 mg/kg, N & Z p.1084 |
| Uterine rupture | Uterine wall defect resulting in fetal distress and/or maternal hemorrhage suf to require C/S or postpartum laparo. Previous uterine trauma/scarring increases risk—incidence less than 1% among parturients with scarred uterus Rare in primigravida women |
| Dose uterine rupture occur with forceps delivery | Yes. it may occur wit forceps delivery trauma |
| Uterine rupture of classic uterine scar. | Rupture of classic uterine scar increases morbidity and mortality because area is highly vascular and may include area of placental implantation |
| Diagnosis of uterine rupture | Variable presentation makes diagnosis difficult Suspected if vaginal bleeding, hypotension, cessation of labor, and fetal distress noted Fetal distress is most reliable sign Can occur post delivery |
| What is the most reliable signs of uterine rupture | Fetal distress |
| More with diagnosis of uterine rupture | Rare in pt with unscarred uterus Risk factors: grand multiparity, malpresentation, and administration of oxytocin or prostaglandin/Cervidil Postpartum hemorrhage, maternal tachycardia, and FHR decelerations may signal rupture |
| Obsteric management uterine rupture | Treatment options: Uterine repair Arterial ligation Hysterectomy—the preferred, definitive approach for most cases |
| What is the most preferred, definitive approach for most cases of utrine rupture | Hysterectomy |
| Anethetic management for uterine rupture | Prepare for emergency laparo Volume resuscitation GETA often necessary, especially if fetal distress involved Some stable patients with preexisting CLE catheter in place may have regional Aggressive volume replacement and maintenance of urine outp |
| Monitoring may include | Invasive hemodynamic monitoring prn |
| What is CLE | continuous labor (lumbar) epidural |
| Postpartum Hemorrhage | Defined as blood loss > 300 ml after delivery |
| What are some causes | Causes include uterine atony, lacerations/disruptions, placental abnormalities, & coagulation abnormalities |
| Does HCP underestimate the severity of obstetrical hemorrhage? | Yes. HCP’s often underestimate severity of obstetrical hemorrhage |
| How do you identify that patient is hemorrhaging? | May be identified clinically by 10% decrease in HCT from admission to postpartum period, or need to administer PRBC’s |
| Risk factors for postpartum Hemorrhage | Precipitous labor (<3hr); Instrumented delivery -stimulated labor General anesthesia -hx of postpartum hemorrhage Prolonged labor -fetal demise Macrosomia-amniotic fluid embolus. Twins -tocolytic therapy. Chorioamnionitis. multiparity prio C/S |
| Primary Postpartum Hemorrhage | Occurs during the first 24 hours |
| Secondary postpartum hemorrhage | occurs between 24 hours and 6 weeks |
| Uterine Atony | Most common cause of postpartum hemorrhage Most common indication for postpartum PRBC’s, common reason for hysterectomy Attempt fundal massage |
| Contraction of uterus represent mechanism for controlling blood loss in parturition. But Uterine atony in this parturient fails to do what? | Uterine atony is the failure of this process. Patients with obstetrical hemorrhage also have uterine arteries that are less responsive to vasoconstriictor substances |
| Condition associated with Uterine atony | Multiple gestation -macrosomia Polyhydramnios Precipitous labor Augmented labor Tocolytic agents High parity Prolonged labor Chorioamniomitis High concentration of volatile halogenated agent |
| Diagnosis of Uterine atony | Soft postpartum uterus and vaginal bleeding are the most common findings The atonic, enlarged uterus may contain 1000 ml of blood, so absence of vaginal bleeding does not preclude this disorder |
| Obstetric management for utrine atony | Initial treatment: bimanual compression, uterine massage, and I.V. oxytocin Small percentage of pt’s require transfusion or hysterectomy Supplemental oxygen Adequate I.V. access Appropriate crystalloid resuscitation |
| What is the first line of drug for prohylaxis and treatment of atony | Oxytocin. Bolus administration causes peripheral vasodilation , may cause hypotension Various EKG changes, significance unclear Usually not a bolus—add 20 units to 1000 ml LR and infuse; may double to 40 units |
| Prostaglandins | Prostaglandins increase myometrial intracellular free calcium concentrations and enhance activity of other oxytocic agents Uterine atony may be caused by failure of prostaglandins to increase in 3rd stage of labor |
| Obstetric management for Prostagladines | 15-Methyl prostaglandin F2-alpha (Hemabate: Carboprost) Side effects: bronchospasm, disturbed V/Q ratios, hypoxemia; N/V, diarrhea, flushing Dose: 250 mcg I.M., may repeat every 15-20 min to max dose 2 mg Can give with Zofran to decrease GI symptoms |
| why is prostaglandine treatment preffered for refractory uterine atony | It may succeed in controlling hemorrhage when other treatments have failed |
| Ergot alkaloids: | : Ergonovine and methylergonovine (Methergine) 0.2mg IM Rapidly produce tetanic uterine contractions, possibly by means of alpha-adrenergic stimulation (caution with beta blockers) |
| What are the side effects of Ergot alkaloids | possible serious CV problems (hypertension, vasoconstriction) HTN—pt’s with preexisting HTN at greatest risk, may get high enough to cause CVA Avoid combination of ergot alkaloid and vasopressors |
| Ergot Alkaloids (Methergine) | Relative contraindications: chronic HTN, preeclampsia, peripheral vascular disease, and ischemic heart disease Dose: 0.2 mg I.M.—rapid onset (2-5min) with effects lasting 2-3 hours (can give orally) |
| Genital trauma | Vaginal hematomas Vulvar hematomas Retroperitoneal hematomas |
| What is the leading cause of early or delay hemorrhage | Retained placenta: leading cause of early and delayed hemorrhage; often insidious, and visual estimates of EBL are low Obstetric management: manual removal and inspection of placenta, administration of oxytocin |
| Anesthesia management for the hemorrhage patient | RSI of GETA, use of volatile halo Agent Previously existing CLE often adequate SAB OK if pt not bleeding 40-50% Nitrous oxide Small doses of Ketamine for I.V. sedation Maintenance of protective airway reflexes is critical; aspiration prophylaxis need |
| What will facilitate manual removal in anesthesia management | Uterine relaxation. |
| Nitroglycerine in anesthetic managment | I.V. titration 50 mcg doses Sublingual metered spray (800 mcg) Probably relaxes uterus by releasing nitric oxide |
| Abnormal Placenta implantations | Defines as abnormally adherent placenta |
| What are the 3 types of abnormal placenta implantation | -Accreta: adherence to myometrium without invasion or passage through uterine muscle (75% of cases) -Increta: invasion of myometrium (15% of cases) -Percreta: invasion of uterine serosa or other pelvic structures (5% of cases) |
| Placenta Accreta | Prior uterine trauma is risk factor Combination of one or more prior C-sections and current placenta previa or low lying placenta prompts suspicion Often requires cesarean hysterectomy Diagnosis: usually at delivery when placenta difficult to separate |
| Obstetric management for Placenta Accreta | Most cases require cesarean or postpartum hysterectomy The most common indication for obstetric hysterectomy Blood loss may be substantial in these cases |
| Uterine Inversion | Defined as turning inside out of part or all of the uterus |
| Uterine inversion incidence | 1:5000-10K pregnancies |
| Risk factors for uterine atony (uterine inversion) | uterine atony, inappropriate fundal pressure, umbilical cord traction, uterine anomalies |
| Diagnosis for uterine inversion | suspected in all cases of postpartum hemorrhage and hypotension; many cases obvious with hemorrhage and mass in the vagina |
| Obstetric management for uterine inversion | early replacement of uterus is best treatment; oxytocin to contract uterus after replacement |
| Anesthesia management for uterine inversion | uterine relaxation may be needed to replace uterus; GETA with volatile halogenated agent most proven method; endotracheal intubation mandatory Use of NTG may preclude GETA |
| Postpartum Hemorrhage in invasion treatment options | Cesarean or postpartum hysterectomy—definitive therapy for hemorrhage Obstetric hysterectomy more difficult than in nonpregnant pt (engorged vessels, edematous tissue, etc) Large EBL and transfusion requirements |
| Anesthetic management regarding postpartum hemorrhage of uterine inversion include central line monitoring and ? | Requires good skeletal muscle relaxation Often requires GETA; preexisting CLE may not be adequate Large EBL; large amount crystalloids and PRBC’s required Resp complications in 21% of pts, DIC in 27%, vaso drug 2 large bore IV’s; 2 units PRBC’s immed |
| Cord Prolapse | See after rupture of maternal membranes See often with breech or malpresentation Cord falls and presenting part compresses Fetal emergency!! Typically emergency C/S!! |
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