Professional Documents
Culture Documents
Obstetric Haemorage
Obstetric Haemorage
Obstetrical Hemorrhage
Hemorrhage
International
Obstetrical Hemorrhage
Antepartum
ObstetricalHemorrhage
Hemorrhage
International
Principles
Prompt diagnosis
Recognize reserve and ability to compensate
Resuscitate vigorously
Identify underlying cause
Treat underlying cause
Antepartum Hemorrhage
International
Antepartum Hemorrhage
Antepartum Hemorrhage
International
Objectives
Antepartum Hemorrhage
International
Definition
vaginal bleeding between 20 weeks and delivery
Incidence
2% to 5% of all pregnancies
various causes of antepartum haemorrhage
- abruptio placenta
40% - 1% of pregnancies
- unclassified
35%
- placenta previa
20% - % of pregnancies
- lower genital tract lesion 5%
- other
Antepartum Hemorrhage
International
Etiology of APH
Cervical
contact bleeding (e.g. intercourse, pap, neoplasia,
examination)
inflammation (e.g. infection)
effacement and dilatation (e.g. labour, cervical
incompetence)
Placental
abruptio
previa
marginal sinus rupture
Vasa previa
Other - abnormal coagulation
Antepartum Hemorrhage
International
Diagnostic Procedures
History and physical - No digital pelvic
exam
Ultrasound
definitive test for previa
less useful in abruptio
Electronic Fetal Monitoring
for fetal compromise and uterine tone
Speculum
do ultrasound first if possible
No digital pelvic exam
Antepartum Hemorrhage
International
Laboratory
CBC, blood type, Rh, Coombs
coagulation status
INR, PTT, fibrinogen or TCT
2 - 4 units of PRBC cross matched as
appropriate
bedside clot test
Kleihauer-Betke or Neirhaus test
vaginal and/or maternal blood
fetal lung maturity indices if appropriate
Antepartum Hemorrhage
International
Vaginal Bleeding
Risk Factors Tests (No vaginal exam)
Fetal / Maternal Assessment
Mother or fetus unstable
Hemodynamic Resuscitation
Expectant
consider ongoing loss, etiology,
gestation
Antepartum Hemorrhage
International
Management - ABC s
talk to and observe mother and
fetus
large bore IV access
crystalloid (N/S)
CBC and coagulation status
cross-match and type
get HELP!
Antepartum Hemorrhage
International
Hemodynamic Resuscitation
early aggressive resuscitation to protect fetus and
maternal organs from hypoperfusion and to prevent
DIC
stabilize vital signs
large bore IV crystalloid infusion, plasma expanders
follow hemoglobin and coagulation status
oxygen consumption is up 20% in pregnancy
Antepartum Hemorrhage
International
Fetal Considerations
lateral position increases cardiac output up to
30%
consider amniocentesis for lung indices
external fetal and labor monitoring
Kleihauer-Betke if suspected abruption
post-trauma monitor at least 4 hours for evidence
of fetal insult, abruptio, fetal maternal transfusion
Antepartum Hemorrhage
International
Antepartum Hemorrhage
International
Antepartum Hemorrhage
International
Antepartum Hemorrhage
International
ABRUPTION
Live Fetus
Dead Fetus
coagulopathy
Delivery
(watch for DIC)
Assess Maturity
Maturity
Vaginal delivery or C/S
Immaturity
Steroids plus expectancy
Transfusion? Transfer?
Antepartum Hemorrhage
International
Antepartum Hemorrhage
International
Antepartum Hemorrhage
International
Antepartum Hemorrhage
International
PREVIA
Assess maturity
Maturity
Immaturity
Antepartum Hemorrhage
International
Complication
ex-sanguination following amniotomy or ROM
Diagnosis
Apt test or Kleihauer test on vaginal blood
terminal fetal bradycardia initial tachycardia or
sinusoidal FH
Prognosis
fetal mortality as high as 50-70%
Antepartum Hemorrhage
International
Conclusions
Antepartum Hemorrhage
International
Kleihauer-Betke
Indications
Measures fetal cells in maternal circulation
Used in assessing for Rh Sensitization
Maternal blood Rh negative
Large antepartum bleed
Mechanism
Blood Film stained with acid elution
Fetal Hgb more acid resistant
Fetal RBC darkly stained, Maternal RBC "ghosts"
Technique
Count Fetal cells per 50 low power fields
Five cells per 50 (lpf) = 0.5 ml bleed
Interpretation
Calculate Maternal Blood Volume (ml) =
(Pre-pregnant weight in kg) x 70 ml/kg x (1.0 + (0.5 x weeks gestation/36)) Estimated Blood loss (ml) at time of test
Calculate Fetal Whole Blood (ml) =
(Fetal Cell Count/Maternal Cell Count) x Maternal Blood Volume
Rh Immune Globulin (RhoGAM) Dose
Give 300 ug per 30 ml fetal whole blood or 15 ml pRBC
Antepartum Hemorrhage
International
Indications
Assess for Vasa Previa in Late Pregnancy Bleeding
Mechanism
Differentiates Fetal from Maternal Blood
Technique
Collect bloody vaginal fluid
Add a small amount of tap water (Hemolyzes blood)
Centrifuge sample
Add 5 cc pink supernatant to 1 cc Sodium Hydroxide 1%
Read in 2 minutes (may be difficult)
Pink sample indicates fetal Hemoglobin
Yellow-Brown sample indicates adult Hemoglobin
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Postpartum Hemorrhage
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Objectives
Definition
Etiology
Risk Factors
Prevention
Management
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Traditional Definition
blood loss of > 500 mL following vaginal delivery
blood loss of > 1000 mL following cesarean
delivery
Functional Definition
any blood loss that has the potential to produce or
produces hemodynamic instability
Incidence
about 5% of all deliveries
Antepartum
PostpartumHemorrhage
Hemorrhage
International
- uterine atony
Tissue
- retained tissue/clots
Trauma
Thrombin
- coagulopathy
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Antepartum
PostpartumHemorrhage
Hemorrhage
International
uterine rupture
uterine inversion
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Prevention
be prepared
active management of the third stage
- prophylactic oxytocin with delivery or with
delivery of anterior shoulder
10 U IM or 5 U IV bolus
20 U/L N/S IV run rapidly
- early cord clamping and cutting
- gentle cord traction with suprapubic
countertraction
Antepartum
PostpartumHemorrhage
Hemorrhage
International
(subjects)
1
Odds Ratio (95% Confidence Interval)
10
Antepartum
PostpartumHemorrhage
Hemorrhage
International
REMEMBER
- blood loss is consistently underestimated
- ongoing trickling can lead to significant blood
loss
- blood loss is generally well tolerated to a point
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Antepartum
PostpartumHemorrhage
Hemorrhage
International
A = airway
B = breathing
C = circulation
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Management - ABC s
talk to and observe patient
16
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Management - Oxytocin
5 units IV bolus
20 units per L N/S IV wide open
i.v access
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Antepartum
PostpartumHemorrhage
Hemorrhage
International
if coagulation is abnormal:
- correct with clotting factors, platelets
if coagulation is normal:
- prepare for O.R. (may consider embolization)
- rule out uterine rupture, inadequate incision repair
- consider uterine/hypogastric ligation, hysterectomy
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Management - ABC s
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Conclusions
be prepared
practice prevention
assess the loss
assess maternal status
resuscitate vigorously and
appropriately
diagnose the cause
treat the cause
Antepartum
PostpartumHemorrhage
Hemorrhage
International
Management - Evolution
Panic
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness
Antepartum
Postpartum Hemorrhage
International