ObstetricObstetric HemorrhageHemorrhage

SUNYSUNY StonyStony BrookBrook EducationEducation Module:Module: ThirdThird Edition,Edition, JanuaryJanuary 20052005 DesignedDesigned toto promotepromote aa systemizedsystemized andand standardstandard responseresponse toto ObstetricalObstetrical HemorrhageHemorrhage

Author: Paul L. Ogburn, MD ObstetricObstetric HemorrhageHemorrhage

StonyStony BrookBrook UniversityUniversity HospitalHospital hashas implementedimplemented aa systemsystem forfor dealingdealing withwith obstetricalobstetrical hemorrhagehemorrhage toto decreasedecrease thethe riskrisk ofof maternalmaternal mortality.mortality. TheThe componentscomponents ofof thethe systemsystem include:include: 1.1. EducationEducation 2.2. PreparationPreparation 3.3. VigilanceVigilance 4.4. PersistencePersistence 5.5. ContinuousContinuous improvementimprovement ObstetricObstetric HemorrhageHemorrhage

1. Education – includes this educational CD. 2. Preparation – includes: a. standard admission orders for labor/delivery; b. standard orders for obstetrical hemorrhage emergency; c. a system developed to maintain obstetrical continuity with Maternal Fetal Medicine supervision for 24 hours after initiation of the obstetrical hemorrhage emergency; d. appropriate equipment for labor and delivery; e. appropriate training for physicians and nurses. ObstetricObstetric HemorrhageHemorrhage

3.3. VigilanceVigilance -- isis maintainedmaintained byby virtuevirtue ofof thethe systemsystem ofof orders,orders, training,training, andand monitoringmonitoring whichwhich includesincludes thethe educationeducation andand preparationpreparation mentionedmentioned above.above. 4.4. PersistencePersistence -- occursoccurs forfor eacheach individualindividual patientpatient byby virtuevirtue ofof thethe mandatedmandated 2424 hourhour monitoringmonitoring (supervised(supervised byby thethe perinatalperinatal andand obstetricalobstetrical teams)teams) followingfollowing thethe acuteacute hemorrhagehemorrhage event.event. 5.5. FormalFormal trainingtraining -- concerningconcerning obstetricalobstetrical hemorrhagehemorrhage willwill occuroccur forfor physiciansphysicians andand nursesnurses andand willwill includeinclude thisthis instructionalinstructional programprogram (with(with additionaladditional practicalpractical drills).drills). ObstetricObstetric HemorrhageHemorrhage

InIn thethe thirdthird trimestertrimester ofof pregnancy,pregnancy, bloodblood flowflow toto thethe uterusuterus isis increasedincreased toto aboutabout 600600 cccc perper minute.minute. MostMost ofof thisthis bloodblood flowsflows toto thethe undersideunderside ofof thethe placentaplacenta wherewhere itit bathesbathes thethe coteledonscoteledons.. TheThe humanhuman placentalplacental isis hemochorialhemochorial.. ThisThis meansmeans thatthat anyany lossloss inin integrityintegrity inin thethe uteroutero--placentalplacental sealseal cancan allowallow leakageleakage ofof virtuallyvirtually allall ofof thethe maternalmaternal bloodblood flowingflowing toto thethe uterus.uterus. InjuryInjury toto thethe birthbirth canalcanal oror uterusuterus oror failurefailure ofof thethe uterusuterus toto contractcontract properlyproperly afterafter deliverydelivery cancan havehave thethe samesame hemorrhagichemorrhagic effects.effects. ObstetricObstetric HemorrhageHemorrhage andand MaternalMaternal DeathsDeaths AbruptioAbruptio placentaplacenta –– 1919 percentpercent UterineUterine rupturerupture –– 1616 percentpercent UterineUterine atonyatony –– 1515 percentpercent CoagulationCoagulation disorderdisorder –– 1414 percentpercent PlacentaPlacenta previaprevia –– 77 percentpercent PlacentaPlacenta accretaaccreta –– 66 percentpercent RetainedRetained placentaplacenta –– 44 percentpercent ChichakiChichaki,, etet al,al, 19991999 CausesCauses ofof MaternalMaternal DeathsDeaths duedue toto HemorrhageHemorrhage InadequateInadequate resourcesresources andand personnelpersonnel –– forfor example,example, homehome deliverydelivery attempts.attempts. FailureFailure toto prepareprepare forfor obstetricobstetric hemorrhagehemorrhage ––forfor example,example, nono IVIV sitesite startedstarted onon admission.admission. DelayDelay inin recognitionrecognition ofof hemorrhage.hemorrhage. DelayDelay inin treatmenttreatment ofof hemorrhage.hemorrhage. TreatmentTreatment failures.failures. AntepartumAntepartum HemorrhageHemorrhage

AbruptioAbruptio placentaplacenta PlacentaPlacenta previaprevia UterineUterine rupturerupture DefinitiveDefinitive treatmenttreatment isis cesareancesarean sectionsection forfor eacheach ofof thesethese conditions.conditions. SimultaneousSimultaneous preparationpreparation forfor transfusiontransfusion shouldshould occuroccur asas needed.needed. IfIf heavyheavy bleedingbleeding continuescontinues afterafter thethe cesareancesarean section,section, treattreat asas postpartumpostpartum hemorrhage.hemorrhage. PostpartumPostpartum Hemorrhage:Hemorrhage:

““ObstetricsObstetrics isis BloodyBloody BusinessBusiness””*

*Cunningham, et. al: Williams Obstetrics, 21st ed., 2001 Postpartum Hemorrhage

Etiology is linked to Risk Factors

Bleeding from Hypotonic myometrium—uterine atony Placental Some general anesthetics Implantation Site Poorly perfused myometrium Over distended uterus Prolonged labor Very rapid labor Oxytocin-induced or augmented labor High parity Uterine atony in previous pregnancy Chorioamnionitis Retained placental tissue Avulsed cotyledon, succenturiate lobe Abnormally adherent—accreta, increta, percreta Postpartum Hemorrhage

Etiology is linked to Risk Factors

Trauma to the Large episiotomy, including extensions Genital Tract Lacerations of perineum, vagina or cervix Ruptured uterus

Coagulation Defects Intensify all of the above Postpartum Hemorrhage DODO NOTNOT UNDERESTIMATEUNDERESTIMATE BLOODBLOOD LOSSLOSS Clinical Features of Shock System Early Shock Late Shock CNS Altered mental states Obtunded Cardiac Tachycardia Cardiac failure Orthostatic hypotension Arrhythmias Hypotension

Renal Oliguria Anuria Respiratory Tachypnea Tachypnea Respiratory failure

Hepatic No change Liver failure Gastrointestinal No change Mucosal bleeding Hematological Anemia Coagulopathy

Metabolic None Acidosis Hypocalcemia Hypomagnesemia Postpartum Hemorrhage

CategorizationCategorization ofof AcuteAcute HemorrhageHemorrhage

Class 1 Class 2 Class 3 Class 4 Blood loss 15% 15%-30% 30%-40% >40% (% blood volume)

Pulse rate <100 >100 >120 >140 Pulse pressure Normal Decreased Decreased Decreased

Blood pressure Normal or Decreased Decreased Decreased increased Postpartum Hemorrhage GoalsGoals ofof TherapyTherapy

•• MaintainMaintain thethe following:following: SystolicSystolic pressurepressure >90mm>90mm HgHg UrineUrine outputoutput >0.5>0.5 mLmL/kg/hr/kg/hr NormalNormal mentalmental statusstatus •• EliminateEliminate thethe sourcesource ofof hemorrhagehemorrhage •• AvoidAvoid overzealousoverzealous volumevolume replacementreplacement thatthat maymay contributecontribute toto pulmonarypulmonary edemaedema Postpartum Hemorrhage

ManagementManagement ProtocolProtocol

To be undertaken simultaneously with management of hypovolemic shock

• ExamineExamine thethe uterusuterus toto rulerule outout atonyatony • ExamineExamine thethe vaginavagina andand cervixcervix toto rulerule outout lacerations;lacerations; repairrepair ifif presentpresent • ExploreExplore thethe uterusuterus andand performperform curettagecurettage toto rulerule outout retainedretained placentaplacenta Postpartum Hemorrhage

ManagementManagement ProtocolProtocol (cont’d.)

•• For uterine atony: • Firm bimanual compression

• Oxytocin infusion, 40 units in 1 liter of D5RL

• 15-methyl prostglandin F2a, 0.25 to 0.50 mg intramuscularly; may be repeated

• Methergine 0.2 mg IM, PGE1 200 mg, or PGE2 20 mg are second line drugs in appropriate patients • Bilateral uterine artery ligation • Bilateral hypogastric artery ligation (if patient is clinically stable and future childbearing is of great importance) • Hysterectomy Postpartum Hemorrhage Management of Hypovolemic Shock

• Insert at least two large catheters. Start saline infusion. Apply compression cuff to infusion pack. Monitor central venous pressure (CVP) and arterial pressure. • Alert blood bank. Take samples for transfusion and coagulation screen. Order at least 6 units of red cells. Do not insist on cross matched blood if transfusion is urgently needed • Place patient in the Trendelenburg position • Warm the resuscitation fluids • Call extra staff, including consultant anesthesiologist and obstetrician. • Rapidly infuse 5% dextrose in lactated Ringer’s solution while blood products are obtained. Postpartum Hemorrhage Management of Hypovolemic Shock (cont’d) • Transfuse red cells as soon as possible. Until then: •crystalloid, maximum of 2 liters •colloid, maximum of 1.5 liters • Restore normovolaemia as priority, monitor red cell replacement with Hematocrit or Hemoglobin • Use coagulation screens to guide and monitor use of blood components • If massive bleeding continues, give FFP 1 unit, cryoprecipitate 10 units while awaiting coagulation results • Monitor pulse rate, blood pressure, CVP, blood gases, acid- base status and urinary output (catheterization) Consider adding oxygen by mask. EmergencyEmergency ObstetricsObstetrics HemorrhageHemorrhage OrdersOrders TransfuseTransfuse twotwo unitsunits ofof packedpacked redred bloodblood cellscells immediately.immediately. UseUse crosscross matchedmatched bloodblood ifif available;available; otherwiseotherwise useuse typetype specificspecific oror OO negativenegative packedpacked redred bloodblood cells.cells. CallCall thethe bloodblood bankbank withwith thethe patientpatient’’ss name,name, medicalmedical recordrecord numbernumber andand DOBDOB toto requestrequest thethe twotwo units.units. BringBring aa ““requestrequest forfor releaserelease ofof bloodblood”” formform forfor crosscross matchedmatched bloodblood [or[or aa ““BloodBlood BankBank EmergencyEmergency BloodBlood ReleaseRelease”” {Downtime}{Downtime} FormForm signedsigned byby thethe physicianphysician forfor 00 negativenegative bloodblood (uncross(uncross matched)].matched)]. HemorrhageHemorrhage causescauses 30%30% ofof AllAll MaternalMaternal MortalityMortality

Causes of 763 Deaths due to hemorrhage - Abruptio Placentae 19% - Laceration or rupture 19% - Atonic uterus 15% - Coagulopathy 14% - Placenta Previa 7% - Placental accreta 6% - Uterine Bleeding 6% - Retained placenta 4% Chichaki, et al, 1999 PostpartumPostpartum HemorrhageHemorrhage

TraditionalTraditional Definition:Definition: LossLoss ofof 500500 mlml ofof bloodblood (or(or more)more) afterafter completioncompletion ofof thethe thirdthird stagestage ofof laborlabor (based(based onon clinicianclinician’’ss estimationestimation ofof bloodblood loss).loss).

– Problem 1: almost 50% of deliveries lose >500 ml of blood. – Problem 2: estimated blood loss is often less than half the actual blood loss. PostpartumPostpartum HemorrhageHemorrhage

– Problem 3: Most of the serious causes of “Postpartum Hemorrhage” have origins prior to the end of the 3rd Stage of labor.

– Problem 4: Postpartum hemorrhage, as defined, is technically misdiagnosed and clinically irrelevant. ChangeChange ofof NomenclatureNomenclature

ForFor thethe reasonsreasons given,given, considerconsider replacingreplacing thethe termterm ““ PostpartumPostpartum HemorrhageHemorrhage”” withwith thethe followingfollowing term:term:

““ObstetricalObstetrical HemorrhageHemorrhage”” ObstetricalObstetrical HemorrhageHemorrhage

NewNew definition:definition: BloodBlood lossloss associatedassociated withwith pregnancypregnancy oror parturitionparturition thatthat meetsmeets oneone oror moremore ofof thethe followingfollowing criteria:criteria: -- causescauses maternalmaternal oror perinatalperinatal deathdeath -- requiresrequires bloodblood transfusiontransfusion -- decreasesdecreases HctHct byby 1010 pointspoints -- triggerstriggers emergencyemergency therapeutictherapeutic responseresponse ObstetricalObstetrical HemorrhageHemorrhage

PlacentalPlacental causes:causes: -- PlacentaPlacenta PreviaPrevia -- AbruptioAbruptio PlacentaePlacentae -- Accreta,Accreta, increta,increta, percretapercreta -- VasaVasa previaprevia ObstetricObstetric HemorrhageHemorrhage

ObstetricObstetric TraumaTrauma -- UterineUterine RuptureRupture -- LacerationsLacerations ofof thethe BirthBirth CanalCanal -- OperativeOperative TraumaTrauma CesareanCesarean sectionssections EpisiotomiesEpisiotomies Forceps,Forceps, Vacuums,Vacuums, RotationsRotations ObstetricObstetric HemorrhageHemorrhage

UterineUterine AtonyAtony -- RetainedRetained placentalplacental tissuetissue -- OverOver distendeddistended UterusUterus -- InhalationInhalation AnesthesiaAnesthesia AgentsAgents -- UterineUterine MuscleMuscle FailureFailure -- GrandGrand MultiparityMultiparity ObstetricObstetric HemorrhageHemorrhage

CoagulationCoagulation DefectsDefects (contributory)(contributory) -- SepsisSepsis -- AmnioticAmniotic FluidFluid EmbolismEmbolism -- AbruptioAbruptio PlacentaePlacentae associatedassociated coagulopathycoagulopathy -- HELLPHELLP SyndromeSyndrome -- DilutionalDilutional CoagulopathyCoagulopathy -- InheritedInherited ClottingClotting DisordersDisorders -- AnticoagulantAnticoagulant TherapyTherapy ObstetricObstetric HemorrhageHemorrhage

AbruptioAbruptio Placenta:Placenta: -- 1/2001/200 deliveriesdeliveries -- PainfulPainful tetanictetanic uterusuterus -- BleedingBleeding maymay bebe hiddenhidden initiallyinitially -- CausesCauses 12%12% toto 15%15% ofof allall stillbirthsstillbirths -- CanCan NOTNOT bebe predictedpredicted byby teststests forfor fetalfetal wellbeingwellbeing (NST(NST nornor BPP)BPP) -- CanCan bebe associatedassociated withwith pretermpreterm laborlabor ObstetricObstetric HemorrhageHemorrhage

AbruptioAbruptio PlacentaPlacenta –– RiskRisk factors:factors: -- PreviousPrevious AbruptioAbruptio PlacentaPlacenta == 10%10% -- ElevatedElevated BloodBlood PressurePressure (chronic(chronic andand preeclampsia)preeclampsia) == 1%1% -- PretermPreterm prematurepremature rupturerupture ofof membranesmembranes == 11--2%2% -- CigaretteCigarette SmokingSmoking == 1%1% -- CocaineCocaine AbuseAbuse == 15%15% -- BluntBlunt abdominalabdominal traumatrauma == 1%1% AbruptioAbruptio PlacentaPlacenta DiagnosisDiagnosis maymay bebe lessless importantimportant thanthan thethe clinicalclinical presentation!presentation!

TreatTreat thethe bleedingbleeding andand fetalfetal distressdistress withwith deliverydelivery (often(often CesareanCesarean--section)section)

TreatTreat maternalmaternal bloodblood lossloss andand disseminateddisseminated intravascularintravascular coagulationcoagulation withwith IVIV fluidsfluids andand bloodblood productsproducts PlacentaPlacenta PreviaPrevia occursoccurs inin aboutabout 0.5%0.5% ofof pregnanciespregnancies (like(like AbruptioAbruptio Placenta)Placenta) :: -- ““painlesspainless”” antepartumantepartum vaginalvaginal bleedingbleeding -- BestBest diagnoseddiagnosed byby ultrasoundultrasound DeliveryDelivery atat termterm oror whenwhen clinicallyclinically necessarynecessary byby CesareanCesarean section.section. PlacentaPlacenta PreviaPrevia –– ObstetricObstetric HemorrhageHemorrhage

CanCan bebe associatedassociated withwith heavyheavy bleedingbleeding atat CesareanCesarean sectionsection becausebecause ofof placentalplacental invasioninvasion ofof thethe myometriummyometrium (placenta(placenta accreta,accreta, increta,increta, oror percreta)percreta) oror placentalplacental growthgrowth throughthrough thethe oldold scarscar ofof aa previousprevious CC--section.section. ObstetricObstetric Hemorrhage:Hemorrhage: MANAGEMENTMANAGEMENT DeliveryDelivery Considerations:Considerations: 1.1. AvoidAvoid difficultdifficult forcepsforceps andand vacuumvacuum deliveriesdeliveries 2.2. ConsiderConsider delayingdelaying oror avoidingavoiding episiotomyepisiotomy 3.3. (Epidural(Epidural anesthesiaanesthesia seemsseems toto helphelp us)us) 4.4. AttendantAttendant forfor thethe newbornnewborn (so(so maternalmaternal carecare isis notnot compromised)compromised) 5.5. BloodBlood bankbank availabilityavailability UterineUterine RuptureRupture

-- PriorPrior CesareanCesarean sectionsection == 11--2%2% -- ModernModern obstetricsobstetrics == 1/10,0001/10,000 toto 1/20,0001/20,000 inin unscarredunscarred uterusuterus -- InIn ““NeglectedNeglected laborslabors””,, thisthis accountsaccounts forfor manymany maternalmaternal deathsdeaths wherewhere modernmodern obstetricalobstetrical carecare isis notnot available.available. ObstetricObstetric Hemorrhage:Hemorrhage: MANAGEMENTMANAGEMENT -- ModernModern ObstetricalObstetrical CareCare –– EarlyEarly PrenatalPrenatal Care:Care: 1.1. ConfirmsConfirms IntrauterineIntrauterine PregnancyPregnancy andand givesgives correctcorrect gestationalgestational ageage (early(early ultrasound)ultrasound) 2.2. IdentifiesIdentifies riskrisk factorsfactors byby HistoryHistory 3.3. PotentialPotential forfor prevention:prevention: STOPSTOP SMOKINGSMOKING 4.4. andand treattreat drugdrug addictionaddiction 5.5. EducateEducate patientpatient andand provideprovide emergencyemergency communicationcommunication andand carecare ObstetricObstetric Hemorrhage:Hemorrhage: MANAGEMENTMANAGEMENT -- ModernModern ObstetricalObstetrical CareCare –– RoutineRoutine ManagementManagement ofof CareCare onon AdmissionAdmission forfor deliverydelivery includes:includes: 1.1. DecreasedDecreased raterate ofof VaginalVaginal BirthBirth afterafter priorprior CesareanCesarean sectionsection (and(and withwith closeclose monitoring)monitoring) 2.2. IntravenousIntravenous lineslines forfor allall patientspatients admittedadmitted inin laborlabor oror forfor inductioninduction 3.3. CloseClose monitoringmonitoring ofof MaternalMaternal andand FetalFetal conditioncondition untiluntil afterafter deliverydelivery ObstetricObstetric Hemorrhage:Hemorrhage: MANAGEMENTMANAGEMENT -- ModernModern ObstetricalObstetrical CareCare ––

1.1. InitialInitial LaboratoryLaboratory work:work: BloodBlood typetype andand HctHct 2.2. 22nd trimestertrimester ultrasoundultrasound forfor placentalplacental positionposition andand otherother riskrisk factorsfactors 3.3. MonitorMonitor bloodblood pressurepressure –– treattreat withwith restrest oror deliverydelivery ifif necessarynecessary 4.4. EMERGENCYEMERGENCY ACCESSACCESS toto HospitalHospital levellevel carecare ObstetricObstetric Hemorrhage:Hemorrhage: MANAGEMENTMANAGEMENT TheThe Placenta:Placenta: 1.1. DeliverDeliver intactintact andand inin 2020 minutes.minutes. 2.2. CheckCheck forfor evidenceevidence ofof missingmissing fragmentsfragments afterafter delivery.delivery. 3.3. IfIf manualmanual extractionextraction isis needed,needed, alertalert thethe operativeoperative teamteam ofof potentialpotential needneed forfor laparotomy.laparotomy. ObstetricObstetric Hemorrhage:Hemorrhage: MANAGEMENTMANAGEMENT BLOODBLOOD BANK:BANK: AllAll patientspatients shouldshould havehave recordsrecords ofof bloodblood typetype andand antibodyantibody screenscreen byby timetime theythey areare admittedadmitted forfor delivery.delivery. PatientsPatients atat riskrisk forfor ObstetricObstetric HemorrhageHemorrhage shouldshould havehave bloodblood drawndrawn onon admissionadmission toto eithereither holdhold inin thethe bloodblood bankbank oror crossmatch.crossmatch. ObstetricObstetric Hemorrhage:Hemorrhage: MANAGEMANTMANAGEMANT OnOn recognitionrecognition ofof Hemorrhage:Hemorrhage: 1.1. InitiateInitiate volumevolume replacementreplacement withwith lactatedlactated ringersringers oror normalnormal saline.saline. 2.2. AlertAlert bloodblood bankbank andand surgicalsurgical team.team. 3.3. ControlControl thethe bloodblood loss.loss. 4.4. InitiateInitiate decisivedecisive therapy.therapy. 5.5. MonitorMonitor forfor complications.complications. ObstetricObstetric Hemorrhage:Hemorrhage: MANAGEMENTMANAGEMENT Control the Blood Loss Immediately: 1. Uterine atony – explore uterus for retained placental tissue. 2. Uterine atony – uterine massage. 3. Uterine atony – oxytocin IM or in the Intravenous fluid, methylergonovine 0.2 mg IM, or 15-methy- prostaglandins F2alpha 0.25 mg IM. 4. Inspect the cervix, vagina, and perineum for lacerations and apply direct pressure until sutures can stop the bleeding. 5. Identification and ligation of arterial bleeding is preferred, if possible. ObstetricObstetric HemorrhageHemorrhage

IfIf HemorrhageHemorrhage isis notnot controlledcontrolled byby medications,medications, massage,massage, manualmanual uterineuterine exploration,exploration, oror suturingsuturing lacerationslacerations inin thethe birthbirth canal,canal, thenthen surgicalsurgical oror radiologicalradiological optionsoptions mustmust bebe considered.considered. AtAt thisthis time,time, start:start: 1. Packed red blood cell transfusion 2. Foley catheter and monitor urine output ObstetricObstetric HemorrhageHemorrhage

IfIf thethe patientpatient isis stablestable andand bleedingbleeding isis notnot ““torrentialtorrential””,, andand ifif interventionalinterventional radiologyradiology isis available,available, thenthen pelvicpelvic arteriographyarteriography maymay showshow thethe sitesite ofof bloodblood lossloss andand therapeutictherapeutic arterialarterial embolizationembolization maymay sufficesuffice toto stopstop thethe bleeding.bleeding. ObstetricObstetric HemorrhageHemorrhage

LaparotomyLaparotomy forfor ObstetricObstetric Hemorrhage:Hemorrhage: -- BleedingBleeding atat CesareanCesarean sectionsection -- ““TorrentialTorrential”” HemorrhageHemorrhage -- PelvicPelvic hematomahematoma (expanding)(expanding) -- BleedingBleeding uncontroleduncontroled byby otherother meansmeans ObstetricObstetric HemorrhageHemorrhage

LaparotomyLaparotomy forfor HemorrhageHemorrhage -- continuecontinue toto replacereplace bloodblood lossloss withwith fluidfluid andand packedpacked redred bloodblood cells;cells; addadd freshfresh frozenfrozen plasmaplasma andand plateletsplatelets afterafter aboutabout 66 unitsunits ofof blood.blood. UseUse pulse,pulse, bloodblood pressure,pressure, andand urinaryurinary outputoutput toto monitormonitor adequacyadequacy ofof fluidfluid replacement.replacement. ObstetricObstetric HemorrhageHemorrhage

LaparotomyLaparotomy forfor Hemorrhage:Hemorrhage: -- TransientTransient compressioncompression ofof thethe aorticaortic bifurcationbifurcation againstagainst thethe sacralsacral prominenceprominence cancan increaseincrease arterialarterial perfusionperfusion pressurepressure toto thethe maternalmaternal heart,heart, brain,brain, andand kidneys;kidneys; alsoalso thisthis willwill decreasedecrease lossloss ofof bloodblood intointo thethe operativeoperative field.field. -- ConsiderConsider cellcell saver.saver. ObstetricObstetric HemorrhageHemorrhage

LaparotomyLaparotomy forfor Hemorrhage:Hemorrhage: --UterineUterine arteryartery ligationligation (with(with additionaladditional ligationligation ofof thethe uteroutero--ovarianovarian artery)artery) -- LigationLigation ofof thethe internalinternal iliaciliac arteryartery (bilateral(bilateral maymay bebe needed)needed) -- HysterectomyHysterectomy (super(super cervicalcervical maymay needneed toto bebe done)done) ObstetricObstetric HemorrhageHemorrhage

ComplicationsComplications followingfollowing heavyheavy bleedingbleeding and/orand/or surgery:surgery: -- ShockShock lunglung requiresrequires carefulcareful fluidfluid managementmanagement andand respiratoryrespiratory therapy.therapy. -- PituitaryPituitary ischemicischemic injuryinjury (Sheehan(Sheehan’’ss syndrome)syndrome) maymay requirerequire endocrinologicendocrinologic replacementreplacement therapy.therapy. -- AcuteAcute renalrenal injuryinjury maymay requirerequire dialysis.dialysis. -- AntibioticAntibiotic therapytherapy maymay bebe indicated.indicated. ObstetricObstetric HemorrhageHemorrhage

CONCLUSIONS:CONCLUSIONS: 1.1. ManagementManagement ofof ObstetricObstetric HemorrhageHemorrhage startsstarts withwith goodgood prenatalprenatal carecare andand aa systemsystem thatthat allowsallows appropriateappropriate emergencyemergency services.services. 2.2. LogicalLogical organizedorganized approachapproach toto evaluationevaluation andand treatmenttreatment ofof ObstetricalObstetrical HemorrhageHemorrhage hashas beenbeen described.described. EmergencyEmergency ObstetricalObstetrical HemorrhageHemorrhage PleasePlease answeranswer thesethese followingfollowing questionsquestions asas aa practicepractice quizquiz followingfollowing thisthis lecturelecture (see(see nextnext slides).slides). PleasePlease makemake suggestionssuggestions concerningconcerning improvingimproving thisthis CDCD lecturelecture inin writing.writing. ThankThank youyou forfor youryour help.help. QuestionsQuestions

WhichWhich ofof thesethese drugsdrugs areare givengiven intravenouslyintravenously toto treattreat uterineuterine atonyatony?? a.a. prostaglandinsprostaglandins b.b. metherginemethergine c.c. oxytocinoxytocin QuestionsQuestions

UterineUterine bloodblood flowflow nearnear thethe endend ofof pregnancypregnancy equalsequals howhow manymany cccc perper minute?minute? AppropriateAppropriate treatmenttreatment forfor uterineuterine rupturerupture withwith vaginalvaginal bleedingbleeding is:is: a.a. cesareancesarean sectionsection b.b. emergencyemergency transfusiontransfusion c.c. prostaglandinsprostaglandins QuestionsQuestions

InIn ChichakiChichaki’’ss studystudy ofof obstetricalobstetrical hemorrhagehemorrhage inin 1999,1999, whichwhich ofof thesethese causedcaused thethe mostmost maternalmaternal deaths?deaths? 1.1. placentaplacenta previaprevia 2.2. uterineuterine atonyatony 3.3. abruptioabruptio placentaplacenta QuestionsQuestions

InIn ChichakiChichaki’’ss studystudy ofof obstetricalobstetrical hemorrhagehemorrhage inin 1999,1999, whichwhich ofof thesethese werewere associatedassociated withwith thethe highesthighest riskrisk ofof abruptioabruptio placenta?placenta? 1.1. cocainecocaine abuseabuse 2.2. previousprevious abruptioabruptio placentaplacenta 3.3. smokingsmoking

ReferencesReferences

Cunningham FG, et. al: Williams Obstetrics. McGraw-Hill, 2001, 21st ed.

Clark S, et. al: Critical Care Obstetrics. Blackwell, 1997, 3rd ed.

Clinical Practice Obstetric Committee, Society of Obstetricians and Gynecologists of Canada: Clinical Practice Committee Guidelines: Hemorrhagic Shock. Vol. 115, June 2002.

Stony Brook University Hospital Transfusion Services Manual.

Stony Brook University Hospital Transfusion Order Reminders. TheThe EndEnd

PaulPaul L.L. Ogburn,Ogburn, Jr.,Jr., M.D.M.D. DirectorDirector ofof MaternalMaternal--FetalFetal MedicineMedicine SUNYSUNY StonyStony BrookBrook