10/28/2016

Is this too much ? I have no disclosures Evaluating post- bleeding

Sara Whetstone, MD, MHS

“My task over the … years hasn't just been Catastrophic to stop the bleeding…” Postpartum Hemorrhage –Barack Obama

1 10/28/2016

Objectives

Persistent To describe bleeding patterns following delivery postpartum and early pregnancy loss bleeding To state 3 diagnostic possibilities for abnormal Case #1 post-pregnancy bleeding Naya calls your office. She is To develop an algorithm for evaluating now 7.5 weeks postpartum and abnormal post-pregnancy bleeding she continues to have light bleeding. She wants to know if this is normal.

What does the term ‘lochia’ mean? A. loss of B. from the C.losing part of oneself D.relating to E. shedding one’s lining 50% 50%

0% 0% 0%

u s e l f e r b i r t h o n e s o f b l o o d f i l d e ’ s l i n i n g h e u t c h Test your knowledge t o o n l o s s o m g t f r sing part o l o r e l a t i n s h e d d i n g

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What is the average duration of Lochia postpartum bleeding?

A. 42-56 days Lochia: postpartum vaginal discharge that contains blood, mucus, and uterine tissue B. 21-28 days C. 14-21 days D. 24-36 days 35%

28%

21% 16%

s a y s a y s d d 1 d a y - 5 6 2 8 http://singaporeschild.com.sg/postpartum-care-for-new-mums 4 2 2 1 - 1 4 - 2 2 4 - 3 6 d a y s

Duration of postpartum bleeding Persistent Postpartum Average duration ranges from 24 to 36 days bleeding Caution: several studies did not follow bleeding until cessation

Very little can be said about quantity of blood loss Case #1 Naya calls your office. She is >10% of women experienced bleeding beyond 40 days now 7.5 weeks postpartum and she continues to have light Common for women to stop bleeding for 1+ days and bleeding. She wants to know if then resume bleeding this is normal. Fletcher et al, 2012; WHO, 1999.

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In what percentage of does secondary postpartum hemorrhage occur? Persistent Postpartum A. Up to 2% bleeding B. 3-5% C. 7% D. up to 10% Case #1 - revised 58%

Naya calls your office. She is 2 weeks postpartum and she is 18% 18% bleeding more heavily. She is 7% filling a pad every 1-2 hours.

7 % 3 - 5 % 1 0 % p t o 2 % U u p t o

Algorithm for secondary postpartum Postpartum hemorrhage hemorrhage

Vaginal • Occurs in first 24 hours after delivery bleeding Primary • Affects 2-5% of deliveries Stable Unstable

• Occurs between 24 hours and 12 weeks Obtain H&P Obtain pelvic Manage Transfer to and labs ultrasound after delivery blood loss OR (CBC, coags) with Doppler Secondary • Affects 0.8-2% of deliveries Consider Surgical differential management diagnosis

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Placental site sub-involution Differential Diagnosis

Large patent uteroplacental Retained products of arteries that failed to conception undergo normal process of involution Arterial-venous Delayed or inadequate malformation (AVM) remodeling of vessels Placental site sub- during 3rd trimester involution Pseudoaneurysm Persistence of low- Endomyometritis Gestational resistance dilated vessels trophoblastic disease with increased flow Abnormal placentation Occurs most often in second week postpartum Weydert et al 2006; Petrovich et al 2009

Arterial-venous malformation (AVM) Pseudoaneurysm

Pseudoaneurysm does not have Can be congenital or acquired all 3 layers of the arterial wall Usually follows a history of previous uterine trauma Extraluminal collection of blood with turbulent flow that Abnormal communication between communicates with parent vessel artery & vein occurs during healing through defect in arterial wall process Can be asymptomatic, may U/S: multiple tubular or “spongy” thrombose or rupture or cause anechoic or hypoechoic areas hemorrhage within the myometrium of a normal endometrium; use of spectral Reported after pelvic surgery, Doppler very helpful vascular trauma, and uterine Vijayakumar et al 2013 curettage Baba et al 2014; Nanjundan et al 2011.

5 10/28/2016

CASE #1 - REVISED History: Uncomplicated NSVD 2 weeks ago, started bleeding heavily this morning, no infectious symptoms Persistent Exam: Vital signs wnl, perineal laceration well-reapproximated, Postpartum active bleeding from the cervix, 8 week sized uterus (non-tender) bleeding CBC & coags wnl Pelvic ultrasound

Case #1 - revised

Naya calls your office. She is 2 weeks postpartum and she is bleeding more heavily. She is filling a pad every 1-2 hours.

How long do dogs bleed after birth?

A. Up to 2 weeks Managing B. Up to 4 weeks C. Up to 6 weeks D. Up to 8 weeks E. Up to 12 weeks Case #2 47% Sonia calls your office. She was just diagnosed with a 23% miscarriage and started bleeding. She wants to know 11% 10% 9% how long to expect bleeding. What do you tell her? s e k s e e k s w e e k s 2 w e e k s 4 o o 6 w t o 8 w e e k p t o p t p t p p t o 1 2 w e U U U U U

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What is the average duration of bleeding after early pregnancy failure?

A. 3 days B. 7 days C. 10 days D. 14 days E. 21 days 35%

22% 22% 20%

Test your knowledge (part II) 1%

s s y a y a y s d a d 3 d a y s 7 1 0 1 4 d 2 1 d a y s

Bleeding after early pregnancy failure Bleeding after EPF: (EPF) some finer details

Median duration of bleeding Expectant Medical Surgical Management of EPF trial reports that a substantial (days) number of women continued to bleed at 2 weeks Early 43% of women who had medical treatment pregnancy 12 (7-15) 11 (7-15) 8 (4-14) 30% of women in the surgical treatment failure

For women with a pregnancy loss prior to 6 wks GA : Embryonic 12 (7-16) 11 (7-15) 9 (4.8-14) Length of bleeding with loss was similar to usual demise menstrual length Bleeding associated with loss slightly longer (0.4 Incomplete days) 10 (7-13.3) 9 (6-14) 7 (4-12)

Trinder et al 2006 (MIST trial) Davis et al, 2007; Promislow et al 2007.

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How long does it take for the B-HCG level to Decline of serum HCG after spontaneous trend to undetectable following early complete abortion pregnancy failure?

A. 7 days B. 14 days C. 21 days Initially a steep decline D. It depends…. Less steep decline if 57% initial value < 500 mIU/mL

24% 18%

0%

s Barnhart K et al Obstet Gynecol a y a y s d d a y s d n d s … . 7 1 4 2 1 2004 I t d e p e

Expected percentage decline in serum hCG levels Managing miscarriage

Case #2 Sonia calls your office. She was just diagnosed with a miscarriage and started bleeding. She wants to know how long to expect bleeding. What do you tell her? Barnhart K et al Obstet Gynecol 2004

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Differential Diagnosis

Managing Retained products of miscarriage Coagulopathy conception Arterial-venous Endomyometritis Case #2 - revised malformation Abnormal Sonia calls your office. She Pseudoaneurysm was diagnosed with a placentation miscarriage; she opted for Gestational medical management. She is Trauma now bleeding heavily. How trophoblastic disease do you manage her?

Algorithm for evaluating bleeding Spectrum of after EPF normal ultrasound Vaginal bleeding findings

Stable Unstable

Obtain H&P Obtain pelvic Manage Transfer to and labs ultrasound blood loss OR (CBC, coags) with Doppler

Consider Surgical differential management diagnosis

9 10/28/2016

Endometrial thickness Ultrasound & retained POCs

Endometrial thickness alone does not predict Normal appearance of who will require D&C cavity after spontaneous abortion is variable and Even when EMS > poorly described 30mm Ultrasound associated with high false positive Endometrial thickness rate of retained POCs is greater in women Endometrial thickness is who require D&C after poor predictor of need medical abortion or Poor test for predicting for surgical intervention medical management need for D&C of SAB Reeve et al, 2008; Reeves et al, 2009.

Are there other So how do we use studies to assess ultrasound? for retained

POCs? Hyperechoic endometrial mass or solid component in endometrium Saline sonogram Retained POCs

Heavy or Hysteroscopy prolonged bleeding

10 10/28/2016

Objectives Managing miscarriage To describe bleeding patterns following delivery and early pregnancy loss

To state 3 diagnostic possibilities for abnormal Case #2 - revised post-pregnancy bleeding Sonia calls your office. She was diagnosed with a To develop an algorithm for evaluating miscarriage; she opted for medical management. She is abnormal post-pregnancy bleeding now bleeding heavily. How do you manage her?

How soon does the next menses occur after early pregnancy failure?

A. 2 weeks B. 4 weeks C.5 weeks Thank you D.6 weeks E. 8 weeks

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