Download 8th Edition APGO Objectives for Medical Students

8th Edition APGO Objectives
for Medical Students
Third Trimester Bleeding, Postpartum
Hemorrhage, & Shock Management
Case Scenarios
Rationale (why we care…)
• 4-5% of pregnancies complicated by
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3rd trimester bleeding
Immediate evaluation needed
Significant threat to mother & fetus
(consider physiologic increase in
uterine blood flow)
Consider causes of maternal & fetal
death
Priorities in management (triage!)
Objectives
The student will be able to:
• Describe the approach to the patient with:
• third-trimester bleeding
• postpartum hemorrhage
• resulting hypovolemic shock
• Compare symptoms, physical findings, and diagnostic
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methods that differentiate bleeding etiologies
Describe management and delivery options for 3rd
trimester bleeding etiologies
Describe potential maternal and fetal morbidity &
mortality
Describe management of postpartum hemorrhage
Describe blood products & indications for use
Apply knowledge in the discussion of clinical case
scenarios
Vaginal Bleeding:
Differential diagnosis
• Common:
• Abruption, previa, preterm labor, labor
• Less common:
• Uterine rupture, fetal vessel rupture,
lacerations/lesions, cervical ectropion,
polyps, vasa previa, bleeding disorders
• Unknown
• NOT vaginal bleeding!!!
(happens more than you think!)
Placental abruption:
definition
• Separation of placenta from uterine
wall
• Incidence
• 0.5-1.5% of all pregnancies
• Recurrence risk
• 10% after 1st episode
• 25% after 2nd episode
Placental abruption:
risk factors & associations
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Cocaine
Maternal
hypertension
Abdominal trauma
Smoking
Prior abruption
Preeclampsia
Multiple gestation
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Prolonged PROM
Uterine
decompression
Short umbilical cord
Chorioamnionitis
multiparity
Placental abruption:
symptoms
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Vaginal bleeding
Abdominal or back pain
Uterine contractions
Uterine tenderness
Placental abruption:
physical findings
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Vaginal bleeding
Uterine contractions
Hypertonus
Tetanic contractions
Non-reassuring fetal status or demise
• Can be concealed hemorrhage
Placental abruption:
laboratory findings
• Anemia
• may be out of proportion to observed
blood loss
• DIC
• Can occur in up to 10% (30% if “severe”)
• First, increase in fibrin split products
• Followed by decrease in fibrinogen
Placental abruption:
diagnosis
• Clinical scenario
• Physical exam
• NOT DIGITAL PELVIC EXAMS UNTIL
RULE OUT PREVIA
• Careful speculum exam
• Ultrasound
• Can evaluate previa
• Not accurate to diagnose abruption
Placental abruption:
management
• Physical exam
• Continuous electronic fetal monitoring
• Ultrasound
• Assess viability, gestational age, previa,
fetal position/lie
• Expectant mgmt
• vaginal vs cesarean delivery
• Available anesthesia, OR team for stat
cesarean delivery
Placenta previa:
definition
• Placental tissue covers cervical os
• Types:
• Complete - covers os
• Partial
• Marginal - placental edge at margin of
internal os
• Low-lying
• placenta within 2 cm of os
Placenta previa:
incidence
• Most common abnormal placentation
• Accounts for 20% of all antepartum
hemorrhage
• Often resolves as uterus grows
• ~ 1:20 at 24 wk.
• 1:200 at 40 wk.
• Nulliparous - 0.2%
• Multiparous - 0.5%
Placenta previa:
risk factors & associations
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Prior cesarean delivery/myomectomy
Prior previa (4-8% recurrence risk)
Previous abortion
Increased parity
Multifetal gestation
Advanced maternal age
Abnormal presentation
Smoking
Placenta previa:
symptoms
• Painless vaginal bleeding
• Spontaneous
• After coitus
• Contractions
• No symptoms
• Routine ultrasound finding
 Avg
gestational age of 1st bleed, 30 wks
 1/3 before 30 weeks
Placenta previa:
physical findings
• Bleeding on speculum exam
• Cervical dilation
• Bleeding a sx related to PTL/normal labor
• Abnormal position/lie
• Non-reassuring fetal status
• If significant bleeding:
• Tachycardia
• Postural hypertension
• Shock
Placenta previa:
diagnosis
• Ultrasound
• abdominal 95% accurate to detect
• transvaginal (TVUS) will detect almost all
• consider what placental location a TVUS may
find that was missed on abdominal
• Physical/speculum exam
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remember: no digital exams unless
previa RULED OUT!
Placenta previa:
management
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Initial evaluation/diagnosis
Observe/admit to L&D
IV access, routine (maybe serial) labs
Continuous electronic fetal monitoring
• Continuous at least initally
• May re-evaluate later if stable, no further
bleeding
• Delivery???
Placenta previa:
management
• Less than 36 wks gestation - expectant
management if stable, reassuring
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Bed rest (negotiable)
No vaginal exams (not negotiable)
Steroids for lung maturation (<32 wks)
Possible mgmt at home after 1st bleed
 70%
will have recurrent vaginal bleeding
before 36 completed weeks requiring
emergent cesarean
Placenta previa:
management
• 36+ weeks gestation
• Cesarean delivery if positive fetal lung maturity
by amniocentesis
• Delivery vs expectant mgmt if fetal lung
immaturity
• Schedule cesarean delivery @ 37 weeks
• Discussion/counseling regarding cesarean
hysterectomy
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Note: given stable maternal and reassuring fetal
status, none of these management guidelines
are absolute (this is why OB is so much fun!)
Placenta previa:
other considerations
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Placenta accreta, increta, percreta
Cesarean delivery may be necessary
History of uterine surgery increases risk
Must consider these diagnoses if previa
present
• Could require further evaluation, imaging
(MRI considered now)
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NOT the delivery you want to do at 2 am
Vasa previa:
definition
• In cases of velamentous cord insertion
fetal vessels cover cervical os
Vasa previa:
incidence
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0.1-1.0%
Greater in multiple gestations
Singleton - 0.2%
Twins - 6-11%
Triplets - 95%
Vasa previa:
symptoms, findings, diagnosis
• Painless vaginal bleeding
• Fetal bleeding
• Positive Kleihauer Betke test
• Ultrasound
• Routine vs at time of symptoms
Vasa previa:
management
• If bleeding, plan for emergent delivery
• If persistent bleeding, nonreassuring
fetal status, STAT cesarean… not a
time for conservative mgmt!
• Fetal blood loss NOT tolerated
Third trimester bleeding:
other etiologies
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Cervicitis
infection
Cervical erosion
Trauma
Cervical cancer
Foreign body
Bloody show/labor
Perinatal mortality and
morbidity
• Previa
• Decreased mortality from 30% to 1% over last 60
years
• Now emergent cesarean delivery often possible
• Risk of preterm delivery
• Abruption
• Perinatal mortality rate 35%
• Accounts for 15% of 3rd trimester stillbirths
• Risk of preterm delivery
• Most common cause of DIC in pregnancy
• Massive hemorrhage --> risk of ARF,
Sheehan’s, etc.
Postpartum hemorrhage:
definitions & ddx
• EBL >500 cc, vaginal delivery
• EBL >1000 cc, cesarean delivery
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Uterine atony
Lacerations
Uterine inversion
Amniotic fluid embolism
coagulopathy
Uterine atony:
(same overall mgmt regardless of delivery
type)
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Recognition
Uterine exploration
Uterine massage
Medical mgmt:
• Pitocin (20-80 u in 1 L NS)
• Methergine (ergonovine maleate 0.2 mg IM)
• Not advised for use if hypertension
• Hemabate (prostaglandin F2 mg IM or
intrauterine)
Uterine atony:
• B-lynch suture (to compress uterus)
• Uterine artery ligation
• Must understand anatomy
• Risk of ureteral injury
• Uterine artery embolization
• Typically an IR procedure
• Plan “ahead” and let them know you may need
them
• Hysterectomy (last resort)
• Anesthesia involved
• Whether in L&D room or the OR!!!
Lacerations:
• Recognition
• Perineal, vaginal, cervical
• All can be rather bloody!
• Assistance
• Lighting
• Appropriate repair
• Control of bleeding
• Identify apex for initial stitch placement
Uterine inversion:
• Uncommon, but can be serious, especially if
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unrecognized
Consider if difficult placental delivery
Consider if cannot recognize bleeding
source
Consider… always!
Delayed recognition is bad news
Patient can have shock out of proportion to
EBL
(though not all sources will agree on this)
Uterine inversion:
• Management
• Call for help
• Manual replacement of uterus
• Uterotonics to necessary to relax uterus &
allow thorough manual exploration of uterine
cavity
• IV nitroglycerin (100 g)
• Appropriate anesthesia to allow YOU to
manually explore uterine cavity
• Concern for shock… to be discussed (and
managed by the help you’ve called into the
room!)
• Exploratory laparotomy may be necessary
Amniotic fluid embolism
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High index of suspicion
Recognition
Again… call for help!
Supportive treatment
Replete blood, coagulation factors as
able
• Plan for delivery (if diagnose
antepartum) if able to stabilize mom
first
Management of shock
• Stabilize mother
• Large-bore IV x 2
• Place patient in Trendelenburg position
• Crossmatch for pRBCs (2, 4, more units)
• Rapidly infuse 5% dextrose in lactated Ringer’s
• Monitor urine output
• Ins/Outs very important
(and often not well-recorded prior to emergency
situation -- how many times did she really void
while in labor??? How dehydrated was she when
presented???)
 By the way… get help (calling for help works
quickly on L&D!)
Management of shock
• Serial labs
• CBC and platelets
• Prothrombin time (factors II, V, VII, X
{extrinsic})
• Partial thromboplastin time (factors II, V,
XIII, IX, X, XI {intrinsic})
Management of shock
Transfusion products
Product
Content
Volume
Whole blood
RBCs, 2,3 DPG, coagulation
factors (50 V, VIII), plasma proteins
500 cc
Packed RBCs
RBCs
240cc
Platelets
55 x 106 platelets/unit
50cc
Fresh frozen
plasma
Clotting factors V, VIII, fibrinogen
200-250cc
Cryoprecipitate
Factor VIII; 25% fibrinogen, von
Willebrand’s factor
10-40cc
Management of shock
Risks of blood transfusion
Infectious disease
Disease
Risk Factor
Hepatitis B
1/200,000
Hepatitis C
1/3,300
HIV
1/225,000
CMV
1/20
MTLV-1/11
1/50,000
Management of shock
• Risks of blood transfusion
• Immunologic reactions
• Fever - 1/100
• Hemolysis - 1/25,000
• Fatal hemolytic reaction - 1/1,000,000
Management of shock
• Delivery
• Vaginally unless other obstetrical
indication, i.e. fetal distress, herpes,
etc.
• Best to stabilize mother before
initiating labor or going to delivery
References
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Baron F, Hill WC. “Placenta previa, placenta abruption”,
Clinical Obstetrics and Gynecology, Sep 1998 41(3) pp527532.
Benedetti T. Obstetric hemorrhage, in obstetrics: normal and
problem pregnancies, Gabbe S, Niebyl J, Simpson J, 3rd ed.
New York: Churchill Livingston 1996, pp161-184.
Hertzberg B. “Ultrasound evaluation of third trimester
bleeding,” The Radiologist, July 1997 4(4) pp227-234.
Sheiner E, Shohan-Vardi I. “Placenta previa: obstetric risk
factors and pregnancy outcome,” Journal of Maternal-Fetal
Medicine, December 2001 10(6) pp414-418.
Adapted from Association of Professors of Gynecology and
Obstetrics Medical Student Educational Objectives, 7th edition,
copyright 1997.