Transcript Management of Obstetrical Hemorrhage

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
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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
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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
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Prolonged labor: “uterine fatigue” (3.4 odds ratio)
Precipitory labor
High parity
Chorioamnionitis
Halogenated anesthetic
Uterine inversion
Treatment of Uterine Atony
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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
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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
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Spontaneous (1/1900 deliveries)
Version-external and internal
Fundal pressure
Blunt trauma
Operative vaginal delivery
Penetrating wounds
Uterine Rupture Etiology
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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
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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
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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
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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)
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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
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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:
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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