ANTEPARTUM &

POSTPARTUM
HEMORRHAGE
LYNN SPEAKS, D.O.
ASSISTANT PROFESSOR
DEPT OF OB/GYN
 OBJECTIVES
Describe the common causes of third trimester
bleeding
Discuss evaluation of a patient with third trimester
bleeding
Identify predisposing factors of placenta previa,
placental abruption, & uterine rupture
Discuss maternal-fetal risks of placenta previa,
placental abruption,& uterine rupture
 OBJECTIVES
Define postpartum hemorrhage
Be aware of the causes of postpartum
hemorrage
Identify factors that predispose to
postpartum hemorrhage
Discuss possible sequelae of postpartum
hemorrhage
PLEASE READ ASSIGNED PAGES
PRIOR TO CLASS
ANTEPARTUM HEMORRHAGE
 ANTEPARTUM HEMORRHAGE
A 26 year old gr2 p1 with previous c/s, presents to labor and
delivery at 32 weeks gestation with complaints of vaginal bleeding.
She reports that she had a gush of bright red blood prior to arrival.
She denies abdominal pain or contractions. A small amount of
bright red blood is noted at the introitus and there is no free
bleeding. Her B/P is 120/80, pulse 92, fetal status is reassuring, no
contractions are noted. Labs: Hgb of 9.2, hct 27, elevated
fibrinogen and nl coags. The next step in her evaluation should be:

A. Induction of labor
B. Sonogram worried about placenta previa
C. Sterile vaginal exam
D. Type and crossmatch for 2 units PRBC
E. Stat C/S
 ANTEPARTUM HEMORRHAGE
The ultrasound reveals the following:

This picture is representative of:

A. Low lying placenta
B. Marginal placenta previa
C. Partial placenta previa
D. Total placenta previa complete coverage of os
 ANTEPARTUM HEMORRHAGE
The patient is hospitalized and placed on bedrest. Her
pregnancy progresses to 35 weeks gestation and she
begins to bleed profusely. A C/S is performed and the
placenta is noted to extend through the uterine serosa to
the bladder. This is most consistent with:
A. Placenta acreta abn attachement of placenta on
the myometrium (attaches too deep)
B. Placenta increta abn attachment of placenta THRU
the myometrium (pnetrates the myometrium)
C. Placenta percreta abn attachment of placenta thru
the entire uterine wall and attaches to an organ such as
bladder
D. Placental abruption
 ANTEPARTUM HEMORRHAGE
Increased risk of previa with:
Previous placenta previa
Multiple gestation
Increasing maternal age
Multiparity
With previous uterine scar:
25% risk of acreta
 ANTEPARTUM HEMORRHAGE
A 36 yr old female gr2 p1 at 32 weeks gestation presents with a
history of uterine tenderness and dark red vaginal bleeding. She
has chronic hypertension and smokes pack cigarettes/day. FHR
tracing is reassuring, uterine irritablity is noted. She has mild
abdominal tenderness on exam and scant blood at the introitus.
Ultrasound reveals anterior placenta, normal fluid, normal fetal
status. A speculum exam reveals normal cervix but no free
bleeding. Cervix is not dilated. Her hgb is 10.2 g/dl.
The most likely diagnosis is:
A. Cervicitis
B. Placenta previa
C. Placenta abruption
D. Premature rupture of membranes
E. Vasa previa fetal bleeding
 ANTEPARTUM HEMORRHAGE
The patient continues to bleed and the fetal heart rate
begins to show signs of distress. A C/S is performed.
Following delivery, profuse bleeding continues, and the
patient begins to have bleeding from her IV site. You are
concerned about:
Disseminated intravascular coagulopathy (DIC) MCC
of DIC is placenta abruption!!!
Retained products of conception
Uterine atony
Von Willebrands
Amnionic fluid embolism
ANTEPARTUM HEMORRHAGE
 ANTEPARTUM HEMORRHAGE
A 24 year old female, gr 3 p2 at 40 weeks gestation, with
one previous c/s presents to labor & delivery with severe
abdominal pain and vaginal bleeding THIS IS NOT
NORMAL LABOR. She has had an uneventful
pregnancy. An ultrasound in 2nd trimester revealed a
fundal placenta. The cervix is 4 cm dilated and no
presenting part is palpable. Fetal monitoring reveals a
bradycardic fetus. At the time of c/s, most likely you will
find
A. Normal labor
B. Placental previa fundal placenta, so no previa
C. Vasa previa
D. Uterine rupture vertical scar from previous c/s has
10-15% risk of uterine rupture!!!
 ANTEPARTUM HEMORRHAGE
Placenta previa Abruptio Placenta
Predisposing factors
Multiparity
Age > 35
Prior previa
Multiple gestation
Diagnosis
Painless bleeding
Ultrasound GOLD STND
Maternal risks
Accreta, increta, percreta
Massive hemorrhage/DIC
Fetal risks
Preterm morbidity/mortality
Fetal death
Predisposing factors
Maternal hypertension
Previous abruption
Trauma
Tobacco use
Cocaine use
Diagnosis
Painful bleeding DX is clinical
Clinical
Maternal risks
Massive hemorrhage/DIC
Abruption is MCC of DIC!!!
Fetal risks
Perinatal mortality 35%
Fetal demise
Neurologic sequelae
 ANTEPARTUM HEMORHAGE
Uterine rupture Vasa Previa
Predisposing factors Predisposing factors
Trauma Velamentous cord insertion
Prior uterine scar Multiple gestation
Spontaneous Diagnosis
Diagnosis Severe vaginal bleeding
Sudden intense pain Fetal distress
+/- vaginal bleeding Apt test blood from vagina to
Retraction of fetal parts*** check for fetal or maternal Hgb
Fetal distress Klie Hauer Betke quantifies fetal
Maternal risks cells in maternal circulation
Shock d/t loss of blood bc 500cc
gives an idea of how much
RhoGam to give to mom
of blood perfuses the placenta q
minute so this is a lot of blood Maternal risks
to lose!!! This is fetal bleeding
Death Fetal risks
Fetal risks 75% mortality bc babys
32% mortality rate vessels rupture and bleed out
POSTPARTUM
HEMORRHAGE
 POSTPARTUM HEMORRHAGE
Defined
Vaginal delivery Ceserean section
> 500cc EBL >1,000 cc EBL
 POSTPARTUM HEMORRHAGE
A 27 year old gravida 6 para 5 presents for induction of
labor for pre-eclampsia. After 18 hours of pitocin, she
has a spontaneous vaginal delivery of a 9 lb baby.
Following delivery, she experiences a postpartum
hemorrhage. The most common cause of postpartum
hemorrhage is:
A. Coagulopathy
B. Genital laceration
C. Retained products of conception
D. Uterine atony shes had 6 babies (lots of uterine
stretching) and 18 hrs of Pitocin (increased contrx) and 9lb baby
(uterine stretching)
E. Uterine rupture
 POSTPARTUM HEMORRHAGE
While evaluating the possible causes of her bleeding,
you note that the uterus is boggy despite vigorous fundal
massage and the use of an oxytocin drip. You determine
that she is in need of an additional uterine contractile
agent. Which of the following is contraindicated in this
patient?
A. Methylergonovine (Methergine) causes vasocontrx and
worsens preeclampsia
B. Prostaglandin (Hemabate) not given with asthma
C. Dinoprostone (Prostin)
D. Misoprostol (Cytotec)
E. Continuation of oxytocin not really gonna do anything bc
weve already saturated the oxytocin receptors
 POSTPARTUM HEMORRHAGE
A 22 year old gravida 2 para 1 with a previous c/s
presents in labor. After an uneventful vaginal delivery of
a 7 lb baby, you decide to manually remove the placenta
after 35 minutes. Following removal the patient bleeds
profusely. Fundal massage reveals firmness alternating
with bogginess. Uterotonic agents are utilized without
success. The most likely cause of her hemorrhage is:
A. Amniotic fluid embolism
B. Coagulopathy
C. Retained products of conception
D. Uterine inversion
E. Ruptured uterus
 POSTPARTUM HEMORRHAGE
You have identified the most likely cause
of hemorrhage is retained products of
conception. Your next action would be:
A. Curettage
B. Hypogastric artery ligation
C. Hysterectomy
D. Uterine artery ligation
E. Uterine packing
 POSTPARTUM HEMORRHAGE
An 18 year old female presents in labor. She
has a known history of VonWillebrands disease.
Following delivery, she has profuse vaginal
bleeding requiring replacement transfusions.
Which product will replace the deficiency that
causes VonWillebrands Disease?
A. Cryoprecipitate
B. Fresh Frozen plasma
C. Packed red blood cells
D. Platelets
E. Whole blood
POSTPARTUM HEMORRHAGE
 POSTPARTUM HEMORRHAGE
An 18 year old gravida 1 presents in labor. Five
minutes after an uneventful delivery the placenta
is delivered. Excessive hemorrhage is noted.
On exam, there is a purple mass at the introitus
and the fundus is not palpable. The most
common cause of this catastrophic event is:
A. Cervical laceration
B. Placental abruption
C. Mismanagement of the third stage of labor
D. Ruptured uterus
E. Retained products of conception
 POSTPARTUM HEMORRHAGE
A 32 year old female gravida 2 para 1 delivers a
healthy 8 lb baby. After an uneventful vaginal
delivery, the patient becomes cyanotic and
experiences cardiopulmonary arrest. You begin
CPR and the patient expires. The most likely
diagnosis is:
A. Placental abruption
B. Concealed hemorrhage
C. Amniotic fluid embolism
D. Uterine inversion
E. Coagulopathy
 POSTPARTUM HEMORRHAGE
A 17 year old gravida 1 was delivered by forceps
following a 2 hour second stage of labor. A midline
episiotomy was performed to assist with delivery. The
patient recovers and is transferred to the postpartum
unit. Four hours later, the patient becomes hypotensive
and tachycardic. She has minimal vaginal bleeding and
her fundus is firm. The most likely cause is:
A. Sepsis
B. Retained products of conception
C. Uterine atony
D. Genital tract traumavaginal vessels become engorged
during pregnancy with use of forceps, you can traumatize the
vaginal wall and lacerate into the vaginal wall, so no outward
bleeding
E. Delayed uterine rupture
POSTPARTUM HEMORRHAGE
 BIBLIOGRAPHY
Hacker,Moore. Essentials of Obstetrics and
Gynecology. 4th edition. 2004 pp. 146-156