Bleeding Emergencies in Pregnancy

OBJECTIVES

• MANAGEMENT OF PLACENTA PREVIA • MANAGEMENT OF PLACENTA ACCRETA BLEEDING EMERGENCIES IN • IDENTIFICATION AND MANAGEMENT OF PLACENTAL ABRUPTION PREGNANCY • IDENTIFICATION AND MANAGEMENT OF POSTPARTUM HEMORRHAGE

PRESENTED BY:

AMY FITCH RNC-OB

ALLISON SHANKLAND RN, BSN

DISCLOSURES PREGNANCY & PLACENTAS

• TEMPORARY ORGAN SUPPLYING NUTRIENTS AND OXYGEN TO A FETUS • TYPICALLY ATTACHES TO THE TOP OR SIDE OF THE UTERUS • SOME PLACENTAL ISSUES CAN BE IDENTIFIED EARLY IN PREGNANCY, BY ULTRASOUND • WE HAVE NO CONFLICT OF INTERESTS TO DISCLOSURE • A HEALTHY PLACENTA IS KEY TO A HEALTHY PREGNANCY • POTENTIAL PLACENTA RELATED COMPLICATIONS INCLUDE: PREVIA ABRUPTION RETAINED PLACENTA CORD ISSUES IMPLANTATION ISSUES

PLACENTA PREVIA WHO IS AT RISK AND COMPLICATIONS

• PLACENTA ATTACHES SO THAT IT PARTIALLY OR COMPLETELY COVERS THE CERVIX • RISK FACTORS: PREVIOUS DELIVERIES, PREVIOUS PREVIA, UTERINE • CAUSE IS UNKNOWN SCARRING, MORE THAN ONE FETUS, MATERNAL AGE 35 OR OLDER, RACE OTHER • CESAREAN SECTION DELIVERY IS INDICATED THAN WHITE, SMOKER, COCAINE USE • DELIVERY INDICATED BETWEEN 36-37 WEEKS GESTATION • EMERGENT CESAREAN MAY BE INDICATED DEPENDING ON SEVERITY OF BLEEDING, • COMPLICATIONS: BLEEDING DURING PREGNANCY, HEMORRHAGE DURING MATERNAL HEMODYNAMIC STABILITY OR FETAL DISTRESS LABOR, DELIVERY OR IMMEDIATE POST PARTUM PERIOD OTHER ABNORMAL PLACENTA IMPLANTATION PLACENTAL IMPLANTATION

• PLACENTA ACCRETA- PLACENTA GROWS TOO DEEPLY INTO THE UTERINE WALL. PLACENTA DOES NOT COMPLETELY DETACH FROM UTERINE WALL AFTER CHILD BIRTH.

• PLACENTA INCRETA- PLACENTA GROWS INTO THE UTERINE MUSCLE.

• PLACENTA PERCRETA- PLACENTA GROWS THROUGH THE UTERINE WALL, POTENTIALLY INTO SURROUNDING ORGANS.

This Photo by Unknown author is licensed under CC BY-SA-NC. This Photo by Unknown author is licensed under CC • MOST OFTEN REQUIRES CESAREAN DELIVERY WITH HYSTERECTOMY BY-NC.

MANAGEMENT OF PLACENTA PREVIA PLACENTAL ABRUPTION

• MONITOR MATERNAL HEMODYNAMIC STATUS • PLACENTA ABRUPTION DEFINITION: PREMATURE SEPARATION OF THE PLACENTA FROM THE UTERINE WALL. • QUANTIFY BLOOD LOSS BY WEIGHING (1GM=1ML) • PREPARE FOR EMERGENCY CESAREAN • OCCURRENCE: 1% OF SINGLETON PREGNANCIES. DOUBLES IN TWIN PREGNANCIES. • IV SITE X2 • TYPE AND CROSSMATCH- 2-4 UNITS RBC. PREPARE FOR MASSIVE TRANSFUSION PROTOCOL • SEVERITY OF ABRUPTION DETERMINES COURSE OF ACTION. • PREPARE FOR DELIVERY WITH POSSIBLE FETAL RESUSCITATION. POSSIBLE PRETERM DELIVERY

CONCEALED VS VISIBLE VAGINAL BLEEDING WHO’S AT RISK FOR ABRUPTION?

• ADVANCED MATERNAL AGE • SMOKING • HYPERTENSION • DRUG USE-COCAINE • CHORIOAMNIONITIS • PRETERM RUPTURE OF MEMBRANES • TRAUMA SIGNS AND SYMPTOMS MANAGEMENT OF PLACENTA ABRUPTION

TRIAD OF SYMPTOMS • SEVERITY OF SYMPTOMS DETERMINES COURSE OF TREATMENT • ABDOMINAL PAIN • MONITOR PATIENTS HEMODYNAMIC STATUS: QUANTIFY BLOOD LOSS, ASSESS LABS, CONSIDER TRANSFUSION • VAGINAL BLEEDING • IV ACCESS • UNUSUAL UTERINE TENDERNESS • FETAL ASSESSMENT • PREPARE FOR DELIVERY: VAGINAL VS CESAREAN

POSTPARTUM HEMORRHAGE

• EXCESSIVE UTERINE BLEEDING AFTER BIRTH OF CHILD • HAPPENS WITH 1-5% OF DELIVERIES • 1 OF THE TOP 5 CAUSES OF MATERNAL MORTALITY • WORLDWIDE, EVERY 4 MINUTES A WOMAN DIES FROM PPH • MORE COMMON AFTER CESAREAN DELIVERY • AVERAGE BLOOD LOSS FOR VAGINAL DELIVERY 500ML, CESAREAN 1000ML

RISK FACTORS CAUSES OF PPH

• UTERINE ATONY- "BOGGY" UTERUS. UTERUS DOES NOT CONTRACT TO COMPRESS • PROLONGED LABOR BLEEDING VESSELS • INDUCTION OF LABOR • TRAUMA-RELATED BLEEDING CAN BE DUE TO LACERATIONS (INCLUDING UTERINE • RETAINED PLACENTA RUPTURE) OR SURGICAL INCISIONS. • MACROSOMIA • HYPERTENSIVE DISORDERS • COAGULOPATHY • ABNORMAL PLACENTATION (PLACENTA ACCRETA OR PREVIA) • INTRAUTERINE FETAL DEMISE • INSTRUMENTAL DELIVERY TREATMENT OF PPH ADDITIONAL CONSIDERATIONS FOR PPH

• EARLY INTERVENTION IS KEY • VITAL SIGNS • FUNDAL MASSAGE • PREVENTING HYPOTHERMIA • MEDICATIONS TO CONTRACT UTERUS: • OXYGENATION OXYTOCIN, CYTOTEC, TXA, METHERGINE, HEMABATE • FOLEY CATHETER • ADDITIONAL IV SITE, IV FLUIDS • DISCONTINUE MAGNESIUM IF APPLICABLE • LABS- CBC/PLATELETS, PT/INR, PTT, FIBRINOGEN, TYPE &CROSS • PREPARE BLOOD PRODUCTS

TREATMENT OF PPH BE PREPARED FOR PPH

• PPH KIT/CART • ORDER SET • MASSIVE TRANSFUSION PROTOCOL FOR OBSTETRICS

BIMANUAL MASSAGE BAKRI BALLOON B LYNCH SUTURE

STATISTICS

• EVERY DAY, APPROXIMATELY 830 WOMEN DIE FROM PREVENTABLE CAUSES QUESTIONS? RELATED TO PREGNANCY AND CHILDBIRTH • MATERNAL MORTALITY IS HIGHER IN WOMEN LIVING IN RURAL AREAS AND AMONG POORER COMMUNITIES • BETWEEN 1990 AND 2013, THE MATERNAL MORTALITY RATIO FOR THE USA MORE THAN DOUBLED FROM AN ESTIMATED 12 TO 28 MATERNAL DEATHS PER 100,000 BIRTHS • UNITED STATES IS THE MOST DANGEROUS OF ALL DEVELOPED COUNTRIES TO GIVE BIRTH REFERENCES

• Y. (2018, APRIL 05). PLACENTA ABRUPTION:MANAGEMENT. RETRIEVED JANUARY 7, 2019, FROM HTTPS://WWW.UPTODATE.COM/CONTENTS/PLACENTAL-ABRUPTION-MANAGEMENT?SEARCH=PLACENTA ABRUPTION&SOURCE=SEARCH_RESULT&SELECTEDTITLE=2~150&USAGE_TYPE=DEFAULT&DISPLAY_RANK=2

• D. (2018, APRIL 04). GROSS EXAMINATION OF THE PLACENTA. RETRIEVED JANUARY 8, 2019, FROM HTTPS://WWW.UPTODATE.COM/CONTENTS/GROSS-EXAMINATION-OF-THE-PLACENTA?SEARCH=PLACENTA&SOURCE=SEARCH_RESULT&SELECTEDTITLE=1~150&USAGE_TYPE=DEFAULT&DISPLAY_RANK=1

• C. (2018, NOVEMBER 13). PLACENTAL ABRUPTION: PATHOPHYSIOLOGY, CLINICAL FEATURES, DIAGNOSIS, AND CONSEQUENCES. RETRIEVED JANUARY 8, 2019, FROM HTTPS://WWW.UPTODATE.COM/CONTENTS/PLACENTAL-ABRUPTION-PATHOPHYSIOLOGY-CLINICAL-FEATURES-DIAGNOSIS-AND-CONSEQUENCES?SEARCH=PLACENTA ABRUPTION&SOURCE=SEARCH_RESULT&SELECTEDTITLE=1~150&USAGE_TYPE=DEFAULT&DISPLAY_RANK=1

• STANFORD CHILDREN'S HEALTH. (N.D.). RETRIEVED JANUARY 10, 2019, FROM HTTPS://WWW.STANFORDCHILDRENS.ORG/EN/TOPIC/DEFAULT?ID=POSTPARTUM-HEMORRHAGE-90-P02486

• LOCKWOOD, C. (2017). PLACENTA PREVIA - SYMPTOMS AND CAUSES. [ONLINE] MAYO CLINIC. AVAILABLE AT: HTTPS://WWW.MAYOCLINIC.ORG/DISEASES-CONDITIONS/PLACENTA-PREVIA/SYMPTOMS-CAUSES/SYC-20352768 [ACCESSED 10 JAN. 2019].

• WORLD HEALTH ORGANIZATION (WHO). 2012. WHO RECOMMENDATIONS FOR THE PREVENTION AND TREATMENT OF POSTPARTUM HAEMORRHAGE. GENEVA: WHO.

• WOMAN TRIAL COLLABORATORS. 2017. EFFECT OF EARLY TRANEXAMIC ACID ADMINISTRATION ON MORTALITY, HYSTERECTOMY, AND OTHER MORBIDITIES IN WOMEN WITH POST-PARTUM HAEMORRHAGE (WOMAN): AN INTERNATIONAL, RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL. LANCET. 389(10084):2105–2116. DOI: 10.1016/S0140-6736(17)30638-4.

• SHAKUR H, BEAUMONT D, PAVORD S, GAYET-AGERON A, KER K, MOUSA H. IN PRESS. ANTIFIBRINOLYTIC DRUGS FOR TREATING PRIMARY POSTPARTUM HAEMORRHAGE. COCHRANE DATABASE SYST REV.

• GAYET-AGERON A, PRIETO-MERINO D, KER K, SHAKUR H, AGERON F-X, ROBERTS I. IN PRESS. IMPACT OF TREATMENT DELAY ON THE EFFECTIVENESS AND SAFETY OF ANTI-FIBRINOLYTICS IN ACUTE SEVERE HAEMORRHAGE: AN INDIVIDUAL PATIENT DATA META-ANALYSIS IN 40,138 BLEEDING PATIENTS. LANCET.

• WHO. 2012. WHO RECOMMENDATIONS FOR THE PREVENTION AND TREATMENT OF POSTPARTUM HAEMORRHAGE. GENEVA: WHO.

• WHO. 2016. STANDARDS FOR IMPROVING QUALITY OF MATERNAL AND NEWBORN CARE IN HEALTH FACILITIES. GENEVA: WHO.

• BELFORT, M. (2019). UPTODATE. [ONLINE] UPTODATE.COM. AVAILABLE AT: HTTPS://WWW.UPTODATE.COM/CONTENTS/OVERVIEW-OF-POSTPARTUM-HEMORRHAGE?SEARCH=POSTPARTUM%20HEMORRHAGE%20RISK&SOURCE=SEARCH_RESULT&SELECTEDTITLE=1~150&USAGE_TYPE =DEFAULT&DISPLAY_RANK=1 [ACCESSED 10 JAN. 2019].