Third Trimester Bleeding, Postpartum Hemorrhage, & Shock Management

UNC School of MedicineObstetrics and Gynecology Clerkship

Case Based Seminar Series

Objectives for Third Trimester Bleeding

List the causes of third trimester bleeding Describe the initial evaluation of a patient with third

trimester bleeding Differentiate the signs and symptoms of third trimester

bleeding Describe the maternal and fetal complications of placenta

previa and abruption placenta Describe the initial evaluation and management plan for

acute blood loss List the indications and potential complications of blood

product transfusion

Objectives for Postpartum Hemorrhage

Identify the risk factors for postpartum hemorrhage Construct a differential diagnosis for immediate and

delayed postpartum hemorrhage Develop an evaluation and management plan for the

patient with postpartum hemorrhage

4-5% of pregnancies complicated by 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!)

Rationale (why we care….)

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!)

Vaginal Bleeding: Differential Diagnosis

Stabilize patient – two large bore IVs if bleeding is heavy, EBL is significant or patient is clearly unstable

Auscultate fetal heart rate - Confirm reassuring pattern Focused history PE

Vitals Brief inspection for petechiae, bruising Careful inspection of vulva Speculum exam of vagina and cervix – NO DIGITAL EXAM until r/o

previa Labs – CBC, coag profile, type and cross match Ultrasound exam to assess placental location and fetal condition

Initial Management for Third Trimester Bleeding

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: Definition

Cocaine Maternal hypertension Abdominal trauma Smoking Prior abruption Preeclampsia Multiple gestation

Prolonged PROM Uterine decompression Short umbilical cord Chorioamnionitis Multiparity

Placental abruption: Risk factors and associations

Vaginal bleeding Abdominal or back pain Uterine contractions Uterine tenderness

Placental Abruption: Symptoms

Vaginal bleeding Uterine contractions Hypertonus Tetanic contractions Non-reassuring fetal status or demise

Can be concealed hemorrhage

Placental Abruption: Physical 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: Laboratory Findings

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: Diagnosis

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

Placental Abruption: Management

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: Definition

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: Incidence

Prior cesarean delivery/myomectomy Prior previa (4-8% recurrence risk) Previous abortion Increased parity Multifetal gestation Advanced maternal age Abnormal presentation Smoking

Placenta Previa: Risk factors and associations

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: Symptoms

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: Physical Findings

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 remember: no digital exams unless previa RULED OUT!

Placenta Previa: Diagnosis

Initial evaluation/diagnosis Observe/admit to L&D IV access, routine (maybe serial) labs Continuous electronic fetal monitoring

Continuous at least initially May re-evaluate later if stable, no further bleeding

Delivery???

Placenta Previa: Management

Less than 36 wks gestation - expectant management if stable, reassuring 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

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: Management

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)

NOT the delivery you want to do at 2 am

Placenta Previa: Other considerations

In cases of velamentous cord insertion fetal vessels cover cervical os

Vasa Previa: Definition

0.1-1.0% Greater in multiple gestations Singleton - 0.2% Twins - 6-11% Triplets - 95%

Vasa Previa: Incidence

Painless vaginal bleeding Fetal bleeding

Positive Kleihauer Betke test Ultrasound

Routine vs at time of symptoms

Vasa Previa: Symptoms, Findings, Diagnosis

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

Vasa Previa: Management

Cervicitis Infection Cervical erosion Trauma Cervical cancer Foreign body Bloody show/labor

Third Trimester Bleeding: Other Etiologies

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.

Perinatal Morbidity and Mortality

EBL >500 cc, vaginal delivery EBL >1000 cc, cesarean delivery

Differential Diagnosis: Uterine atony Lacerations Uterine inversion Amniotic fluid embolism Coagulopathy

Postpartum Hemorrhage: Definition and Differential Diagnosis

Prolonged labor Augmented labor Rapid labor h/o prior PPH Episiotomy Preeclampsia Overdistended uterus (macrosomia, twins, hydramnios) Operative delivery Asian or Hispanic ethnicity Chorioamnionitis

Risk Factors for Postpartum Hemorrhage

Uterine Atony(same overall mgmt regardless of delivery type)

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)

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!!!

Uterine Atony

Recognition Perineal, vaginal, cervical All can be rather bloody!

Assistance Lighting Appropriate repair

Control of bleeding Identify apex for initial stitch placement

Lacerations

Uncommon, but can be serious, especially if 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

Uterine Inversion

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

Amniotic Fluid Embolism

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 VolumeWhole 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

No universally accepted guidelines for replacement of blood components

If lab data available, most providers will transfuse patients with hemoglobin values less than 7.5 to 8 g/dL

If no labs, it is reasonable to transfuse 2 units of packed red blood cells (pRBCs) if hemodynamics do not improve after the administration of 2 to 3 liters of normal saline and continued bleeding is likely.

Indications for Transfusion

Risks of blood transfusion

Infectious Disease Risk FactorHepatitis 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

Management of Shock

Bottom Line Concepts

Common causes of third trimester bleeding - Abruption, previa, preterm labor, labor

NO DIGITAL EXAMS until placenta previa has been ruled out

Ultrasound – can use to evaluate previa but not accurate to diagnose abruption

Postpartum hemorrhage refers to EBL >500 cc, vaginal delivery or EBL >1000 cc, cesarean delivery

Most common cause of PPH – uterine atony No universal rule for when to transfuse – decision made with

clinical judgment and based on each patient’s individual circumstance and presentation

References and Resources

APGO Medical Student Educational Objectives, 9th edition, (2009), Educational Topic 23, 27 (p48-49, 56-57).

Beckman & Ling: Obstetrics and Gynecology, 6th edition, (2010), Charles RB Beckmann, Frank W Ling, Barabara M Barzansky, William NP Herbert, Douglas W Laube, Roger P Smith. Chapter 12, 21 (p133-39, 207-11).

Hacker & Moore: Hacker and Moore's Essentials of Obstetrics and Gynecology, 5th edition (2009), Neville F Hacker, Joseph C Gambone, Calvin J Hobel. Chapter 10 (p128-136).

Baron F, Hill WC. “Placenta previa, placenta abruption”, Clinical Obstetrics and Gynecology, Sep 1998 41(3) pp527-532.

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.

Jacobs, Allan J. “Management of postpartum hemorrhage at vaginal delivery.” UpToDate. May 2011