Obstetric Haemorrhage

Obstetric haemorrhage Threatened miscarriage Antepartum haemorrhage Intrapartum haemorrhage Postpartum haemorrhage = up to 24 weeks = 24 weeks à onset of labour = onset of labour à end of 2nd stage = 3rd stage à end of puerperium Antepartum Haemorrhage Can be placental abruption, preaveia (2 main causes), vasa praevia or cervical polyps (or other LGT factors e.g. ectropion, laceration, carcinoma or vulval varicosity). In severe cases could be uterine rupture. Placenta Praevia = PAINLESS Placenta on lower segment (5cm from internal os) Commoner in older mothers & those with previous section. Classification: I = encroaches on lower segment, II = reaches internal os (marginal), III = covers part of os (partial), IV = completely covers the os (complete). NB: I & II = minor, III & IV = major Haemorrhage is inevitable with major praevia à consider admission from 32 weeks, C-section & anticipate large blood loss If low lying placenta detected on early scan, monitor & rescan in 3rd trimester to review Baby is more likely to be transverse or breech (as head cannot engage due to placenta). Free high head is praevia until proven otherwise Placenta Acreta – into myometrium, more common if prev LCSC, more difficult to separate Placenta percreta – through uterus and into peritoneum +/- organs Placental Abruption = PAINFUL Retroplacental haemorrhage & involves some degree of placental separation. “Woody” tense, tender uterus due to trapped blood NB: can be concealed and therefore assume worse than it appears (assess pain, tenderness, shock) Major bleed usually required immediate delivery. Risk of DIC due to placental damage Small abruptions can self resolve & the pregnancy continue. NB risk of further abruption or impaired fetal growth (increased Doppler, decreased AFI). Rescan baby regularly Vasa Praevia Blood vessing in the membrane across the os. (“velamentous insertion of the cord”) Loss of fetal blood so small volume can have profound effect on baby Present as ROM with some blood & fetal bradycardia. Must delivery ASAP Often not prediagnosed Management Bleep team ABC (pulse will change before BP, can lose 12-1500mls = 35% vol before signs) IV access, FBC, Group, X-match & clotting. If Rh-ve do kleihauer test (look for fetal cells in maternal blood) to calculate Anti D required Examine mother CTG (from 26 weeks) for fetal condition, if < 24 weeks --> US. If fetal bardycardia --> deliver now If placenta praevia = deliver NOW by C-sect (lower segment is slow to contract so high risk PPH & DIC) Intrapartum haemorrhage Show – is normal (rapid, pulsing or gushing blood is not!) Vase Praevia – cord vessels (running in the fetal membranes) rupture if they cross the internal os à intrapartum haemorrhage and severe fetal distress Uterine Rupture – should also be considered (see later sheet) Postpartum Haemorrhage 200-300 ml loss during 3rd stage is normal Primary PPH = 5% of all deliveries >500ml loss within 24 hrs of delivery of baby (if >1000ml = massive), If 1500ml lost do clotting Increased risk if grand multip, multiple birth, fibroids, placenta praevia & long labour Tone - 90% due to atony (failure of uterus to contract) Mulitiple births (twins), multiparity, fibroids (muscle dysfunction), polyhydramnios, macrosomia, obstructed labour with syntocinon, instrumental delivery Bimanual compression Sytometrine (ergometrine & syntocinon) = tocolytic, can cause nausea & hypotension Haemobait (carboprost) i.m. every 15 minutes Misoprostol (PR) = last resort Balloon compression Laparotomy – blinked suture, clamp/ablate/embolise uterine aa, ligate branch of internal iliac, hysterectomy (subtotal) Tissue Placenta (should be delivered within 30 mins) Can also be clots (preventing contraction), membranes (check placenta complete) or extra lobe of placenta. Give 500 syntocinon after delivery of anterior shoulder. Use controlled cord traction (beware inversion) Stimulate contractions (breast feed, massage uterus) If no success --> theatre for manual removal (under spinal) Trauma - 7% trauma – episiotomy, tear or uterine rupture Tears/episiotomy – if spurting vessel, clamp it Cervical tear – EUA & repair Broad ligament or lower section tear from instrumentation Missed apex of tear during repair Thrombin 3% coagulation problems (usually DIC) Management – assess loss, pulse & BP, assess tone of uterus, check for trauma, abdominal massage / bimanual compression, IV access & crossmatch, syntocinon, hysterectomy if no success or radiological controlled arterial embolisation Secondary PPH = any significant loss between 24hrs and 6 weeks Usually due to infection or retained products of conception eg. Placenta acreta/percreta (very rarely vulval Ca)