Obstetrics hemorrhage

Rubleva Elizabeth
Bleeding during pregnancy is not a rare phenomenon
and has been associated with significant maternal and
fetal morbidities and even mortality.
Hemorrhage is a major complication of abnormal
placentation, and early diagnosis and intervention in
these conditions can more readily enable the
physician to minimize the risks to mother and fetus.
 Main causes
➢placenta previa
➢premature detachment of the normally located placenta
➢erosion and polyps of the cervix
➢cancer of the cervix and vagina
➢rupture of varicose veins of the vagina
➢vaginal trauma
➢rupture of the umbilical cord vessels during their
envelope attachment
 Placenta previa
Placenta previa is an obstetric complication that
classically presents as painless vaginal bleeding
in the third trimester secondary to an abnormal
placentation near or covering the internal
cervical os.
Because of the inherent risk of hemorrhage,
placenta previa may cause serious morbidity and
mortality to both the fetus and the mother.
Placenta previa often leads to preterm delivery,
with 44% of pregnancies with placenta previa
delivered before 37 weeks.
 Classification
Placenta previa is classified by the degree of
encroachment upon the internal cervical os.
➢total placenta previa
➢partial placenta previa
➢marginal placenta previa
 Low-lying placenta
The term low-lying placenta has
been used when the placental
edge does not reach the cervical
os, but is close enough to be
palpated by an examiner's finger.
Placental edge that approaches to
within 2 cm of the cervix on
ultrasound examination.
 Invasive placentas
➢ In placenta accreta, the abnormally adherent placental villi are attached
directly into the myometrium, but do not invade it.
➢ In a placenta increta, the villi invade the myometrium.
➢ When the placental villi penetrate through the myometrium, reaching the
serosal surface of the uterus, then a placenta percreta is present.
 Risk factors

✓ Maternal age ≥ 40 ✓ Pregnancy-induced hypertension

✓ Illicit drugs ✓ Previous placenta previa
✓ Cesarean section ✓ Caesarean delivery
✓ Prior abortion ✓ Myomectomy
✓ Multiparty ✓ Alcohol use during pregnancy
✓ Smoking ✓ Women with a large placentae
✓ Congenital anomalies from twins or erythroblastosis

✓ Placental pathology
 Presentation of placenta previa
➢Painless vaginal hemorrhage in a previously normal
pregnancy.
➢Bleeding episodes that often cease within 1 or 2 hours.
➢The amount of bleeding is usually proportional to the
degree of placenta previa.
➢An absence of abdominal discomfort;
➢Normal fetal heart tracing on electronic monitoring.
Patients with a complete placenta previa
bleed earlier and heavier than do those
with a partial or marginal previa.
 Diagnostics
✓History
✓Abdominal examination
✓ Leopold's maneuvers
✓ Malpresentation

VAGINAL EXAMINATION IS AVOIDED IN

KNOWN CASES OF PLACENTA PREVIA
 Confirmatory
Previa can be confirmed with an ULTRASOUND.
Transvaginal ultrasound has superior accuracy as compared to transabdominal
one, thus allowing measurement of distance between placenta and cervical
os.
The diagnosis can be confirmed after surgery
with histopathologic examination of the
uterus or by biopsy of the placental bed.

Diagnosis before delivery would allow

adequate surgical preparation to decrease
maternal morbidity and mortality.
 Differential Diagnoses

➢Abruptio Placentae
➢Cervicitis
➢Disseminated Intravascular Coagulation
➢Pregnancy, Delivery
➢Premature Rupture of Membranes
➢Preterm Labor
➢Uterine Rupture in Pregnancy
➢Vaginitis
➢Vulvovaginitis
 Management
➢ An initial assessment to determine the status of the mother and fetus.
➢ In most cases mothers should be treated in the hospital from the first
bleeding episode until birth.
➢ Immediate delivery of the fetus may be indicated if the fetus is mature or if
the fetus or mother are in distress.
• Corticosteroids are indicated at 24–34 weeks gestation, given the higher
risk of premature birth.
Elective cesarean delivery are usually advocated at 35
to 36 weeks' gestation.

Blood volume replacement and blood plasma

replacement may be necessary.
 Partial placenta previa
Most practitioners use ultrasound to assess the degree of
previa when delivery decisions are being made.
There is agreement that when the placental edge is at least
2 cm from the cervical edge, and the fetus is in vertex
presentation, it is usually safe to allow the patient a trial
of vaginal labor.
In most cases, when the placental edge is less than 2 cm
from the cervical os, it is considered preferable to
proceed with elective cesarean to prevent massive
hemorrhage and its complications.
Placenta accreta, increta, and percreta remain among the greatest treatment
challenges in modern obstetrics.
The cooperation of members of a multidisciplinary team headed by the
obstetrician and including neonatology, anesthesia, blood bank, urology (if
bladder involvement is suspected), general surgery, and possibly
interventional radiology.
uterine artery catheters placed before surgery
 Complications
Maternal Fetal

➢ Antepartum hemorrhage ➢ IUGR

➢ Malpresentation ➢ Hypoxia
➢ Abnormal placentation ➢ Premature delivery
➢ Postpartum hemorrhage ➢ Death
➢ Placenta previa increases the risk
of puerperal
sepsis and postpartum
hemorrhage
 Placental abruption
The complete or partial separation of a normally located placenta from its
uterine site before the delivery of the fetus.
This definition differentiates this process from placenta previa, in which the
placenta is implanted in an abnormal anatomical position covering the
internal cervical os.
Placental abruption of various degrees occurs in approximately
1% of all pregnancies or 1 in 100 births.
Abruption is associated with a perinatal mortality rate of 119 per
1000 births.
 Risk factors

✓ Maternal age and parity ✓ Chronic hypertension +

✓ Cigarette smoking preeclampsia

✓ Cocaine and drug use ✓ Premature rupture of membranes

✓ Multiple gestations ✓ Oligohydramnios

✓ Chronic hypertension ✓ Chorioamnionitis

✓ Mild and severe preeclampsia ✓ Dietary/nutritional deficiency

✓ Male fetus
The magnitude of the placental surface that becomes separated from the
maternal blood supply determines the clinical picture by affecting the
amount of acute blood loss from the mother and the decrease in oxygen
supply to the fetus, leading to fetal distress or possible death.

Patients with a small placental detachment may be

asymptomatic.
 Symptoms

➢sudden onset of antepartum vaginal bleeding

➢ a distinctive tender uterus with increased resting tone
➢hypertonic or hyperactive uterine contractions.
➢ Blood tracking to the decidua basalis results in placental separation and resultant

fetal hypoxia.

➢ Hemorrhage into the decidua basalis with the formation of a hematoma.

➢ The decidua separates because of localized anoxic necrosis and pressure resulting

from bleeding into a confined space

➢ As the hematoma expands, disruption and separation of the basal plate from the

decidua increases until complete placental detachment results.

 The hematoma that results may remain localized and may not extend to a
point at which it becomes manifest clinically.
In most patients, the bleeding from placental separation extends to the edge of
the placenta, at which point it may either break through the amniotic
membranes and enter the amniotic fluid or, more frequently, continue to
dissect between the chorion and decidua vera until it reaches the internal
cervical os and vagina.
The blood exits from the vagina as revealed hemorrhage.

The color of the blood varies from bright red to dark brown.

Depending on the time elapsed since initiation of bleeding and the distance of
implantation of the placenta from the cervical os, the hemorrhage may
remain concealed and completely retained inside the uterus.
If the concealed hemorrhage Most patients with abruptio
dissects through the amniotic placentae, however, have
membranes to discolor the “mixed” bleeding, containing
amniotic fluid, it often elements of external and
produces the classic “port internal hemorrhage.
wine” discoloration that is
almost pathognomonic of
abruption.
It is important to remember that the amount of vaginal
bleeding often is only a small portion of the total lost
from the circulation and is not necessarily a reliable
indicator of the severity of the condition.
Grade I: Mild There may be slight vaginal bleeding and uterine irritability. Maternal blood
pressure usually is normal, and there is no maternal coagulopathy or fetal distress. The
diagnosis of this class of abruptio placentae is confirmed on postpartum detection of a
small retroplacental clot.

Grade II: Intermediate. This diagnosis is based on the classic features of abruptio placentae
with uterine hypertonicity, but the fetus still is alive. There is a greater amount of vaginal
bleeding (mild to moderate), hypofibrinogenemia, and fetal distress. Blood pressure is
maintained, but the pulse rate may be elevated and postural blood volume deficits may
be present.

Grade III: Severe. In such cases, the fetus is always dead. Usually, heavy vaginal bleeding
occurs, although in some cases this may be concealed. Maternal hypotension,
hypofibrinogenemia, and thrombocytopenia are present, along with a tetanic uterus.
 Diagnostics
✓ sudden, sharp, severe pain that persists or evolves into a poorly localized
dull ache in the lower abdominal or sacral areas.
✓ abnormal uterine tenderness
✓ vaginal bleeding
✓ bloody amniotic fluid
✓ fetal heart rate abnormalities
✓ maternal hypovolemia
 Laboratory values
➢ Hematocrit may be normal or low.
➢ The leukocyte count is variable, but often there may be a mild or moderate
leukocytosis.
➢ Coagulation defects manifested by decreased platelets, elevated
prothrombin time (PT), decreased fibrinogen levels, and elevated fibrin

split products.
 Ultrasonography
The sonographic diagnosis of abruptio placentae classically has been
described as a diagnosis of exclusion when ultrasound has failed to show a
placenta previa and other causes of vaginal bleeding have been ruled out.
 The differential diagnosis

➢placenta previa
➢premature labor
➢genital tract trauma
➢carcinoma of the cervix or vagina
➢coagulation defects
➢hemorrhagic cystitis
 Complications
Maternal Fetal

➢ hemorrhagic shock The four major causes of perinatal

➢ generalized coagulopathy death are:
➢ ischemic necrosis of distant ➢ fetal anoxia
organs. ➢ exsanguination
➢ preterm PROM ➢ prematurity
➢ intrauterine growth restriction
 Management
A plan of management for patients with placental abruption must
take into account the condition of both mother and fetus.

Presented here is a discussion of the initial evaluation and

stabilization of patients, evaluation of the maternal hemostatic
mechanisms, formulation of a satisfactory therapeutic plan,
and postpartum care.
✓Patients presenting with antepartum bleeding should be
immediately admitted to the labor and delivery suite.

✓Maternal vital signs should be assessed and taken initially.

✓Electronic fetal heart rate and uterine activity monitoring

should be instituted.
✓Replacement of fluid and blood products as needed.

✓Blood should be drawn for hemoglobin, hematocrit,

PT, fibrinogen, fibrin split products, electrolytes, and
renal function studies.
 After a brief initial evaluation, a careful speculum
examination should be performed to ensure that the
bleeding is coming from the uterine cavity rather than
the perineum, vagina, or cervix.
✓Gestational age and fetal status must be rapidly and
accurately assessed.

✓ The responsible members of the anesthesia and

pediatric departments should be informed of the
patient's status.
✓Determination of fetal status.
✓Heart rate monitoring.
✓ Ultrasonography.
 Therapeutic Plan
➢The longer the interval between diagnosis and
delivery, the greater the risk for maternal
complications and the poorer the outlook for
fetal or neonatal salvage.
➢The timing and method of delivery depend on
maternal and fetal condition, gestational age,
and cervical status.
➢ The premature fetus with a mild abruption and minimal bleeding may be
managed expectantly with close observation, because this often is a self-
limiting event.

➢ Tocolysis may be considered and has been used with caution in certain cases.

➢ There is evidence that such pregnancies may be successfully prolonged without

increased jeopardy to the mother or fetus.

➢ Magnesium sulfate is the tocolytic agent of choice because betamimetic agents

can have adverse hemodynamic effects on a bleeding patient by accentuating
further signs of hypovolemia (hypotension and tachycardia).
In the premature fetus with persistent, heavy vaginal bleeding,
however, use of tocolytics would be contraindicated, and
expeditious delivery is recommended.

Any attempt at tocolysis should be weighed against the severity

of abruption and likelihood of neonatal survival and morbidity.
If the abruption is adversely affecting maternal or
fetal condition, delivery should be performed.

In cases of premature placental separation,

cesarean delivery should be performed liberally
for maternal or fetal reasons.
 Vaginal delivery
❖Many patients with placental abruption already have contractions;
therefore, cesarean delivery may not be necessary.
❖Abruption may even cause a rapid and tumultuous labor.
❖Oxytocin may be used to augment uterine contractions.
In a patient with extensive
uterine involvement and
uncontrollable blood loss,
a hysterectomy may be
indicated.
 Postpartum Care
✓ After delivery, a patient's hemodynamic status should be carefully
monitored.
✓ Judicious use of transfusion or diuretics may be required, based on
central hemodynamic monitoring indices, hemoglobin
concentration, and urine output.
✓ Coagulation defects generally correct rapidly, although fresh-frozen
plasma or platelet transfusions occasionally are necessary to hasten
the process.
✓ Pulmonary status must be carefully monitored.
✓ Patients may have acute renal failure as a result of hypovolemia and
vasospasm.
 Postpartum Hemorrhage

Because PPH is one of the more common and, usually, easily

treated complications of delivery, the obstetrician may be
lulled into underestimating the volume and impact of PPH
until a catastrophic situation has developed.
PPH is best managed by a high level of awareness of the causes
of hemorrhage and a systematic approach to management
when this problem develops.
Postpartum hemorrhage is widely defined as a blood
loss of more than 500 mL after delivery of the
placenta in case of vaginal delivery or more than
1000 mL in case of cesarean section.
 Uterine Atony

Patients at increased risk for uterine atony:

➢high parity;
➢overdistended uterus;
➢prolonged or rapid labor;
➢use of oxytocin for induction or
augmentation;
➢use of magnesium sulfate.
 Laceration
Lacerations of the perineum, vagina, cervix, or uterus
may result in visible or concealed hemorrhage.
Careful examination of the birth canal, including both
inspection and palpation, is necessary to eliminate
laceration as a source of PPH.
The obstetrician should also be aware of the potential
of uterine rupture to cause massive hemorrhage.
High parity, oxytocin use, and obstetric procedures
(e.g., forceps, breech delivery) are risk factors for
uterine rupture.
 Retained Placenta
Retained placenta causes uterine atony by preventing uterine
contraction, which compresses the myometrial spiral arteries.

At the time of delivery, the maternal surface of the placenta should be

carefully inspected to ensure that no fragments are missing.

The fetal surface is then examined, with particular attention to the

margins to look for severed blood vessels that may have led to a
succenturiate placental lobe.
 Placenta Accreta
Placenta accreta occurs when placental villi attach directly to or invade the
myometrium, preventing normal placental separation.
Placenta accreta is commonly associated with placenta previa or a history of
prior cesarean section, dilatation and curettage, or abortion.
Accreta should be considered whenever a retained placenta occurs or when
manual removal of the placenta is particularly difficult.
 Coagulopathy

Most coagulopathies (e.g., idiopathic thrombocytopenic purpura,

von Willebrand's disease) may also cause PPH.
Disseminated intravascular coagulation from abruptio or severe
preeclampsia may also result in PPH.
Coagulopathies have the potential to cause PPH up to several
days after delivery.
 Uterine Inversion
Uterine inversion has been reported in the past to be
extremely rare and to have an associated high mortality
rate.
The major complication of uterine inversion is PPH. Shock
is directly related to the volume of blood lost.
Uterine inversion can occur spontaneously but usually is
associated with uterine fundal pressure and cord traction
to deliver the placenta.

In all of the cases the uterus was replaced

manually.
 MANAGEMENT
Management of PPH begins before excessive blood loss has occurred
by carefully observing for the rate of bleeding immediately after
delivery.
Active management of the third stage involves early cord clamping,
prophylactic administration of uterotonic agents before placental
delivery, and controlled cord traction.
✓Obtaining history
✓Physical examining
✓Vaginal examination
✓Vital signs
✓Laboratory tests ( complete blood count, hemoglobin,
hematocrit, coagulation studies, electrolytes, creatinine,
fibrinogen, blood group, Rh factor, platelets)
✓Lee white test
 Uterine atony
Diagnostic maneuver - Palpate uterus
✓Uterine massage
✓Establish intravenous access (if not established)
✓Oxytocin
✓Methylergonovine
✓Prostaglandin (Carboprost or alternative)
✓Catheterize bladder
✓Obtain blood for transfusion (if not already available)
✓Prevent/treat shock
 Lacerations

Diagnostic maneuver - Examine perineum, vagina,

cervix
Repair lacerations
 Retained products

Diagnostic maneuver - Manually explore uterus

✓Manual removal
✓Dilatation and curettigs
 Uterine inversion
Diagnostic maneuver –
Manually explore uterus
✓Replace uterus
✓Surgical replacement
 Uterine rupture
Diagnostic maneuver - Manually explore uterus
Laparotomy for repair or hysterectomy
 Coagulopathy

Diagnostic maneuver -
Coagulation studies

Specific factor replacement

If above measures are unsuccessful, presume uterine atony,
uterine rupture, or intra-abdominal lace
✓ Repeat prostaglandin
✓ MAST suit (if available)
✓ Uterine artery embolization
✓ Uterine tamponade
✓ Laparotomy
✓ B-Lynch compression suture
✓ Hypogastric artery ligation
✓ Hysterectomy
 Arterial Embolization
As interventional radiology techniques become more widely available, arterial
embolization is a reasonable choice for control of continued hemorrhage when
lacerations have been excluded or repaired and uterotonics are not effective.
This approach has also been effective in situations of continued hemorrhage after
hypogastric artery ligation or hysterectomy.
 Uterine artery ligation
The needle is passed into and through the myometrium from anterior to posterior 2–3
cm medial to the uterine vessels and brought through the avascular area of the
broad ligament lateral to the artery and the vein.
This appears to be effective by reducing the pulse pressure to the uterus, because
approximately 90% of the blood flow to the uterus is from the uterine artery.
 Uterine compression procedures

The B-Lynch suture mechanically compresses the

uterus to treat hemorrhage resulting from intractable
atony.
 Hypogastric artery ligation

The reported success rate of hypogastric

artery ligation varies from 40% to 80%.

It works by reducing pulse pressure and

not by absolute control of blood flow; it
decreases ipsilateral blood flow by
approximately 50% and decreases pulse
pressure by approximately 85%.
 Hysterectomy
Hysterectomy can be a life-saving operation, and
temporizing measures can lead to further
deterioration of the patient's hemodynamic
status.
The choice of total versus subtotal
(supracervical) hysterectomy is dictated by
the patient's status at the time of operation, as
well as by the difficulty of the procedure.
The cervix should be removed if it is technically
feasible and the patient is stable.

The indication for the operation is

massive hemorrhage.
 Replacement of a Uterine Inversion
Uterine inversion may present as the uterine fundus
protruding through the cervix and vaginal introitus
(complete inversion) or as only a depression of the
uterine fundus into the endometrial cavity (partial
inversion).
The uterus can usually be replaced by steady pressure
against the fundus or by gradually replacing the
uterus from the edges with pressure from the
fingertips

Replacement of the uterus may be facilitated

by tocolytic drugs.
Changes in coagulation and fibrinolysis after delivery

✓ Increase in clotting activity at the time of delivery is most likely related to expulsion of the
placenta and release of thromboplastic substances at the site of separation.
✓ The changes in the haemostatic mechanism during the puerperium were the same as those
observed after extensive surgery.
✓ The mean platelet count decreases slightly at the time of placental delivery and starts to
increase on days 2–5 post-partum.
✓ In high-risk patients where thromboprophylaxis is indicated postpartum, the difference in
reactive thrombocytosis postpartum, due to operative delivery, ought to be taken into account.
✓ Plasma AT levels significantly rise after normal delivery for at least 2 weeks
postpartum.
✓ A rise inprotein C level has been shown immediately after delivery and still 3 days
postpartum.
✓ The level of total and free protein S increases significantly after delivery from the first day of
the puerperium
✓ Total protein S normalizes in the first week postpartum, free protein S was reported not
normalized at 5 weeks postpartum.
 Prevention of postpartum hemorrhage
Antenatal preparation.
✓ Identifying clinical and obstetric risk factors for PPH is a key step in preventing
PPH from occurring.
✓ The prenatal evaluation should include a thorough history taking, a complete
physical examination, and laboratory screening.
✓ Necessary laboratory tests include determination of the content of basic blood
elements, prothrombin time, activated partial thromboplastin time.
✓ Special attention should be paid to family history: bruising, bleeding with minimal
damage, surgery, pregnancy and childbirth.
✓ Patients with a history of metromenorrhagia should be carefully examined.
✓ Thorough study of platelet function is necessary.
 Prenatal laboratory screening includes the following
laboratory tests:
✓complete blood count;
✓prothrombin time (RT);
✓activated partial thromboplastin time (PTT);
✓bleeding time.