Antepartum and Postpartum Hemorrhage

Dr. Megha Jain

www.anaesthesia.co.in email: anaesthesia.co.in@gmail.com

University College of Medical Sciences & GTB Hospital, Delhi

Antepartum hemorrhage

Bleeding from or into genital tract after 28th week of gestation.

Incidence: 3 – 5% among hospital deliveries.

CAUSES placental unexplained local lesions

Placenta abruptio -traumaPraevia placentae -cervical

polyp -carcinoma

cervix

Placenta praevia

Placenta partially or completely implanted in lower uterine segment.

Types or degrees: Type 1(lateral): placenta encroaches onto LUS Type 2(marginal): placenta reaches internal os but does not cover it Type 3(incomplete central): placenta partially

covers the internal os Type 4(central): placenta completely covers the

internal os even after full dilation

Risk factor

Multiparity Increased maternal age History of previous CS or any other

scar in the uterus(myomectomy) Big size placenta

Clinical presentation

1st vaginal bleeding episode- after 36th week- 60% b/w 32 - 36 week- 30% before 32 week- 10% # painless and recurrent bleeding # GC and anemia – prop. to blood loss # Size of uterus prop. to POG # Presenting part is usually high up # FHS is usually present # Diagnosis by USG

The double set up examination

Vaginal examination in OT Preparation- # Two large bore i/v cannula # Blood for transfusion # Oral antacid # Oxygen # Skilled assistant If profuse bleeding CS GA(RSI) # Treat hypovolemia # Induction- Ketamine, intubate- Sch # Maintenance- O2, N2O # Awake extubation

Abruptio placentae

Bleeding due to premature separation of placenta Varieties: Revealed(m/c) concealed, mixedEtiology: advanced maternal age, high parity pre eclampsia trauma sudden uterine decompression short cord history of previous abruption smoking

Abruptio placentae

Clinical presentation

Continuous painful bleeding Lower abdominal tenderness Rapid abnormal uterine contractions Fetal heart rate abnormalities Premature labour Intrauterine death Maternal cardiovascular collapse DIC, ARF Definitive diagnosis by USG

Resuscitation

Rapid assessment and initial maneuvers can be life saving

1. O2 supplementation

2. 2 large bore iv cannulas

3. Send – CBC, BUSE, coagulation profile, BGCM

4. Arrange whole blood

5. ABG

6. Warm fluids

Monitoring

1. ECG, NIBP, Pulse oximetry2. Urine output monitoring3. CVP monitoring4. Frequent ABG analysis

FLUID THERAPY-Crystalloids-Colloids if hypotension persists-Group typed blood if blood loss > allowable/

preexisting anemia is present-Use fluid warming devices -FFP and platelet according to lab values.

Anesthetic management in placenta praevia

The mode of delivery should be based on clinical judgment supplemented by ultrasound findings

Grade III and IV

Posterior

Thick regional

No active bleeding yes hemodynamically stable no

GA

Caesarean section

Regional anaesthesia –associated with more blood loss because

-placenta praevia patients are at increased risk of placenta accreta

-obstretician may cut into placenta during uterine incision

-LUS has lesser power of contraction and retraction

General anesthesia

RSI – preferred technique Induction agent- Ketamine safest for

hypovolemic patients(0.5 to 1mg/kg) Intubation with Sch(1.5mg/kg) Maintenance with- O2(50%)+ N2O(50%)+ low

conc of volatile agent if tolerated Extubate when fully awake and responding to

verbal commands

Anesthetic management of abruptio placentae

Definitive treatment is delivery of the fetus Route of delivery depends on – degree of abruption maternal hemodynamics status of the fetus If abruption is mild to moderate and the

mother is hemodynamically stable with fetus being mature – continuous lumbar epidural, caudal or SAB may be used for labour and vaginal delivery

Anesthetic management (contd….)

For severe abruption – Em LSCS ↓ GA(RSI) ↑ risk of persistent hemorrhage due to uterine

atony and coagulopathy Thus give oxytocin immediately after delivery Other drugs used are methergin and PG

analogues Transfuse blood, FFP and platelet

Postpartum hemorrhage

Definition: blood loss > 500 ml after vaginal delivery of fetus > 1000 ml after CS

Clinically it refers to any amount of bleeding from or into genital tract which adversely affects maternal condition

Incidence: 3-5% among all deliveries

Types

# Primary: in 24 hrs following delivery

Third stage hge- before placental expulsion

True PPH- after placental expulsion

# Secondary: beyond 24 hrs but within puerperium

Etiology

1. Atonic uterus: (80%) can be due to- # grand multipara # over distention of uterus (twins,

macrosomia) # malnutrition and anemia # APH # prolonged labour # uterine fibroid 2. Trauma3. Blood coagulation disorder

Assessment of obstetric hemorrhage

-None None <15-20%-Mild Tachycardia 20-25% Mild hypotension Peripheral vasoconstriction-Moderate HR- 100-120/min 25-35% SBP- 80-100 mmHg Restlessness Oliguria-Severe HR>120/min >35% SBP<60 mmhg Altered consc Anuria

Severity of shock Finding % blood loss

Management of third stage hemorrhage

Uterine massage Injec. Oxytocin/ methergin Start RL/NS arrange for blood Catheterise the bladder Placenta Not

separated separated

Express by CCT Manual removal under GA

Retained placenta Definition: placenta not expelled out even

30 min. after birth of the baby. Incidence: 1% of all vaginal deliveries Dangers associated with prolonged

retention: Hemorrhage, shock, puerperal sepsis.

If mother has epidural or spinal block from T10 to S4 MRP can be accomplished without pain.

If not then I/V sedation (BZD/ Ketamine / Fentanyl) can be tried.

But if the patient is hemodynamically unstable GA should be administered.

Role of NTG in MRP

50 – 100 µg of I/V nitroglycerine provides uterine relaxation sufficient to remove the placenta.

MOA – releases nitric oxide which relaxes uterine smooth muscle.

Advantages- 1. Avoidance of GA- reduced risk of failed

intubation and aspiration 2. Onset is immediate

3. Recovery is smooth and rapid (without sedation)

S/E – hypotension and headache.

Placenta accreta

Definition: Abnormal adherence of placenta to the uterine wall after the baby is born

Underlying pathology: absent decidua, placental villi attach directly to myometrium

Types: Placenta accreta- adherence to

myometrium Placenta increta- invasion of myometrium Placenta percreta- invasion of uterine serosa or other pelvic structures

Risk factors: Placenta previa Prior CS Prior uterine trauma

Diagnosis- retained placenta massive hemorrhage after manual removal of placenta hematuria Transvaginal color Doppler USG MRI

Anesthetic mgt. of placenta accreta

Most patients require hysterectomy ↓ GA Insert large bore I/V line Arrange blood Secure airway- Endotracheal intubation Routine monitoring-ECG , NIBP, Pulse oximetry, urine

output Consider CV line and arterial line Use fluid warming devices May require ICU care

Uterine inversion

Rare C/C of 3rd stage where uterus turns inside out partially or completely

Etiology- may be spontaneous or - due to pulling of the cord - uterine atony - inappropriate fundal pressure - placenta accreta Dangers associated- hemorrhage, shock,

pulmonary embolism

Management

Best T/T – early replacement of the uterus

GA with volatile halogenated agent- most proven method for providing uterine relaxation

Uterine relaxation may be achieved

by nitroglycerine, thus avoiding GA

Uterine atony

- M/C cause of PPH - Conditions associated with uterine atony

are- Multiple gestation Macrosomia Polyhydramnios High parity Prolonged/precipitous/augmented labor Tocolytic drugs High conc. Of volatile halogenated

agents

Management

Resuscitation and immediate management- Administer 100% O2 2 large bore I/V cannula and arrange blood Fluid resuscitation- crystalloid/colloid using

pressure bag Transfuse cross matched blood( O-Negative if

group specific not available) Use fluid warmer and warming blanket Monitor- ECG,NIBP,O2 sat., urine output, acid

base status, hemoglobin(using hemocue) and coagulation parameters

Consider arterial line and CVP line only after definitive treatment has commenced

Management (contd….)Drugs used for uterine atony

1. Oxytocin 10-40 U in 1000 ml I/V hypotension

tachycardia

2. Ergometrine 200 µg I/M hypertension

vasocons.

vomiting3. PG F2 alpha 250 µg I/M

hypotension I/U

bronchocons.

Agent Dose Route S/E

Management (contd….)

Other maneuvers include- Uterine massage Repair lacerations if present Bimanual packing of uterus Consider vaginal/uterine packing Interrupt arterial supply- Embolization Surgical ligation (uterine/ant. Division of

internal iliac B/L) Hysterectomy

Thank You

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