Obstetric Hemorrhage

M Fahlevy MD, O&G

Obstetrics and Gynecology
Pelabuhan Ratu General Hospital
 Third Trimester Bleeding
A 32 yo G2P1 presents at 36 weeks
complaining of bright red vaginal bleeding.
Upon further questioning she does admit
to having had some light bleeding on 1 to
2 occasions last week. Her previous
pregnancy was delivered at term by a
Classical Cesarean Section for footling
breech presentation.
 Differential Diagnosis?
Placenta Previa
Uterine Rupture
Placental Abruption
Vasa Previa
Laceration
Vaginal mass
 Placenta Previa
Painless third-trimester bleeding
Complicates 4-6% pregnancies between 10 and 20
wks, 0.5% pregnancies >20 weeks
Risk factors
Increasing parity, maternal age, prior c/s, curettages for
sabs/tabs
Placental tissue overlying the internal os. Types?
Complete previa (20-30%)
Partial previa (does not completely cover)
Marginal (proximate to os)
Management: pelvic rest, u/s, IV, T+S, C/S
 Associated Conditions
Placenta accreta, increta, percreta
Risk inc w/ inc no. of prior c/s (50% risk in pt
w/ previa and 2 prior c/s)
Vasa Previa
Vessels traverse the membranes in the lower
uterine segment in advance of the fetal head.
Rupture can lead to fetal exsanguination
 Uterine Rupture
Associated with Prior c/s
Rates of uterine rupture?
Spontaneous rupture (no c/s history): 1/2000
(0.05%)
Low Transverse: 0.5%-1%risk rupture, VBAC
80% success rate
Classical C/s: 10% risk rupture, schedule
amnio/c/s ~37 weeks.
 Placental Abruption
Premature separation of placenta
Painful third-trimester bleeding
Risk Factors
smoking, trauma, HTN cocaine, pprom,
polyhydramnios, multiples
Trauma evaluation
bleeding, contractions, abdominal pain and NRFHT in
4hrs
U/s misses up to 50% of abruptions
Management: IV, T+X, Continuous monitoring,
c/s vs. vag delivery
 Case Contd
U/s reveals active, vertex fetus. Placenta
anterior and free of os. Pt having
contractions q 2-3 minuters. Bleeding
increases. BP drops from 110/60 to
palpable systolic pressure of 70. FHT
drops from 120 to 90 bpm.

What do you do???

 Post Partum Hemorrhage
A 34yo G6P6 patient at term has just
delivered a 4000gm infant after second
stage of labor lasting 3 hours. The
placenta delivered spontaneously and the
patient is bleeding briskly.
What is average EBL w/ SVD?
500cc
What is average EBL w/ C/S?
1000cc
 Classes of Hemorrhage
Class 1
<900cc
Minimal symptoms
Class 2
1200-1500cc
Tachycardia, tachypnea
Class 3
1800-2100cc
Overt Hypotension, cold, clammy skin
Class 4
2400cc
Shock, absent BP
 Management
Fluids
Crystalloid, open wide/bolus
Labs
Cbc, coags, fibrinogen
Transfuse PRPCs
FFP
Larger vol (250cc/unit, all coagulation factors)
Cryopercipitate
Smaller volume (20cc/unit, many coagulation
factors)
 Differential Diagnosis
Atony
Uterine inversion
Laceration (cervical, vaginal)
Retained Placenta
 Uterine Atony
Risk factors
multiparity, multiple gestation, macrosomia, abruption, retained
POCs, placenta previa, induction (prolonged pitocin)
Management
Bimanual exam/massage
IV acess/fluids
Oxytocin, methergine 0.2mg IM, Hemabate 250mcg IM,
misoprostol 800 to 1000mcg rectally
Laparotomy
Uterine artery ligation
B Lynch
Hysterectomy
UAE
 Uterine Inversion
Inverted fundus extends beyond cervix
(looks beefy red)
Stop pitocin if infusing
Replace uterus
Relaxants if necessary (terbutaline,
MgSo4, Nitrogylcerin)
Anesthesia
Laparotomy