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OBSTETRICAL HAEMORRHAGE
OBGYN DEPT. RSMH/FK UNSRI

Dr. Hj. Hartati, SpOG(K)


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INTRODUCTION

Obsterics Is “ Bloody Business”


Us : 17% Direct Cause Of Maternal Deaths
Uk: Major Factor For Maternal Deaths
Developing Countries : Almost Half Of
Postpartum Deaths.
+ CAUSES AND PREDISPOSING
FACTORS

Abnormal Placentation
Trauma During Labour And Delivery
Small Maternal Blood Volume
Uterine Atony
Coagulation Defects- Intensify Other
Causes
Other Factors
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ANTEPARTUM

TRIMESTER 1
TRIMESTER 2
TRIMESTER 3
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TRIMESTER 1

Threatened Abortion
Hydatidiform Mole
Blighted Ovum
Death Conceptus
Ectopic Pregnancy
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TRIMESTER 2

Threatened Abortion
Ectopic Pregnancy
Death Conceptus
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TRIMESTER 3

Placenta Praevia
Placental Abruption
Vasa Praevia
Uterine Rupture
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Threatened Abortion

 Most common complication in the first half of pregnancy

 Its incidence varies between 20—25%

 Miscarriage is 2.6 times as likely

 17% of cases are expected to present complications later in


pregnancy

 Etiology: embryonic abnormalities, maternal, anatomic,


endocrine, infectious, immunologic factors
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Threatened Abortion

 Chief complain: bleeding per vaginum & pain

 Examination: blood, urine, pelvic examination,


ultrasonography

 Complications: fetuses are risked for intrauterine growth


retardation, preterm delivery, low birth weight, and perinatal
death.
Maternal: antepartum hemorrhage, manual removal of the
placenta, Caesarean delivery
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Threatened Abortion

Management:

 Bed rest

 Progesterone therapy

 hCG therapy

 Tocolytic agents
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Threatened Abortion

Progesterone therapy:

Oral micronized progesterone: 200 mg 1 or 2 times a day

Vaginal progesterone suppositories: 200 mg 1 or 2 times a day

Progesterone vaginal gel: 100 mg 2—3 times/day

Intramuscular progesterone: injection oil given 50 mg/day


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Threatened Abortion

Tocolytics:

Adrenergic receptor agonists

Ca2+channel blockers: Nifedipin most likely to improve fetal


outcomes and less likely to cause maternal side effects.

Oxytocin-receptor antagonist

Magnesium sulphate: IV 4—6 g loading dose, then 2—4 g/hour


titrated to uterine response and maternal toxicity.

Cycloxygenase inhibitors
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Hydatidiform Mole

 Approx. 20% patients with


primary hydatidiform mole
develop persistent GTD
(invasive mole, choriocardinoma,
placental site trophoblastic
tumor)

 Categorized as complete or
partial
+ Hydatidiform Mole
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Complete Mole

 Between 11—25 weeks, average 16 weeks

 Vaginal bleeding (97% cases), excessive uterine enlargement (50%


cases)

 Severe vomiting and pregnancy-induced HTN (25%) and


parathyroidism (7%)

 Ovarian enlargement caused by theca lutein cysts occurs in 25—


35% cases

 Levels of hCG are typically above 50.000 mIU/mL.

 USG: snowstorm appearance


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Incomplete/partial Mole
 Between 9 and 34 weeks

 Consistently associated with embryonic/fetal tissue

 Uterine size is generally small for gestational age; excessive uterine


size only in 4% patients

 Patients present with abnormal uterine bleeding in 75%

 Clinical diagnosis of missed/spontaneous abortion is made in 91%


cases of incomplete molar pregn.

 Serum hCG level normal/low

 Pre-eclampsia occurs (2.5%)


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Hydatidiform Mole

Complete hydatidiform mole. The classic “snowstorm”


appearance is created by the multiple placental vesicles
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Hydatidiform Mole

 Treatment: primary treatment for hydatidiform mole is


suction D & C

 Uterine evacuation is accomplished with the largest plastic


cannula that can safely be introduced through the cervics

 IV oxytocin is begun after the cervix is dilated and suction is


initiated, and continued postoperatively for several hours.
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Hydatidiform Mole
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Blighted Ovum

 Also called an anembryonic pregnancy or anembryonic gestation

 Occurs when a gestational sac develops without an embryo

 Often due to chromosomal abnormalities in the fertilized egg

 Occurs in the first few weeks of pregnancy

 The placenta secretes hCG  symptoms of pregnancy (+)

 Eventually results in miscarriage

 Minor abdominal cramping and light spotting/bleeding (+)


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Blighted Ovum
 An ultrasound will show an empty gestational sac
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Blighted Ovum

Management:

 D&C

 Tissue analysis after D&C


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Death Conceptus

 Fetal death before the onset of labor or fetus with no signs of


life in utero after 20 weeks of gestation

 WHO: An infant delivered without signs of life after 20 weeks


of gestation or weighing <500 gms when gestation age is not
known
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Death Conceptus

Etiology:

Unknown in 50% cases

Known:

 Maternal 5—10%
 Fetal 25—40%
 Placeental 20—35%
 Unexplained 15—35%
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Death Conceptus

Diagnosis:

 Symptoms: Absence of fetal movements

 Signs:
 Retrogression of the positive breast changes
per abdomen
 Retrogression of the height of the uterus
 Uterine tone is diminished
 Fetal movement are not felt during palpation
 Fetal heart sound not audible
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Death Conceptus

Diagnosis:

 USG (100%) + associated features can be noted (oligo,


hydrops)

 Straight X-ray abdomen (obsolete)


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Death Conceptus

Management:

Depends on:
 Single or multiple gestation
 Gestation age at death
 Parents’ wish (varied response)
 Expectant approach: 80% goes in labor within 2—3
weeks)
 Active approach
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Death Conceptus

Induction of labor:

 Fetal death <28 weeks:


 Mifepristone 200 mg followed by misoprostol
400 ug 4-6 hourly
 Fetal death >28 weeks
 Cervical ripening (mechanical/chemical)
followed by oxytocin induction
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Ectopic Pregnancy

 Implantation
outside uterine
cavity
 95% in the fallopian tube
(70% ampulla, 12%
isthmus, 11% fimbriae, 2%
interstitial/cornual)

 Ovarian occurs about 3%


of the time, abdominal 1%
and cervical <1%
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Ectopic Pregnancy
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Ectopic Pregnancy

Incidence

 Increased due to PID, use of IUCD, Tubal surgeries, assisted


reproductive techniques (ART)

 Average range is 1:100 normal pregnancies

 Late marriages and late childbearing  2%

 Recurrence rate: 15% after 1st, 25% after 2 ectopics


+ Risk Factor for Ectopic Pregnancy

 Previous PID – chlamydia infection

 Previous ectopic pregnancy

 Tubal ligation

 Previous tubal surgery

 Intrauterine device

 Prolonged infertility

 Diethylstilbestrol (DES) exposure in-utero

 Multiple sexual partners


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 THE OUTCOME OF ECTOPIC PREGNANCY

 Tubal abortion – usually in ampullary about 8 weeks –


forming pelvic haematocele
 Rupture into the peritoneal cavity
 Occur mainly from the narrow isthmus before 8 weeks or later from
the interstitial portion of the tube. Haemorrhage is likely to be
severe.
 Sometimes rupture is extraperitoneal between the leaves of the
broad ligament – Broad ligament haematoma. Haemorrhage is
likely to be controlled
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 Tubal pregnancy – effect on uterus

 Theuterus enlarge in first 3 months as if the implantation


were normal, reach the size of a gravid uterus of the same
maturity.

 Uterine decidua grows abundantly and when the embryo


dies bleeding occurs as the decidua degenerates due to
effect of estrogen withdrawal.
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Ectopic Pregnancy
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+ Clinical Finding:
 Variable - Early diagnosis
- location of the implantation
- Whether rupture has occurred
 Classic symptom
 Amenorrhoea, abdominal pain, abnromal
vagina bleeding
 Classic signs – adnexal or cervical motion
tenderness.
 With ruptured ectopic pregnancy, finding parallel
with the degree of internal bleeding and
hypovolemia – abdominal guarding and rigidity,
shoulder pain and fainting attacks and shock.
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Ectopic Pregnancy
Classical triad (50% patients)

PAIN (95% patient, variable in severity)

Amenorrhea (60—80%, slight spotting possible)

Vaginal bleeding (scanty dark brown)

Signs:

 Pain : constant, cramp-like


 Vaginal bleeding – occur usually after death of the ovum and is an
effect of oestrogen withdrawal.
 Internal blood loss – severe and rapid
 Peritoneal irritation – muscle guarding
- frequency of micturation
- fever
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 Differential diagnosis:
1. Salpingitis
2. Abortion
3. Appendecitis
4. Torsion of pedicle of ovarian cyst
5. Rupture of corpus luteum or follicular cyst
6. Perforation of peptic ulcer.
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Ectopic Pregnancy

USG Picture:

“Bagel” sign– hyperechoic ring around gestational sac in


adnexal region

“Blob” sign – seen as small inconglomerate mass next to


voary with no evidence of sac or embryo

Adnexal sac with fetal pole and cardiac activity

Corpus luteum is useful guide when looking for EP as present


in 85% cases in ipsilateral voary
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Ectopic Pregnancy
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Ectopic Pregnancy

 B-hCG

 Serum progesterone

 Diagnostic laparoscopy (GOLD STANDARD)

 Dilatation and Curretage (D&C)

 Other hormonal tests


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Ectopic Pregnancy

PRINCIPLE: Resuscitaion and Laparotomy

Shock treatment: IV line, blood sample, Folley’s catheter, colloids

Laparotomy:

Quick in quick out

Rapid exploration of abdominal cavity

Salpingectomy is the definitive surgery

Blood transfusion

Autotransfusion only when donated blood not available


 Treatment:
 If haemorrhage and shock present

 Restore blood volume by the transfusion of red cells or

volume expander
 Proceed with Laparotomy

 The earlier diagnosis of tubal pregnancy has allowed a more

conservative approach to management where the tube is less


damage.
 Pregnancy removed from the tube by laparoscopy

(salpingostomy) hopefully retaining tubal function.


 Trophoblast destroyed by chemotherapeutic agent such as

methotrexate
Medical Managment
Methotrexate 1 mg/kg body weight
Indications:
Haemodynamically stable, no active bleeding, No
haemoperitneum, minimal bleeding and no pain
No contra indication to methotrexate
Able to return for follow up for several weeks
Non laparoscopic diagnosis of ectopic pregnancy
General anaesthesia poses a significant risk
Unruptured adenexal mass < 4cm in size by scan
No cardiac activity by scan
+ HCG does not exceed 5000 IU/L
Contraindications:
 Breastfeeding
 Immunodeficiency / active infection
 Chronic liver disease
 Active pulmonary disease
 Active peptic ulcer or colitis
 Blood disorder
 Hepatic, Renal or Haematological
dysfunction
+ Side Effects:
 Nausea & Vomiting
 Stomatitis
 Diarrhea, abdominal pain
 Photosensitivity skin reaction
 Impaired liver function, reversible
 Pneumonia
 Severe neutropenia
 Reversible alopecia
 Haematosalpinx and haematoceles
+ Treatment Effects:
 Abdominal pain (2/3 of patient)
  HCG during first 3 days of treatment
 Vaginal bleeding

 Signs and Treatment failure and tubal rupture:


 Significantlyworsening abdominal pain, regardless
of change in serum HCG (Check CBC)
 Haemodynamic instability
 Level of HCG do not decline by at least 15%
between Day 4 & 7 post treatment
  or plateauing HCG level after first week of
treatment
+ Follow-Up:
 Repeat HCG on Day 5 post injection if <15 %
decrease – consider repeat dose
 If BHCG >15  recheck weekly until <25 ul/l
 Surgery should also considered in all
women presenting with pain in the first few
days after methotrexate and careful clinical
assessment is required. If these is
significant doubt surgery is the safest
option
SURGICAL MANAGEMENT:
 Laparoscopy approach – salpingostomuy
 Laprotomy – salpingostomy
 salpingectomy
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Ectopic Pregnancy
MANAGEMENT OF ECTOPIC PREGNANCY
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1. Positive pregnancy test

Asymptomatic with factors


Lowe abdominal pain + for ectopic pregnancy
Minimal Vaginal bleeding
Risk factors
Previous ectopic pregnancy
Previous PID
Tubal surgery
Tubal Surgery
Tubal pathology (PID, endometriosis
Infertility, ovarian stimulation
IUCD failure
Sterilization failure
Previous abdominal surgery
DES exposure in utero
Multiple sexual partners

2. History + clinical examination


+If sure of date of LMP and /or
If unsure of date of LMP
Regular cycle, i.e. and /or irregular cycle,
>6 wks. gestation, Measure serum hCG
Arrange TV ultrasound

If hCG <100 If Hcg >1000, use


(?early Intrauterine/ protocol for
? Ectopic pregnancy suspected
Ectopic pregnancy

3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000

Meet criteria for Does not meet criteria


Methorexate treatment for methotrexate treatment
Laproscopic /salpingotomy/
Use methotrexate Salpingectomy ?Proceed to
protocol laparotomy OR Laparotomy if
haemodynamically unstable
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TRIMESTER 3

PLACENTA PRAEVIA
PLACENTAL ABRUPTION
VASA PRAEVIA
UTERINE RUPTURE
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Placenta Previa

 The presence of placental tissue overlying the proximate to


the cervical os

 Several forms:
 Complete
 Partial
 Marginal
 Low-lying (within 2—3 cm os)
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Placenta Previa

 Incidence: 4/1000 pregnancy over 20 weeks

 Risk factors:
 Parity

 Maternal age

 Number of C-section

 Number of curettage for spontaneous/induced


abortion
 Maternal smoking

 Multiple gestation
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Placenta Previa

Clinical manifestations:

Painless vaginal bleeding: 70—80%

Asymptomatic (ultrasound): <10%

Initial bleeding typically 34 weeks

Diagnosis:

Ulstrasound
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Placenta Previa
Management:

 Admit to labor

 Maternal & fetal monitoring

 Large bore IV & crystalloid & hemodynamic stability &


adequate urine output

 Crossmatch

 Maternal cardiac monitor

 FHR: continuously monitored

 Urine output

 Laboratory monitoring
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Placental Abruption

 Separation of the placenta from the site of implantation


before delivery

 Also referred to as premature separation of placenta,


accidental hemorrhage, ablation placenta, placental
abruption

 Affects in about 9 in 1000 pregnancies.

 Usually occurs in the 3rd trimester

 Up to 15% abruptions aren’t obvious until labor or after


delivery

 Fetal distress appears early in the condition in approx. 40—


50% cases.
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Placental Abruption
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Placental Abruption

Signs and Symptoms:

 Sharp abdominal pain/back pain

 Uterine tenderness

 Vaginal bleeding

 Signs of maternal shock

 Fetal distress
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Placental Abruption
Management:

 Carefully monitored for signs of increasing separation

 Ultrasound is necessary to differentiate abruptio and previa

 Monitor fetal heart rate

 Monitor vital signs

 Check urine output, hematocrit, platelet counts, and


fibrinogen concentration determination

 C-section delivery

 Blood replacement
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Vasa Previa

 Fetal vessels crossing/running in close proximity to the inner


cervical os

 At risk of rupture

 Prevalence: 1,5—4:10.000 pregnancies

 Risk factors:
 Low-lying placenta
 Placenta previa
 Multiple pregnancy
 Multilobate placenta and velamentous insertion
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Vasa Previa

USG:
 Use color Doppler over the cervix: arterial
flow and venous flow recognized

Alternative methods:
 Digital palpation
 Amnioscopy
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Vasa Previa

Management:

Outcome is improved (97% survival vs. 44%) when prenatal


diagnosis followed by elective C-section at 35 weeks or earlier

30—32 weeks with corticosteroid to promote lung maturity


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Uterine Rupture

 A tear in the wall of the uterus, most often at the site of a


previous c-section incision.

 The vast majority of uterine ruptures occur during labor, but


can also happen before the onset of labor

 Causes:
 cephalopelvic disproportion
 grand multiparity
 uncontrolled use of oxytocin
 placental abruption
 Malpresentation
 Operative deliveries (forceps, internal version)
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Uterine Rupture

 Types: incomplete or complete

 Incomplete: mother’s peritoneum remains intact


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Uterine Rupture

Complete: the peritoneum tears and the contents of the


mother’s uterus spills into the peritoneal cavity
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Uterine Rupture

Signs & symptoms:


Vaginal bleeding
Sharp pain between contractions
Contractions that slow down or become less intense
Unusual abdominal pain or tenderness
Recession of he fetal head (baby’s head moving back up into
the birth canal)
Bulging under the pubic bone (baby’s head has protruded
outside of the uterine scar)
Sharp onset of pain at the site of the previous scar
Uterine atony
Maternal tachycardia and hypotension
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Uterine Rupture

Treatment:

 General condition must be improved: transfusion/glucose


solution

 Immediate laparotomy

 Hysterectomy
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