10 Cghgj14

Obstetrical Hemorrhage
International
Obstetrical
Hemorrhage
International
Principles
Prompt diagnosis
Recognize reserve and ability to
compensate
Resuscitate vigorously
Identify underlying cause
Treat underlying cause
International
A 25 year- old G3 woman presents to the

maternity unit with vaginal bleeding.
Fetal heart rate is 140/mnt and her BP is
110/60mmHg and her HR 85/mnt. Fundal height
is 28cm. She has been given nothing.
What are the possible diagnosis ?
--------------------------------------------------------------How would you distinguish between the
diagnosis ? ----------------------------------------------
International
Estimated average interval between onset of major

obstetric complications and death, in the absence of
medical interventions
Complication
Haemorrhage
Postpartum
Antepartum
Ruptured uterus
Eclampsia
Obstructed labour
Infection
Hours
Days
2
12
1
2
3
6
From Maine, D. Prevention of Maternal Deaths in Developing Countries: Program Options and
Practical Considerations, in International Safe Motherhood Conference. 1987. npublished data:
Nairobi
WHO, UNPF, UNICEF, Health MSoP. Monitoring emergency obstetric care: a handbook 2009
International
Sebagian besar kematian maternal terjadi pada trimester ketiga dan satu minggu
pasca persalinan.
Dari penelitian di Matlab Bangladesh didapatkan lebih dari separuh kematian
maternal terjadi dalam minggu pertama setelah persalinan (gambar 1 dan 2). 2, 4
International
RS
Rumah
FasKes
Perjalanan
Tempat lain
International
Numbers of maternal deaths by clinical area
Qomariyah SN, Bell JS, Pambudi ES, Anggondowati T, Latief K, Achadi EL, et al. A practical approach to identifying maternal
deaths missed from routine hospital reports: lessons from Indonesia: Global Health Action 2009.
International
Modified early warning scoring

system
3
2
<40
30%
8
<35,0
1
40-50
15%
0
1
HR (bpm)
51-100
101-110
BP
>45%
Normal
15%
RR (/min)
9-14
15-20
Temp (oC)
35,0-38,4
CNS
A
V
Urine
0,5-1
Nil
<1ml/kg/2h <1ml/kg/h
>3ml/kg/2 h
Output
mL/kg/h
2
111-129
30%
21-29
>38,5
P
3
130
>45%
30
U
A = Alert V = Responds to Verbal commands P = Responds to Pain U = Unresponsive.
Intensive Care Society. Guidelines for the Introduction of Outreach Services. Intensive Care Society; 2002. In :Kakar V, OSullivan G. Management of obstetric
hemorrhage: anesthetic management. In: Briley A, Bewley S, editors. The Obstetric Hematology Manual. Cambridge: Cambridge University Press; 2010. p. 159-
International
Classification (EBV Maternal 100 mL/kgBW)

Hemorrhage
class
Estimated blood
loss (ml)
Blood volume
loss (%)
0 (normal
loss)
< 500
< 10
Clinical signs and

symptoms
Action
none
ALERT LINE
5001000
< 15
minimal
Need observation replacement

therapy
ACTION LINE
12001500
2025
18002100
3035
> 2400
> 40
urine output
pulse rate
Replacement therapy and oxytocics
respiratory rate
postural hypotension
narrow pulse pressure
hypotension
tachycardia
Urgent active management
cold clammy
tachypnea
Critical active management (50%
profound shock
mortality if not managed actively)
Benedetti T. Obstetric haemorrhage. In Gabbe SG, Niebyl JR, Simpson JL, eds. A Pocket Companion to Obstetrics, 4th edn. New York: Churchill Livingstone,
2002:Ch 17. In: B-Lynch C, Keith LG, Lalonde AB, Karoshi M, editors. A Textbook Of Postpartum Hemorrhage-A comprehensive guide to evaluation, management
and surgical intervention. Dumfriesshire: Sapiens Publishing; 2007. p. 35-44.
International
Modified Early Obstetric

Warning Scoring system
(MEOWS)
Aberdeen Maternity Hospital

and Liverpool Womens
Hospital
Risk management and medicolegal issues related to

postpartum haemorrhage
Upadhyay, Kalpana, MRCOG, Best Practice & Research:
Clinical Obstetrics & Gynaecology, Volume 22, Issue 6,
1149-1169
Shock
International
The Course of Hypovolaemic Shock in Absence of Therapy

Blood Pressure (mm Hg)
Blood Pressure
Heart Rate
Heart rate (min)

150
Bleeding
100
50
Compensation
Decompensation
Shock Phases
Irreversibility
(Time)
International
Antepartum
Hemorrhage
International
Objectives
Definitions and Incidence

Etiology and Risk Factors
Diagnosis
Management
- maternal and fetal assessment
- appropriate resuscitation
- no vaginal exam prior to determining
placental location
Individual Causes
International
Definition
vaginal bleeding between 20 weeks and delivery
Incidence
2% to 5% of all pregnancies
various causes of antepartum haemorrhage
- abruptio placenta
40% - 1% of
pregnancies
- unclassified
35%
- placenta previa
20% - % of
pregnancies
- lower genital tract lesion 5%
- other
International
Etiology of APH
Cervical
contact bleeding (e.g. intercourse, pap, neoplasia, examination
inflammation (e.g. infection)
effacement and dilatation (e.g. labour, cervical incompetence)
Placental
abruptio
previa
marginal sinus rupture
Vasa previa
Other - abnormal coagulation
International
Diagnostic Procedures
History and physical - No digital pelvic exam
Ultrasound
definitive test for previa
less useful in abruptio
Electronic Fetal Monitoring
for fetal compromise and uterine tone
Speculum
do ultrasound first if possible
No digital pelvic exam
International
Laboratory
CBC, blood type, Rh, Coombs
coagulation status
INR, PTT, fibrinogen
2 - 4 units of PRBC cross matched as
appropriate
bedside clot test
Kleihauer-Betke or Neirhaus test
vaginal and/or maternal blood
fetal lung maturity indices if appropriate
International
Vaginal Bleeding
Risk Factors Tests (No vaginal exam)
Fetal / Maternal Assessment
Mother or fetus unstable

Hemodynamic Resuscitation
Mother and fetus stable

Labs / Fetal Monitoring
U/S vaginal exam
Mother or fetus unstable

Delivery
Expectant
consider ongoing loss, etiology,
gestation
International
Management - ABC s
talk to and observe mother and fetus
large bore IV access
crystalloid (N/S)
CBC and coagulation status
cross-match and type

get HELP!
International
Hemodynamic Resuscitation
early aggressive resuscitation to protect fetus and
maternal organs from hypoperfusion and to prevent
DIC
stabilize vital signs
large bore IV crystalloid infusion, plasma expanders
follow hemoglobin and coagulation status
oxygen
consumption is up 20% in pregnancy
International
Fetal Considerations
lateral position increases cardiac output up to
30%
consider amniocentesis for lung indices
external fetal and labor monitoring
Kleihauer-Betke if suspected abruption
post-trauma monitor at least 4 hours for

evidence of fetal insult, abruptio, fetal
maternal transfusion
International
Abruptio Placenta - Definition

premature separation of normally implanted
placenta
Abruptio Placenta - Classification

Total fetal death
Partial fetus may tolerate up to 30-50%
abruption
International
Risk Factors for Abruption
hypertension: gestational and pre-existing

abdominal trauma
cocaine or crack abuse
previous abruption
overdistended uterus
multiple gestation, polyhydramnios
smoking, especially >1 pack/day
International
Clinical Presentation of Abruption

vaginal bleeding usually painful, unremitting
presence of risk factor
hemodynamic status may not correlate with amount
of vaginal blood loss concealed abruption
may be evidence of fetal compromise
uterus - tender, irritable, contracting or tetanic
ultrasound rules out previa and may show clot
International
ABRUPTION
Live Fetus
Dead Fetus
coagulopathy
Delivery
(watch for DIC)
Assess Maturity
Maturity
Vaginal delivery or C/S
Immaturity
Steroids plus expectancy
Transfusion? Transfer?
International
Placenta Previa - Definition

placenta covers or lies near the cervix
Placenta Previa - Classification

total
- entirely covers the os
partial
- partially covers the os
marginal - close enough to the os to increase risk
of bleeding as cervical effacement and dilatation
occur
International
Risk Factors for Previa

previous placenta previa
previous caesarian section or uterine surgery
multiparity (5% in grand multiparous patients)
advanced maternal age
multiple gestation
smoking
International
Clinical Presentation of Previa

vaginal bleeding usually painless (unless in labour)
maternal hemodynamic status corresponds to
amount of vaginal blood loss
well tolerated by fetus unless maternal instability
uterus - non-tender, not irritable, soft
may have abnormal lie
ultrasound shows previa !
International
PREVIA
Assess maturity
Maturity
Delivery by C/S (consider accreta)

May try vaginal if marginal
Immaturity
Steroids plus expectancy

Transfusion? Transfer?
International
Cesarean deliveries and the risk of

abnormal placentation and hysterectomy
Cesarean
Primary
Second
Third
Fourth
Fifth
Accreta (%)
0,24
0,31
0,57
2,13
2,33
Previa (%) Previa-Accreta (%) Hysterectomy (%)

0,26
3-5
0,65
0,65
11-24
0,42
1,8
39-47
0,9
3
40-60
2,41
10
67
3,49
Clark SL, Koonings PP, Phelan JP. Placenta previa / accreta and prior cesarean section. Obstet Gynecol 1985;66:8992.
Grobman WA, Gersnoviez R, Landon MB, et al. Pregnancy outcomes for women with placenta previa in relation to the number of prior
cesarean deliveries. Obstet Gynecol 2007;110:124955.
Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. NICHD-MFMU Network.
Obstet Gynecol 2006; 107:122632.
Lee YM, D'Alton ME. Cesarean delivery on maternal request: maternal and neonatal complications. Curr Opin Obstet Gynecol. 2008 Dec;20(6):597-601.
International
Vasa Previa - Definition
blood vessels in the membranes run across the cervix

requires a vellamentous insertion or succenturiate lobe
Complication
ex-sanguination following amniotomy or ROM
Diagnosis
Apt test or Kleihauer test on vaginal blood

terminal fetal bradycardia initial tachycardia or
sinusoidal FH
Prognosis
fetal mortality as high as 50-70%
International
Conclusions
assess maternal status and stability

assess fetal well-being
resuscitate appropriately
assess cause of bleeding - avoid vaginal exam
expectant management if appropriate
deliver if indicated based on maternal or fetal
status
International
Postpartum Hemorrhage
International
You have just delivered a 37 week twin

pregnancy per vagina. The third stage is
complicated by post partum hemorrhage
unresponsive to uterine message and the
use of oxytocin.
What would your next management
steps be ---------------------------------- ?
International
Objectives
Definition
Etiology
Risk Factors
Prevention
Management
International
Traditional Definition
blood loss of > 500 mL following vaginal delivery
blood loss of > 1000 mL following cesarean
delivery
Functional Definition
any blood loss that has the potential to produce or
produces hemodynamic instability
Incidence
about 5% of all deliveries
International
Jumlah Perdarahan Dalam Bedah

Obstetri
Prosedur
Jumlah Perdarahan
(mL)
Persalinan pervaginam
450
Seksio sesarea
1000
Seksio histerektomi elektif
1400
Seksio histerektomi darurat
3200
Clark, 1984; Chestnut, 1985; Gahres, 1962; Gilbert, 1987; Newton, 1961; Pritchard, 1962; and all of their
colleagues.
International
Uterine blood flow at various stages of pregnancy
Hytten F, Chamberlain G: Clinical Physiology in Obstetrics. Boston, Blackwell Scientific Publications, 1980
International
Empat T pengingat penyebab perdarahan

postpartum
Empat T
Perkiraan
Kejadian
(%)
Kasus
Tonus
Atonia uterus
70
Trauma
Laserasi, hematoma, inversio, ruptura
20
Tissue
Retensio plasenta, Plasenta akreta

perkreta inkreta, sisa plasenta
10
Thrombin
Koagulopati
1
Am Fam Physician 2007;75:875-82.
International
Risk Factors for PPH - Antepartum

previous PPH or manual removal
placental abruption, especially if concealed
intrauterine fetal demise

placenta previa
gestational hypertension with proteinuria
overdistended uterus (e.g. twins, polyhydramnios)
pre-existing maternal bleeding disorder (e.g. ITP)
International
Risk Factors for PPH - Intrapartum
Operative delivery - cesarean or assisted vaginal

Prolonged labour
Rapid labour
Induction or augmentation
Chorioamnionitis
Shoulder dystocia
Internal podalic version and extraction of second
twin
Acquired coagulopathy (e.G. Hellp, dic)
International
Risk Factors for PPH - Postpartum

Lacerations or episiotomy
Retained placenta/placental
abnormalities
Uterine rupture
Uterine inversion
Acquired coagulopathy (e.G. Dic)
Cara Persalinan & risiko PPH >1.000

mL
International
Mode of delivery
Emergency cesarean section
vs. elective
vs. operative vaginal delivery
vs. spontaneous vaginal delivery
Elective cesarean section
vs. operative vaginal delivery
vs. spontaneous vaginal delivery
Operative vaginal delivery
vs. spontaneous delivery
Source: Stones RW, et al.
Relative risk of PPH (99% CI)
2.2 (1.43.5)
3.7 (2.55.4)
8.8 (6.7411.6)
1.7 (0.982.8)
3.9 (2.56.2)
2.4 (1.63.5)
International
Prevention
be prepared
active management of the third stage
prophylactic oxytocin with delivery or with
delivery of anterior shoulder
- 10 U IM or 5 U IV bolus
- 20 U/L N/S IV run rapidly
early cord clamping and cutting
gentle cord traction with suprapubic
countertraction
International
Active v.s Expectant Third Stage Management

Outcome
(subjects)
PPH > 500 mL (n=4636)

PPH > 1000 mL (n=4636)
Maternal Hb < 91 (n=4256)
Blood transfusion (n=4829)
Therapeutic oxytocin (n=4829)
Nausea (n=3407)
Manual removal (n=4829)
0.1
1
Odds Ratio (95% Confidence Interval)
Cochrane Library
Issue 1, 2000
10
International
Diagnosis - Is this a PPH?

consider risk factors
observe vaginal loss
express blood from vagina following C/S
REMEMBER
- blood loss is consistently underestimated
- ongoing trickling can lead to significant blood loss
- blood loss is generally well tolerated to a point
International
Diagnosis - What is the cause?

Assess the fundus
Inspect the lower genital tract

Explore the uterus
Retained placental fragments
Uterine rupture
Uterine inversion
Assess coagulation
International
A = airway
B = breathing
C = circulation
International
HAEMOSTASIS Mnemonic
Mnemonic
H
Help. Ask for Help
A
Assess (vital sign, blood loss) and resucitate
Establish aetilogy, ensure aviabioity of blood, acbolic (oxytocin,
E
ergometrine, or syntometrine bolus IV/IM)
M
Massage uterus
O
S
T
A
S
I
S
Oxytocin infusion, ergometrine bolus IV/IM, prostaglandins per rectal

Shift to the theatre. Exclude retain products and trauma, bimanual
compression, abdominal aorta compression
Tamponade ballon and uterine packing
Apply compression uterus, B-Lynch technique or modified
Systemic pelvic devascularization : uterine, ovarian, quadriple, internal
iliaca, Lasso-Budiman technique
Initial Management
Medical Treatment
Conservative Non
Surgical Management
Conservative Surgical
Management
Interventional radiologist, if appropriate, uterine artery embolization

Subtotal/total hysterectomy
Last Effort- Non Conservative Surgical

Management
Mishra N, Chandraharan E. Postpartum haemorrhage (PPH). In: Warren R, Arulkumaran S, editors. Best Practice in Labour and Delivery. Cambridge: Cambridge
University Press; 2009. p. 160-70.
International
Classification (EBV Maternal 100 mL/kgBW)

Hemorrhage
class
Estimated blood
loss (ml)
Blood volume
loss (%)
0 (normal
loss)
< 500
< 10
Clinical signs and

symptoms
Action
none
ALERT LINE
5001000
< 15
minimal
Need observation replacement

therapy
ACTION LINE
12001500
2025
18002100
3035
> 2400
> 40
urine output
pulse rate
Replacement therapy and oxytocics
respiratory rate
postural hypotension
narrow pulse pressure
hypotension
tachycardia
Urgent active management
cold clammy
tachypnea
Critical active management (50%
profound shock
mortality if not managed actively)
Benedetti T. Obstetric haemorrhage. In Gabbe SG, Niebyl JR, Simpson JL, eds. A Pocket Companion to Obstetrics, 4th edn. New York: Churchill Livingstone,
2002:Ch 17. In: B-Lynch C, Keith LG, Lalonde AB, Karoshi M, editors. A Textbook Of Postpartum Hemorrhage-A comprehensive guide to evaluation, management
and surgical intervention. Dumfriesshire: Sapiens Publishing; 2007. p. 35-44.
International
Modified Early Obstetric

Warning Scoring system
(MEOWS)
Aberdeen Maternity Hospital

and Liverpool Womens
Hospital
Risk management and medicolegal issues related to

postpartum haemorrhage
Upadhyay, Kalpana, MRCOG, Best Practice & Research:
Clinical Obstetrics & Gynaecology, Volume 22, Issue 6,
1149-1169
International
Shock Index
It refers to heart rate divided by the systolic blood

pressure HR/SD
The normal value is 0.50.7.
With significant haemorrhage, it increases to 0.91.1.
A shock index of over 0.9 is associated with a need for
intensive therapy on admission.
The change in shock index of an individual woman
seems to correlate better in the identification of early
acute blood loss than other parameters, such as heart
rate and blood pressure taken in isolation.
Lin Lin Su. Haematological Disorders in Pregnancy Massive obstetric haemorrhage with disseminated intravascular
coagulopathy. Best Practice & Research Clinical Obstetrics & Gynaecology, 2012, Vol, Issue 1, Pages 77-90
International
Management - ABC s
talk to and observe patient
large bore IV access ( No. 16 G)

crystalloid - lots!
CBC
cross-match and type
get HELP!
International
Flow rates through intravenous

cannulae
Gauge number*
Colour code
20G
18G
16G
14G
Pink
Green
Grey
Orange
Flow rate
mL/min**
40-80
75-120
130-220
250-360
* G refers to a wire gauge classification of the size of the internal diameter of the cannula. It is slightly different to the
American and Standard Wire Gauges.
** The British standard for determining flow rate: involves in-vitro testing using distilled water at 22 C, kept at constant
pressure. The flow rates are therefore not the same as those achievable clinically.
International
Management - Assess the fundus

simultaneous with ABC s
atony is the leading cause of PPH

if boggy bimanual massage
- rules out uterine inversion
- may feel lower tract injury
- evacuate clot from vagina and/or cervix
- may consider manual exploration at this
time
International
Roles and goals of crisis team members
Roles
Airway manager (#1)
Goals
Manages ventilation and oxygenation, intubates if
necessary
Airway assistant (#2) Provides equipment to airway manager, assists with bagmask ventilation, Check breathing,
Oxygen administered
Bedside assistant (#3) Provides patient information including AMPLE*,
medications delivery , Draws up medications, supplies crash
Equipment manager cart contents to appropriate team members
(#4)
Treatment:
IM Syntometrine, Syntocinon infusion, Misoprostol SL
Data manager/
Documentation :
recorder (#8)
Records vital signs, exam findings, test results, chart ,
Timings, drugs, persons present
Circulation (#6)
Circulation :
Lie flat or head down, Insert two large gauge cannulae, Take
blood for FBC, Clotting, Cross match 4 units, Commence 4
@ 500 mL crystalloid, FFP 4 Units or Cryoprecipitate 8 Units,
Consider O negative blood
Monitoring :
Evaluates pulses, Performs chest compressions , Blood
pressure,
Circulation, tissue perfusion, Consider CVP
Procedure MD (#7)
Performs procedures such as central lines, chest tubes,
pulse check
Treatment leader (#5) Inspection :
Blood loss, Uterine Tone, Placenta and membranes,
Perineum
Treatment :
Stop Bleeding : Uterine Massage, Bimanual compression,
Misoprostol PR, Decision for EUA
DeVita MA, Hillman K, Bellomo R, editors.

Medical Emergency Teams Implementation and
Outcome Measurement. Pittsburgh: Springer
Science+Business Media; 2006 p. 80-90.
International
Post partum haemorrhage clinical checklist
Call for assistance

Emergency bell activated
Airway
Check airway
Monitoring
Blood pressure
Heart rate
Circulation, tissue perfusion
Catheter and hourly urine
Consider CVP
Breathing
Inspection
Check breathing
Blood loss
Oxygen administered
Uterine Tone
Placenta and membranes
Perineum
Circulation
Treatment
Lie flat or head down
IM Syntometrine
Insert two large gauge cannulae
Syntocinon infusion
Take blood for FBC, Clotting, Cross match 6 Misoprostol PR
units
Carboprost/Hemabate IM
Commence 2 litres crystalloid
Uterine Massage
Consider O negative blood
Bimanual compression
Decision for EUA
Documentation
Timings, drugs, persons present etc
International
Management - Bimanual Massage
International
Management - Oxytocin
5 units IV bolus
20 units per L N/S IV wide open
10 units intramyometrial given
transabdominally
International
Management - Manual Exploration

if no response to bimanual massage and
oxytocin then proceed to exploration
manual exploration will:
- rule out uterine inversion
- palpate cervical injury
- remove retained placenta or clot from
uterus
- rule out uterine rupture or dehiscence
International
Uterotonika
International
Farmakodinamik Oksitosin & Misoprostol
Menit
10
20
30
40
50
60
International
Replacement of Inverted Uterus
International
Mengoreksi Inversio Uteri
International
Management - Additional Uterotonics

ergotamine - caution in hypertension
- 0,2 mg IM / IV, interval 15
- maximum dose 1 mg
Hemabate (carboprost) - asthma is relative
contraindication
- 15 methyl-prostaglandin F2
- 0,25 mg IM or intramyometrial
- Maximum dose 2 mg
Cytotec (misoprostol) - caution in asthma
- 400 g pr or po
International
Management - Bleeding with firm uterus

explore the lower genital tract
requirements -
appropriate analgesia
- good exposure and lighting

appropriate surgical repair
- may temporize with packing
International
Management - Continued uterine bleeding

possible coagulopathy - INR, PTT, TCT, fibrinogen
if coagulation is abnormal:
- correct with clotting factors, platelets
if coagulation is normal:
- prepare for O.R. (may consider embolization)
- rule out uterine rupture, inadequate incision repair
- consider uterine/hypogastric ligation, hysterectomy
International
Management - ABC s
ENSURE that you are always

ahead with your
resuscitation!!!
consider need for Foley catheter, CVP, arterial line, etc
consider need for more expert help
International
HAEMOSTASIS Mnemonic
Mnemonic
H
Help. Ask for Help
A
Assess (vital sign, blood loss) and resucitate
Establish aetilogy, ensure aviabioity of blood, acbolic (oxytocin,
E
ergometrine, or syntometrine bolus IV/IM)
M
Massage uterus
O
S
T
A
S
I
S
Oxytocin infusion, ergometrine bolus IV/IM, prostaglandins per rectal

Shift to the theatre. Exclude retain products and trauma, bimanual
compression, abdominal aorta compression
Tamponade ballon and uterine packing
Apply compression uterus, B-Lynch technique or modified
Systemic pelvic devascularization : uterine, ovarian, quadriple, internal
iliaca, Lasso-Budiman technique
Initial Management
Medical Treatment
Conservative Non
Surgical Management
Conservative Surgical
Management
Interventional radiologist, if appropriate, uterine artery embolization

Subtotal/total hysterectomy
Last Effort- Non Conservative Surgical

Management
Mishra N, Chandraharan E. Postpartum haemorrhage (PPH). In: Warren R, Arulkumaran S, editors. Best Practice in Labour and Delivery. Cambridge: Cambridge
University Press; 2009. p. 160-70.
International
Kondom Kateter
International
Kompresi Aortaabdominalis
International
International
International
B-Lynch
International
Hayman uterine compression suture.
Evaluation and Management of Postpartum Hemorrhage

Sibai, Baha M., M.D., Management of Acute Obstetric Emergencies: Female Pelvic Surgery Video Atlas Series, 4, 41-70, 2011
International
Quadriple
International
HAEMOSTASIS
Systemic pelvic devascularization
Quadruple ligation
International
Operative technique of internal iliac artery ligation

A , The retroperitoneal
space over the right
internal and external ilia
vessels has been opened
and the ureter retracted
medially. B , A right-angled
clamp is passed between
the iliac artery and the iliac
vein to receive a ligature of
No. 0 silk. The vessel
should be doubly ligated.
Reproduced from Pauerstein C [ed]: Clinical Obstetrics. New York, Wiley, 1987.) Postpartum Hemorrhage and Other Problems of the Third Stage
Belfort, Michael A., High Risk Pregnancy: Management Options, Chapter 75, 1283-1311.e5 2011
International
Indications for Peripartum

Hysterectomy
n
Kastner et al 48
Glaze et al
87
Knight et al 315
Kwee et al
48
Accreta
Atony
49%
33%
38%
50%
30%
37%
53%
27%
Uterine
Previa
Rupture
9%
2%
0%
1%
14%
8%
0%
8%
Other
12%
29%
20%
15%
Glaze S, Ekwalanga P, Roberts G, et al: Peripartum hysterectomy: 1999 to 2006. Obstet Gynecol 111:732-738, 2008
Kwee A, Bots ML, Visser GH, et al: Emergency peripartum hysterectomy: A prospective study in The Netherlands. Eur J Obstet Gynecol Reprod
Biol 124:187-192, 2006
Chestnut DH, Eden RD, Gall SA, et al: Peripartum hysterectomy: A review of cesarean and postpartum hysterectomy. Obstet Gynecol 65: 365-370,
1985
Kastner ES, Figueroa R, Garry D, et al: Emergency peripartum hysterectomy: Experience at a community teaching hospital. Obstet Gynecol
99:971-975, 2002
Shah M, Wright JD. Surgical Intervention in the Management of Postpartum Hemorrhage. Semin Perinatol. 2009;33:109-15
International
Complications Associated with Peripartum Hysterectomy

Knight (n= 315)
Silver et al (n = Kastner et al (n Kwee et al (n =

216)
= 48)
48)
4,20%
Death
0,60%
Cystotomy
12,20%
12,00%
6,30%
8,30%
Ureteral injury
4,50%
2,30%
6,30%
Oophorectomy
5,80%
NA
6,30%
NA
Reoperation
19,60%
11,60%
NA
33,30%
ICU admission
Mechanical
ventilation
Thromboembolic
events
Cardiac arrest
84,00%
23,20%
20,10%
75,00%
7,20%
12,50%
NA
NA
1,30%
1,90%
4,20%
4,20%
1,90%
NA
2,10%
2,10%
Febrile morbidity
NA
NA
34%
NA
Mercier FJ, Velde MVd. Major Obstetric Hemorrhage. Anesthesiology Clin. 2008;26:53-66
International
Medical Anti Schock Trouser &

Penekan Infus
International
Conclusions
be prepared
practice prevention
assess the loss
assess maternal status
resuscitate vigorously and appropriately
diagnose the cause
treat the cause
International
Management - Evolution
Panic
Panic
Hysterectomy
Pitocin
Prostaglandins
Happiness
International
Thank You
International
Kleihauer-Betke
Indications
Measures fetal cells in maternal circulation
Used in assessing for Rh Sensitization
Maternal blood Rh negative
Large antepartum bleed
Mechanism
Blood Film stained with acid elution
Fetal HbF more acid resistant
Fetal RBC darkly stained, Maternal RBC "ghosts"
Technique
Count Fetal cells per 50 low power fields
Five cells per 50 (lpf) = 0.5 ml bleed
International
Interpretation
Calculate Maternal Blood Volume (ml) =
(Pre-pregnant weight in kg) x 70 ml/kg x (1.0 +
(0.5 x weeks gestation/36)) Estimated Blood loss (ml) at time of test
Calculate Fetal Whole Blood (ml) =
(Fetal Cell Count/Maternal Cell Count) x
Maternal Blood Volume
Rh Immune Globulin (RhoGAM) Dose
Give 300 g per 30 mL fetal whole blood or 15
mL PRBC
International
International
International
Keep your bloody fingers off

the cervix!
International
Uterine Atony
most common cause of PPH (75-80%)
risk factors:
multiple gestation
polyhydramnios
macrosomia
prolonged labor
grandmultiparity
precipitous labor
International
Uterine Atony
failure of the uterus to contract down on
the myometrial spiral arteries and
decidual veins
the uterus is soft and boggy
Initial Management
ABCs
large bore IVs, NS bolus
CBC, PT, PTT, crossmatch
rule out traumatic causes of PPH
International
Uterine Atony
Management
bimanual massage of the uterus
oxytocin
- 5-10 U IV bolus or
- 40 U in 1 L NS @ 250 cc/hr or
- 10 U intrauterine (transabdominal)
International
Uterine Atony
Management
methylergonovine
- 0.2 mg IM
- contraindicated in hypertension
Hemabate (prostaglandin F2-alpha)

- 0.25 mg IM or intrauterine
- asthma is relative contraindication
International
Uterine Atony
Management
if pharmacological measures fail, surgical
intervention may be necessary
- uterine artery embolization
- uterine artery ligation
- hysterectomy
International
Trauma
genital tract trauma
2nd most common cause of PPH
vaginal lacerations remember to place
first suture above the apex
cervical lacerations suture only if
actively bleeding
large/expanding hematomas require
surgical evacuation
International
Trauma
Uterine inversion
1/2500 pregnancies
associated with uterine atony or
excessive cord traction during 3rd stage
sudden onset pain/shock/hemorrhage,
uterus seen in vaginal vault or introitus
should attempt immediate repositioning
may require uterine relaxant (terbutaline
0.25 mg IV followed by 2 g of MgSO4 over
10 min)
International
Trauma
Uterine Rupture
1/2000 deliveries
risk factors: C-section, grand multiparity,
previous uterine surgery, advanced age
may be full or partial thickness
postpartum presents as abdominal pain/
distension, PPH, shock, palpable defect
require surgical intervention
International
Tissue
retained placental fragments
prevents uterine contraction
inspect placenta for any defects
treatment requires manual removal of
retained fragments
if the placenta is abnormally adherent to
the myometrium then this is placenta
accreta
International
Thrombin
coagulopathies
congenital: von Willebrands disease,
hemophilia A/B
acquired: ITP, TTP, DIC (2 sepsis,
placental abruption, amniotic fluid
embolus, pre-eclampsia
treament: platelets, cryoprecipitate, FFP
International
The use of B-Iynch technique and Lasso Budiman technique

to control post partum hemorrhage due to uterine atony
Technique
B-Lynch
Lasso-Budiman
Total
Cases
26
12
38
Success
25 (96%)
11 (91%)
36 (94%)
Failure
1 (4%)
1 (7%)
2 (6%)
Complication
2 (14%)
2 (6%)
M. Nurhadi Rahman, Gulardi H.Wiknjosastro, Ali Sungkar, Novan Satya Pamungkas, Budiman, Iswan Syarif, Agung Suhadi.
The use of B-Iynch technique and Lasso Budiman technique to control post partum hemorrhage due to uterine atony. PIT
International
B-Lynch

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Obstetrical Hemorrhage

A 25 year- old G3 woman presents to the

Estimated average interval between onset of major

Numbers of maternal deaths by clinical area

Modified early warning scoring

A = Alert V = Responds to Verbal commands P = Responds to Pain U = Unresponsive.

Classification (EBV Maternal 100 mL/kgBW)

Clinical signs and

Need observation replacement

Modified Early Obstetric

Aberdeen Maternity Hospital

Risk management and medicolegal issues related to

The Course of Hypovolaemic Shock in Absence of Therapy

Heart rate (min)

Definitions and Incidence

Other - abnormal coagulation

Mother or fetus unstable

Mother and fetus stable

Mother or fetus unstable

cross-match and type

post-trauma monitor at least 4 hours for

Abruptio Placenta - Definition

Abruptio Placenta - Classification

Risk Factors for Abruption

hypertension: gestational and pre-existing

Clinical Presentation of Abruption

Placenta Previa - Definition

Placenta Previa - Classification

Risk Factors for Previa

Clinical Presentation of Previa

Delivery by C/S (consider accreta)

Steroids plus expectancy

Cesarean deliveries and the risk of

Previa (%) Previa-Accreta (%) Hysterectomy (%)

Vasa Previa - Definition

blood vessels in the membranes run across the cervix

ex-sanguination following amniotomy or ROM

Apt test or Kleihauer test on vaginal blood

fetal mortality as high as 50-70%

assess maternal status and stability

You have just delivered a 37 week twin

Jumlah Perdarahan Dalam Bedah

Seksio histerektomi elektif

Seksio histerektomi darurat

Uterine blood flow at various stages of pregnancy

Empat T pengingat penyebab perdarahan

Laserasi, hematoma, inversio, ruptura

Retensio plasenta, Plasenta akreta

Risk Factors for PPH - Antepartum

intrauterine fetal demise

Risk Factors for PPH - Intrapartum

Operative delivery - cesarean or assisted vaginal

Risk Factors for PPH - Postpartum

Cara Persalinan & risiko PPH >1.000

Relative risk of PPH (99% CI)

Active v.s Expectant Third Stage Management

PPH > 500 mL (n=4636)

Diagnosis - Is this a PPH?

Diagnosis - What is the cause?

Inspect the lower genital tract

Oxytocin infusion, ergometrine bolus IV/IM, prostaglandins per rectal

Interventional radiologist, if appropriate, uterine artery embolization

Last Effort- Non Conservative Surgical

Classification (EBV Maternal 100 mL/kgBW)