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1、1OBSTETRICAL HEMORRHAGE2Rationale(why we care)4-5%of pregnancies complicated by 3rd trimester bleedingImmediate evaluation neededSignificant threat to mother&fetus(consider physiologic increase in uterine blood flow)Consider causes of maternal&fetal deathPriorities in management(triage!)3OBSTETRICAL
2、 HEMORRHAGElOBSTETRICS -“bloody business”Delivery should be considered in any woman at term with unexplained vaginal bleeding-hemorrhage is leading cause of maternal mortality and ICU care in obstetrics hospital4Vaginal Bleeding:Differential diagnosisCommon:Abruption,previa,preterm labor,laborLess c
3、ommon:Uterine rupture,lacerations/lesions,vasa previa,fetal vessel rupturecervicitis,polyps,cervical cancer,foreign body,bleeding disordersUnknownNOT vaginal bleeding!(happens more than you think!)5normal hemorrhagelBloody show:-antepartum in active labor the consequence of effacement&dilatation of
4、cervix tearing of small veins 6Definition conditionslThe definition of obstetrical hemorrhage cannot be determined preciselylBleeding500mllNeed transfusionlHct drop of 10 vol%7Predisposing conditionslPredisposing conditions cannot be determined preciselyl3.9%in vaginal deliveryl68%in cesarean delive
5、ry lthe high risk factors89 Causes of hemorrhage causes of hemorrhage number(%)Placental abruption 141(19)Laceration/uterine rupture 125(16)Uterine atony 115(15)Coagulopathies 108(14)Placental previa 50(7)Uterine bleeding 47(6)Placenta accreta/increta/percreta 44(6)Retained placenta 32(4)10OBSTETRIC
6、AL HEMORRHAGElAntepartumlplacental previalplacetal abruptionlvasa previalPostpatrumluterine atonylnormal placentationlgenital tract lacerationlcoagulation defects 11 PLACENTA PREVIAlDefinition -the placenta is located over or very near the internal os of cervix total partial marginal low-lying12Etio
7、logy -multiparity -multifetal gestations -prior cesarean delivery:1.9%(2 times c/sec)4.1%(3 times c/sec)prior uterine incision with a previa increases the incidence of cesarean hysterectomy -smoking :CO hypoxemia compensatory placetal hypertrophy13DiagnosislThe time of uterine bleeding lduring the l
8、ater half of pregnancydigital examination:torrential hemorrhage!lsonography -placental location can almost be obtained -transabdominal -transvaginal -transperineal-MRI 1415Managementl may be considered as follows:1.fetus is preterm 2.indication for delivery or in laborHave indication:partial,less bl
9、eeding vaginal delivery 3.fetus is reasonably mature 4.hemorrhage is so severe as to mandate delivery despite fetal immaturity16Management:other considerationsMust consider these diagnoses if previa presentPlacenta accreta,increta,percretaCesarean delivery may be necessaryHistory of uterine surgery
10、increases riskCould require further evaluation,imaging(MRI considered now)17Deliverylcesarean deliverylincision(transverse or vertical)lif incision extends through the placenta,maternal or fetal outcome:risk increaseladequate transfusion and cesarean delivery :marked reduction in maternal mortality
11、fail.Hysterectomy!18PLACENTAL ABRUPTION lDefinition -the separation of the placenta from its site of implantation before delivery Frequency Incidence 0.5-1.5%of all pregnancies -total vs.partial external vs.concealed :concealed-much greater maternal and fetal hazard -diagnosis typically is made late
12、r1920Perinatal mortalityRisk factors for intrauterine fetal death(1988-2009).placental abruption(OR 2.9,95%CI 2.4-3.5,p 500mL after completion of the third stage of labor-late postpartum hemorrhage :hemorrhage after the first 24 hours POSTPARTUM HEMORRHAGE40PPH Clinical characteristics -the effect o
13、f hemorrhage depend to :nonpregnant blood volume :magnitude of pregnancy induced hypervolemia :degree of anemia at the time of delivery :hypovolemic ex)normotensive hypertensive at initially hypertensive normotensive although remarkably hypovolemic 41PPH Clinical characteristics -with severe preecla
14、mpsia :not normally expanded blood volume :very sensitive and intolerant to blood loss :so,when excessive hemorrhage is suspected,prompt vigorous crystalloid and blood replacement 42Estimated blood losslexcept intrauterine&intravaginal accumulation of blood or intraperitoneal bleeding(uterine ruptur
15、e)lweight methodlmeasure volumelarea-methodlocular estimatelHblSymptoms and physical findings 43EBLlShock index blood loseShock index blood lose（mlml）rate of blood rate of blood volume volumel 0.60.60.9 5000.9 500750 20%750 20%l=1.0 1000=1.0 10001500 201500 2030%30%l=1.5 1500=1.5 15002500 302500 305
16、0%50%l2.0 25002.0 25003500 503500 5070%70%44Uterine atonysame overall mgmt regardless of delivery typeRecognitionUterine explorationlblood may not escape vaginally-adherent pieces of placenta or large blood clots prevent effective contraction and retractionUterine massage45Bleeding unresponsive to m
17、edicinesl1.bimanual uterine compression 2.help!3.2nd IV line:crystalloid with medicines 4.blood transfusion 5.explore uterine cavity manually :placental remnant or laceration 6.inspect the cervix and vagina 7.foley keep:urine output check(renal perfusion)4647Uterine atonyMedical mgmt:Pitocin(20-80 u
18、 in 1 L NS)Long-acting Pitocin(100 iv)Methergine(ergonovine maleate 0.2 mg IM)Not advised for use if hypertensionHemabate(prostaglandin F2)48Uterine atonyB-lynch suture(to compress uterus)Uterine packingUterine artery ligationInternal iliac artery ligationUterine artery embolizationHysterectomy(last
19、 resort)Anesthesia involvedWhether in L&D room or the OR!4950宫腔填塞51Internal iliac artery ligationl-reduce the hemorrhage technically difficult,successful in less than half -nonabsorbable material suture -mechanism :85%reduction in pulse pressure in those arteries distal to the ligation :more amenabl
20、e to hemostasis via simple clot formation -bilateral:dose not interfere subsequent reproduction5253Under what circumstances is arterial embolization indicated?lA patient with stable vital signs and persistent bleeding,especially if the rate of loss is not excessive,may be a candidate for arterial em
21、bolization.lRadiographic identification of bleeding vessels allows embolization with Gelfoam,coils,or glue.lBalloon occlusion is also a technique used in such circumstances.lEmbolization can be used for bleeding that continues after hysterectomy or can be used as an alternative to hysterectomy to pr
22、eserve fertility.54Proposed Performance MeasureIf hysterectomy is performed for uterine atonythere should be documentation of other therapy attempts.55Lacerations:RecognitionPerineal,vaginal,cervical,UterineAll can be rather bloody!AssistanceLightingAppropriate repairControl of bleedingIdentify apex
23、 for initial stitch placement5657Uterine inversion:ManagementCall for helpManual replacement of uterusUterotonics and Appropriate anesthesia to necessary to relax uterus&allow thorough manual exploration of uterine cavityConcern for shock to be discussed(and managed by the help youve called into the
24、 room!)Exploratory laparotomy may be necessary58What are the clinical considerations for suspected placenta accreta?lIf the diagnosis or a strong suspicion is formed before delivery,a number of measures should be taken:-The patient should be counseled about the likelihood of hysterectomy and blood t
25、ransfusion.-Blood products and clotting factors should be available.-Cell saver technology should be considered if available.-The appropriate location and timing for delivery should be considered to allow access to adequate surgical personnel and equipment.-A preoperative anesthesia assessment shoul
26、d be obtained.5960Amniotic fluid embolismlImprove hyoxemialAntiallergiclManagement of shocklPrevention and cure DIClPrevent renal failurelPrevent infectionlManagement of obstetrics61Amniotic fluid embolismHigh index of suspicionRecognitionAgain call for help!Supportive treatmentReplete blood,coagulation factors as ablePlan for delivery(if diagnose antepartum)if able to stabilize mom first62ManagementDeliveryVaginally unless other obstetrical indication,i.e.fetal distress,herpes（HSV),etc.Best to stabilize mother before initiating labor or going to delivery 63