Obstetrical

Hemorrhage

OBSTETRIC AND GYNECOLOGY DEPARTMENT

HASANUDDIN UNIVERSITY MAKASSAR
2021
Contents
1. General Considerations
2. Uterine Atony
3. Uterine Inversion
4. Injuries to the Birth Canal
5. Puerperal Hematomas
6. Uterine Rupture
7. Placental Abruption
8. Placenta Previa
9. Morbidly Adherent Placenta
10. Obstetrical Coagulopathies
11. Management o Hemorrhage
12. Adjunctive Surgical
Procedures
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 Obstetrical Hemorrhage
“
Obstetric hemorrhage is one of the leading causes of maternal mortality
throughout the world

3
 General Considerations
“
 Mechanism of Normal Hemostasis:
myometrial contraction 
compresses large vessels, followed by
clotting and obliteration of vessel
lumens
 Obstetrical hemorrhage: antepartum
& post partum

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 Placental
abruption
Antepartum
Placenta previa

Obstetric hemorrhage Tone

Tissue
Postpartum
Tear

Thrombin

5
Causes of Obstetrical
Hemorrhage

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 Uterine Atony
The most frequent cause of
obstetrical hemorrhage is failure of
“
uterus to contract sufficiently after
delivery & to arrest bleeding from
vessels at placental implantation site

If heavy bleeding persist after

delivery of newborn while placenta
remains attached  manual
placental removal
Risk factors: primiparity, high parity, labor
abnormalities, labor induction/ augmentation,
prolonged 3rd stage labor, prior post partum
hemorrhage (PPH)

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Uterine Atony Management
 Explore, remove retained placental fragments,
massage uterus
 Give uterotonic agents:
 Oxytocin 20UI in 1000ml crystalloid solution at 10ml/min (200mU/min)
 Ergot alkaloids (methylergonovine/ methergine 0,2 mg IM), repeat 2-4
hour interval
 E-&F- prostaglandin (carboprost tromethamine/ hemabate 0,25 mg IM),
repeat 15-90 min interval, max 8 doses
 Dinoprostone (prostaglandin E2) 20 mg supp/ per vaginam every 2 hours
 Misoprostol 600-1000 𝛍g per rectal, oral or sublingual

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 Uterine Atony Management
Bleeding unresponsive to uterotonic agents:

Begin bimanual Call for help, call Request urgent

uterine for PRC or whole help from
compression blood anesthesia team

2 large IV cath: Pts sedated: explore

Volume uterine cavity for retained
crystalloid +
resuscitation placental fragment/
oxytocin lacerations/rupture

Inspect vagina and

if still unstable 
cervix for
blood transfusion
lacerations

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Uterine Atony Management

Surgical procedures: compression

suture, pelvic vessel ligation,
angiographic embolization,
hysterectomy

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 Uterine Inversion
“
Risk factors: fundal placental implantation, uterine atony, cord traction
applied before placental separation, abnormally adherent placenta

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 Uterine Inversion Management

Evaluate for
Call for help:
Call for PRC or whole emergency general
obstetrical &
blood anesthesia, establish
anesthesia
large IV access

If placenta still
If placenta has When uterus is
attached, tocolytic,
separated, push the restored to normal
reposition uterus then
inverted fundus up to configuration, stop
remove placenta
replace uterus tocolysis
manually

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Uterine Inversion Management

Surgical intervention: Huntington

procedure, Haultain incision, Uterine
compression suture

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 Injuries to the Birth Canal
 Vulvovaginal Lacerations
“
 Require thorough inspection, look for
retroperitoneal hemorrhage/ perforation
 Repair needed depend of the extent of
laceration
 Cervical Lacerations
 Need adequate exposure
 Usually not problematic unless causing
hemorrhage or extend to vagina  repair

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 Puerperal Hematomas
 Classification: Vulvar,
vulvovaginal, paravaginal,
“
retroperitoneal
 Risks: perineal laceration,
episiotomy, operative
delivery, forceps delivery,
coagulopathy
 Management: according to
the size, expectant or surgical
incision + evacuation of blood
and clots, angioembolization

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 Uterine Rupture
 Primary or secondary
“
 Fetal prognosis
dependent on the degree
of placental separation &
magnitude of maternal
hemorrhage and
hypovolemia
 Surgical management,
hysterectomy may be
necessary

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 Placental Abruption
 Premature separation of the
normally implanted placenta, can be
“
total or partial
 Begin with rupture of decidual spiral
artery  expanding retroplacental
hematoma
 Bleeding insinuates between
detached placenta & uterus 
escape through cervix causing
external hemmorrhage or concealed
hemorrhage & delayed diagnosis
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 Placental Abruption
 Hemorrhage derives from separation
within maternal decidua  most of the
blood is maternal, placental villi usually
intact
 Severe placental abruption if:
 Maternal sequelae: DIC, shock, transfusion,
hysterectomy, renal failure, or death
 Fetal complication: nonreassuring fetal
status, growth restriction, or death
 Neonatal outcome: death, preterm
delivery, growth restriction

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Placental Abruption: Frequency &
Predisposing Factors
Predisposing factors:
 Demographic: advanced
maternal age, multi
parity, race, familial
association
 Pregnancy-associated
hypertension
 Preterm prematurely
ruptured membranes
 Prior abruption
 Others: cigarette
smoking, cocaine
abuse, uterine
leiomyoma, isolated
single umbilical artery,
thromboembolic
disorder
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 Placental Abruption:
Clinical Findings & Diagnosis

 Sudden onset abdominal pain, vaginal

bleeding, uterine tenderness, frequent
contractions, persistent hypertonus, preterm
labor
 No external bleeding  concealed abruption
 Complications: hypovolemic shock,
consumptive coagulopathy, couvelaire uterus,
end-organ injury

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Placental Abruption: Management
 Treatment varies depending on: Clinical condition,
Gestational age, Amount of hemorrhage
 In cases of unstable clinical condition Intensive
resuscitation with crystalloid and blood
Living viable fetus,
cesarean
vaginal delivery not
delivery
imminent

Fetus has died or vaginal

not viable-aged delivery
Diagnosis is uncertain,
fetus is alive without close
evidence of observation
compromise
If possible, delaying
expectant
delivery may benefit an
management
immature fetus

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 Placenta Previa
“
 Placenta previa: internal os covered
partially or completely by placenta
 Low-lying placenta: implantation in
the lower uterine segment,
placental edge lies within 2-cm wide
perimeter around internal os

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 Placenta Previa
• 1 per 300-400 births, rising during
Incidence the past 30 years

Demographic • maternal age, multiparity, cigarette

Factors smoking, uterine leiomyoma

• prior cesarean deliveries, high

maternal serum alpha-fetoprotein
Clinical Factors (MSAFP), assisted reproductive
technology

• painless bleeding, sentinel bleed

Clinical Features (without contraction  bleding vary
from slight to profuse

• morbidly adherent placenta,

Complications coagulation defect

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 Placenta Previa
 Diagnosis:
 Uterine bleeding after
midpregnancy suspect for
placenta previa or abruption
 Cervical digital exam should only
be done if delivery is planned
(woman in the operating room
prepared for immediate
cesarean delivery)
 sonography (preferred), MRI

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 Placenta Previa
 Management:
If bleeding dischar
 Based on fetal age and maturity,
ceased for ged
labor, & bleeding severity
2 days & home,
 Emergency delivery in 25-40% fetus is pelvic
cases healthy sched
rest
 All by cesarean delivery, uled
Hysterectomy may be needed in Near term
cesare
case of abnormally adherent and not
an
placenta bleeding
deliver
 Maternal and Perinatal Immature y
Outcomes: close
fetus &
 Increased maternal mortality and observ
bleeding
perinatal death ation
subsides

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 Morbidly Adherent Placenta


Ethiopathogenesis:
Absence of decidua
“
basalis & imperfect
development of
fibrinoid/ Nitabuch layer
 prevents placental
separation after delivery
 Tissue
hyperinvasiveness,
cesarean scar pregnancy
 Classification

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 Morbidly Adherent Placenta
 Incidence: 100 years ago: 1
in 20.000 births  1980: 1 in
“
2500 births  2015-2016: 1
in 270-731 births
 Risk Factors: associated
previa, prior cesarean
delivery, more likely if
combination of both
 Clinical Presentation:
hemorrhage
 Diagnosis: sonography, MRI

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 Morbidly Adherent Placenta
 Management: “
Timing of delivery,
Preoperative
Prophylactic
Catheterization,
Cesarean delivery &
Hysterectomy,
Conservative
Management
 Pregnancy
Outcomes
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 Obstetrical Coagulopathies
May result from:
• Disseminated Intravascular
“
Coagulation in Pregnancy,
Pregnancy Induced Coagulation
Changes, Activstion of Normal
Coagulation, Activation of
Pathological Coagulation
Diagnosis:
• Bioassay, lab tests (levels of
fibrinogen, fibrin, degradation
product, PT, PTT,
Thromboelastometry &
Thromboelastography
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 Obstetrical Coagulopathies
“
• prompt identification & removal of
the source of coagulopathy,
replacement of procoagulants,
Management restoration & maintenance or
circulation, treat hypovolemia,
antifibrinolytic agents, rFVIIa

• placental abruption,
Comorbid preeclampsia, eclampsia, HELLP
Conditions syndrome

• Fetal death and delayed delivery,

Amniotic Fluid Embolism, Sepsis
Complications Syndrome, Purpura Fulminans,
Abortion

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Management of Hemorrhage
 Fluid Resuscitaton
“
 Blood Replacement: blood component products:
 Packed Red Blood Cells, Platelets, Fresh Frozen Plasma,
Cryoprecipitate and Fibrinogen Concentrate
 Recombinant Activated Factor VII
 Tranexamic Acid
 Topical Hemostatis Agent
 Cell Salvage and Autologous Transfusion

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Management of Hemorrhage: Blood Replacement


Blood Component Products:
Packed Red Blood Cells,
Platelets, Fresh Frozen
“
Plasma, Cryoprecipitate and
Fibrinogen Concentrate
 Dillutional Coagulopathy
 Type and Screen vs
Crossmatch
 Massive Transfusion
Protocol
 Viscoelastic Assay to guide
blood product replacement

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 Adjunctive Surgical Procedures
 Uterine Artery
Ligation
“
 Uterine
Compression
Sutures
 Internal Iliac
Artery Ligation
 Angiographic
Embolization
 Pelvic Packing

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 Adjunctive Surgical Procedures
 Uterine Artery
Ligation
“
 Uterine
Compression
Sutures
 Internal Iliac
Artery Ligation
 Angiographic
Embolization
 Pelvic Packing

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Thank You
Wiiliam’s Obstetrics Chapter 41: Obstetrical Hemorrhage

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