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Management of Obstetrical Hemorrhage Jeffrey L. Stern, M.D. Management of Obstetrical Hemorrhage • VS q 15 minutes, oxygen by mask 10 liter/min. – to keep O2 saturation > 94% • 1st IV: LR w/ Pitocin 20-40 units at 1000 ml/ 30 minutes • Start 2nd, 18 G IV: warm LR - administer wide open • CBC, fibrinogen, PT/PTT, platelets, T&C 4u PRBCs • Monitor I&O, urinary Foley catheter • Get help -Anesthesia,Interventional Radiology, GYN ONC, Intensivist, etc. Management of Obstetrical Hemorrhage • • • • • • LR or NS replaces blood loss at 3:1 Volume expander 1:1 (albumin, hetastarch, dextran) Administer uterotonic medications Anticipate disseminated Intravascular coagulapathy (DIC) Verify complete removal of placenta, may need ultrasound Inspect for bleeding – episiotomy, laceration, hematomas, inversion, rupture • Emperic transfusion – 2 u PRBC; FFP 1-2 u/4-5 u PRBC – Cryo 10 u, uncrossed (O neg.) PRBC • Warm blood products and I.V.infusions – prevent hypothermia, coagulopathy, arrhythmias Target Values • • • • • • • • Invasive monitoring: central/ arterial lines Maintain systolic BP>90 mmHg Maintain urine output > 0.5 ml per kg per hour Hct > 21% Platelets > 50,000/ul Fibrinogen > 100 mg/dl PT/PTT < 1.5 times control Repeat labs as needed – every 30 minutes Blood Component Therapy • Fresh Frozen Plasma (45 minutes to thaw) – INR > 1.5 - 2u FFP – INR 2-2.5 - 4u FFP – INR > 2.5 - 6u FFP • Cryoprecipitate (1 hour to thaw) – Fibrinogen < 100 mg/dl – 10u cryo – Fibrinogen < 50 mg/dl – 20u cryo • Platelets (5 minutes when in stock) – Platelet. count. < 100,000 – 1u plateletpheresis – Platelet. count. < 50,000 – 2u plateletpheresis Blood Component Therapy Blood Comp Contents Volume (ml) Effect Packed RBCs RBC, Plasma 300 Inc. Hgb by 1 g/dl Platelets Platelets, Plasma 250 Inc. count by 25,000 FFP Fibrinogen, antithrombin III, clotting factors, plasma 250 Inc. Fibrinogen 10 mg/dl Cryoprecipitate Fibrinogen, antithrombin III, clotting factors, plasma 40 Inc. Fibrinogen 10 mg/dl Uterine Atony: 1:20 to 1:100 deliveries (80% of Obstetrical Hemorrhage) • Uterine over distension – Polyhydramnios, Multiple gestations, Macrosomia • • • • • • Prolonged labor: “uterine fatigue” (3.4 odds ratio) Precipitory labor High parity Chorioamnionitis Halogenated anesthetic Uterine inversion Treatment of Uterine Atony • • • • • • • • Message fundus continuously Uterotonic agents Foley catheter/ Bakri balloon (500cc) Uterine packing usually ineffective- can temporize Modified B-Lynch Suture (#2chromic) Uterine/ utero-ovarian artery ligation Hypogastric artery ligation Subtotal or Total abdominal hysterectomy Treatment of Uterine Atony • Oxytocin – 90% success – 10-40 units in 1 liter NS or LR rapid infusion • Methylergonovine (Methergine) - 90% success – 0.2 mg IM q 2-4 hours max. 5 doses; avoid with hypertension • Prostaglandin F2 Alpha (Hemabate) - 75% success – 250 mcg IM; intramyometrial, repeat q 20-90 min; max 8 doses. – Avoid if asthma/Hi BP. • Prostaglandin E2 suppositories (Dinoprostone, Prostin E2) - 75% success – 20 mg per rectum q 2 hours; avoid with hypotension • Prostaglandin E1 Misoprostol (Cytotec): 75 -100% success – 1000 mcg per rectum or sublingual (100 or 200 mcg tabs) Uterine Inversion: 1: 2500 Deliveries • Risk factors: Abnormal placentation, excessive cord traction • Treatment – – – – – Manual replacement May require halothane/ general anesthesia Remove placenta after re-inversion Uterine tonics and massage after placenta is removed May require laparotomy Uterine Rupture Etiology • Previous uterine surgery - 50% of cases – C-section, Hysterotomy, Myomectomy • • • • • • Spontaneous (1/1900 deliveries) Version-external and internal Fundal pressure Blunt trauma Operative vaginal delivery Penetrating wounds Uterine Rupture Etiology • • • • Oxytocics Grand multiparity Obstructed labor Fetal abnormalities-macrosomia, malposition, anomalies • Placenta percreta • Tumors: Trophoblastic disease, cervical cancer • Extra-tubal ectopic pregnancy Classic Symptoms of Uterine Rupture • • • • • • Fetal distress Vaginal bleeding Cessation of labor Shock Easily palpable fetal parts Loss of uterine catheter pressure Uterine Rupture • Myth: Uterine incisions that do not enter the endometrial cavity will not rupture in the future • Type of closure: no relation to tensile strength – Continuous or interrupted sutures: chromic, Vicryl, Maxon – Inverted or everted endometrial closure • Degree of complications – – – – Inciting event- spontaneous, traumatic Gestational age Placental site in relation to rupture site Presence or absence of uterine scar • Scar: 0.8 mortality rate • No scar: 13% mortality rate – Location of scar • Classical scar- majority of catastrophic ruptures • Transverse scar- less vascular; less likely to involve placenta – Extent of rupture Uterine Scar Dehiscence • Separation of scar without rupture of membranes – 2-4% of deliveries after previous transverse uterine incision – Morbidity is usually minimal unless placenta is underneath or it tears into the uterine vessels – Diagnosis after vaginal delivery • Often asymptomatic, incidental finding • Difficult to diagnose- lower uterine segment is very thin • Therapy is expectant if defect small and asymptomatic – Diagnosed at C-section: • Simple debridement and layered closure Management of Uterine Rupture • Laparotomy – Debride and repair in 2-3 layers of Maxon/PDS – Subtotal Hysterectomy – Total Hysterectomy Pregnancy After Repair of Uterine Rupture • Not possible to predict rupture by HSG/Sono/MRI • Repair location – Classical -------------------------48% – Low transverse------------------16% – Not recorded---------------------36% • Re-rupture-------------------12% • Maternal death--------------1% • Perinatal death--------------6% Plauce WC, 1993 Prepare for Laparotomy • General anesthesia usually best • Allen or Yellowfin stirrups • Uterine cavity manual exploration for retained placenta with ultrasound present/ uterine rupture • Uterine inversion • Uterine packing (treatment vs. temporizing) – 4” gauze (Kerlex) soaked in 5000 u of thrombin in 5ml of sterile saline – 24 Fr. Foley with 30ml balloon filled with 30-80 ml of saline (may need more than one) – Bakri (intrauterine) balloon - 500 cc – Antibiotics – Remove in 24-48 hours Intraoperatively • • • • • • • • Consider vertical abdominal incision General anesthesia usually best Get Help! Avoid compounding problems by making major mistakes Direct manual uterine compression / uterotonics Direct aortic compression Modified B-Lynch Suture for atony: #2 chromic Ligation of uterine and utero-ovarian vessels: #1 chromic Intraoperatively • Internal iliac (hypogastric) artery ligation ( 50% success) – – – – – Desirous of children Experience of surgeon Palpate common iliac bifurcation Ligate at least 2-3 cm from bifurcation #1 silk. Do not divide vessel • Interventional Radiology: uterine artery embolization (catheters placed pre-op) • Hysterectomy/ subtotal hysterectomy (put ring forceps on anterior lip of dilated cervix, to help identify it) • Cell saver: investigational (amniotic fluid problems) Modified B-Lynch Suture Artery Ligation Management of Abnormal Placentation • Placenta will not separate with usual maneuvers • Curettage of uterine cavity • Localized resection and uterine repair: (Vasopressin 1cc/10cc N.S-sub endometrial) • Leave placenta in situ – If not bleeding: Methotrexate – Uterus will not be normal size by 8 weeks • Uterine, utero-ovarian, hypogastric artery ligation • Subtotal/ total abdominal hysterectomy Post-Hysterectomy Bleeding • Patient usually has DIC – Rx with whole blood, FFP, platelets, etc. • Military Anti-Shock Trousers (MAST) – Increases pelvic and abdominal pressure to reduce bleeding – Can use at any point in the procedure • Transvaginal or transabdominal (pelvic) pressure pack – Bowel bag with opening pulled through vagina cuff/ abd. wall – Stuff with 4 inch gauze tied end-to-end until pelvis packed tight – Tie to 10-20 lbs. Weight and hang over edge of bed to help keep constant pressure • May have to leave clamps or accept ligation of ureter or a major side wall vessel • Interventional Radiology Selective Artertial Embolization by Angiography • Clinically stable patient – Try to correct coagulopathy • Takes approximately 1-6 hours to work • Often close to shock, unstable, require close attention • Can be used for expanding hematomas • Can be used preoperatively, prophylactically for patients with placenta accreta • Analgesics, anti-nausea medications, antibiotics Selective Artertial Embolization by Angiography • • • • Real time X-Ray (Fluoroscopy) Access right femoral artery Single bleeding blood vessel is best Embolize: - Both uterine or hypogastric arteries - May need to treat entire anterior division or all of internal iliac artery - Sometimes need a small catheter distally to prevent reflux into non-target vessel • Risks: Can embolize nearby organs and presacral tissue, resulting in tissue necrosis • Technique: – – – – Gelfoam pads/slurry – Temporary, allows recanalization Autologous blood clot or tissue Vasopressin, dopamine, Norepinephrine Balloons, steel coils Evaluate for Ovarian Collaterals May need to embolize Mid-Embolization “Pruned Tree Vessels” Post Embolization Post Embolization Pre Embo Post Embo