William’s

William’sObstetric
ObstetricChapter
Chapter
41:
41:

Obstetrical
Obstetrical
Hemorrhag
Hemorrhag
e
e

OBSTETRIC AND GYNECOLOGY DEPARTMENT

HASANUDDIN UNIVERSITY MAKASSAR
2021
CONTENTS

1. General Considerations 6. Placenta Previa

2. Uterine Atony 7. Morbidly Adherent Placenta
3. Uterine Inversion 8. Obstetrical Coagulopathies
4. Injuries to the Birth Canal 9. Management of Hemorrhage
5. Puerperal Hematomas 10. Adjunctive Surgical
6. Uterine Rupture Procedures
7. Placental Abruption
Obstetric
Obstetrichemorrhage
hemorrhageis
isone
oneof
ofthe
theleading
leadingcauses
causesof
of
maternal
maternalmortality
mortalitythroughout
throughoutthe
theworld
world
GENERAL
GENERAL
CONSIDERATIONS
CONSIDERATIONS
Mechanism of Normal Hemostasis :
myometrial contraction  compresses
large vessels, followed by clotting and
obliteration of vessel lumens
 OBSTETRIC HEMORRHAGE

ANTEPARTUM POSTPARTUM

OBSTETRIC Placental
abruption
Tone
HEMORRHAGE
CLASSIFICATION
CLASSIFICATION Placenta previa Tissue

Tear

Thrombin
CAUSES
CAUSES OF
OF OBSTETRICAL
OBSTETRICAL HEMORRHAGE
HEMORRHAGE
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 RISK FACTORS:
remains attached  manual primiparity, high parity, labor abnormalities, labor
placental removal induction/ augmentation, prolonged 3rd stage labor,
prior post partum hemorrhage (PPH)
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/ pervaginam every 2 hours
 Misoprostol 600-1000 𝛍g per rectal, oral or sublingual

8
 UTERINE
UTERINE ATONY
ATONY MANAGEMENT
MANAGEMENT

Bleeding unresponsive to uterotonic agents:

Begin bimanual uterine compression

Call for help, call for PRC or whole blood

Request urgent help from anesthesia team

2 large IV cath: crystalloid + oxytocin

Volume resuscitation

Pts sedated: exlplore uterine cavity for retained placental fragment/ lacerations/rupture

Inspect vagina and cervix for lacerations

if still unstable  blood transfusion

9
 Uterine Atony
Management

Surgical procedures:
compression suture, pelvic vessel ligation, angiographic
embolization, hysterectomy
10
UTERINE INVERSION
Risk factors: fundal placental implantation, uterine atony, cord traction
applied before placental separation, abnormally adherent placenta

11
 Call for help: obstetrical & anesthesia

Call for PRC or whole blood

UTERINE
UTERINE Evaluate for emergency general anesthesia,
establish large IV access

INVERSION
INVERSION If placenta has separated, push the inverted

Management
fundus up to replace uterus
Management
If placenta still attached, tocolytic, reposition
uterus then remove placenta manually

When uterus is restored to normal

configuration, stop tocolysis
12
UTERINE INVERSION
Management
Management

Surgical intervention : Huntington

procedure, Haultain incision, Uterine
compression suture.
13
 INJURIES
INJURIES TO
TO THE
THE
BIRTH
BIRTH CANAL
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
 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
UTERINE
RUPTURE
• Primary or secondary
• Fetal prognosis depends on
the degree of placental
separation & magnitude of
maternal hemorrhage and
hypovolemia
• Surgical management,
hysterectomy may be
necessary
 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
Placental Abruption:
Frequency &
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
 Placental
Placental Abruption:
Abruption:
Clinical
Clinical Findings
Findings &
&
Diagnosis
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
 PLACENTAL ABRUPTION: MANAGEMENT
 Treatment varies depends 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 not vaginal

viable-aged delivery

Diagnosis is uncertain,
close
fetus is alive without
observation
evidence of compromise

If possible, delaying
expectant
delivery may benefit an
management
immature fetus
20
 PLACENTA
PREVIA

Classification:
• 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

21
 PLACENTA PREVIA
• 1 per 300-400 births, rising during the
Incidence past 30 years

• prior cesarean deliveries, high

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

• painless bleeding, sentinel bleed

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

• morbidly adherent placenta,

Complications coagulation defect

22
 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

23
 PLACENTA PREVIA
Management: If bleeding
• Based on fetal age and maturity, dischar
ceased for
labor, & bleeding severity ged
2 days &
• Emergency delivery in 25-40% home,
fetus is
cases rest
healthy sched
• All by cesarean delivery, uled
Hysterectomy may be needed in Near term
cesare
case of abnormally adherent and not
an
placenta bleeding
deliver
Immature y
Maternal and Perinatal Outcomes: close
fetus &
• Increased maternal mortality and observ
bleeding
perinatal death ation
subsides

24
MORBIDLY ADHERENT
PLACENTA
Ethiopathogenesis:
 Absence of decidua basalis
& imperfect development
of fibrinoid layer 
prevents placental
separation after delivery
 Tissue hyperinvasiveness,
cesarean scar pregnancy
 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
Morbidly
Morbidly Adherent
Adherent
Placenta
Placenta
• Management: Timing of
delivery, Preoperative
Prophylactic
Catheterization, Cesarean
delivery & Hysterectomy,
Conservative Management
 Obstetrical Coagulopathies
May result from:
• Disseminated Intravascular
Coagulation in Pregnancy,
Pregnancy Induced Coagulation
Changes, Activation of Normal
Coagulation, Activation of
Pathological Coagulation

Diagnosis:
• Bioassay, lab tests (levels of
fibrinogen, fibrin, degradation
product, PT, PTT,
Thromboelastometry &
Thromboelastography

28
 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,
Conditions HELLP syndrome

• Fetal death and delayed

delivery, Amniotic Fluid
Complications Embolism, Sepsis Syndrome,
Purpura Fulminans, Abortion
Management
Management of
of
Hemorrhage
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
 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
 Adjunctive Surgical Procedures

• Uterine Artery
Ligation
• Uterine Compression
Sutures
• Internal Iliac Artery
Ligation
• Angiographic
Embolization

32
Adjunctive
Adjunctive Surgical
Surgical
Procedures
Procedures
• Uterine Artery Ligation
• Uterine Compression Sutures
• Internal Iliac Artery Ligation
• Angiographic Embolization
• Pelvic Packing CREDITS: This presentation template
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THANK YOU