Definitions Bleeding in 1. trimester Bleeding in 2. & 3. trimester Placenta praevia + accreta Placental abruption Uterine rupture Post partum

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1 Bleeding in pregnancy and post partum Aims of the lecture Definitions Bleeding in 1. trimester Bleeding in 2. & 3. trimester Placenta praevia + accreta Placental abruption Uterine rupture Post partum hemorrhage

2 Inndeling av graviditeten Grav. veckor Embryo 2/0 10/0 Foster 10/1 Förl. Barn Förl. 1. Trimester Trimester Trimester 28 40

3 Pregnancy loss % fertilized ovum 60 % LMP-based gestational age (weeks)

4 Clinical classification Threatening abortion Ongoing abortion (In)complete abortion Septic abortion Missed abortion Blighted ovum Trophoblast disease IUED IUFD Anembryonic pregnancy

5 Blödning i trimester Skicka til förlossningen samma dag Orsaker: Teckningsblödning Placenta praevia Ablatio placentae Andra orsaker sår/rifter cervical polyp vulva varicer cervix cancer

6 Placenta praevia Ultrasound - 18 weeks 5 % At birth 0.5 % Placenta praevia marginalis Deep seated Placenta praevia totalis Partly covering internal os Completely covering internal os

7 Placenta praevia totalis

8 Placenta praevia totalis

9 Placenta praevia marginalis

10 Placenta praevia marginalis

11 Placenta praevia Bleeding without pain or contractions 97% attend a routine scan at 18 weeks - diagnosis should be easy No vaginal exploration Refer to hospital Intravenous access Cesarean delivery

12 Placenta Accreta

13 Placenta Accreta Risk Factor OR 95% CI P Age > <.01 Prior CS <.0001 > <.0001 Miller. Am J Obstet Gynecol 1997;177:210-4

14 Association of Cesarean, Previa and Accreta Previous C/S % with previa % with accreta % of previa with accreta % 0.01% 5% % 0.16% 24% 2 1.8% 0.82% 47% 3 3.0% 1.09% 57% 4 or more 10% 6.9% 67%

15 Placental abruption - moderkaka lossning Previous abruption Hypertension/preeclampsia Trauma Polyhydramnios External version of breech

16 Placental abruption

17 Placental abruption Incidence 0,5-2% Bleeding +/- Pain Hypertonic uterus Abruption is not an ultrasound diagnosis

18 Uterine rupture Para 0 Incidence 1: Para 1+ with previous CS Incidence 1:200-0,5% In Norway One CS - VBAC Two CS - Always CS

19 Post partum hemorrhage - PPH > 500 ml 3-5% of vaginal births 5-7% of CS > 1000 ml 1-2% of all deliveries

20 PPH - Risk factors Previous PPH Antenatal bleeding Polyhydramnios, twins, macrosomia Protracted labour Placenta praevia marginalis High age and/or BMI PE, DIC, IUFD, Abruption

21 PPH - prophylaxis Active management of 3rd stage Oxytocin i.m. - after anterior shoulder is delivered Light cord traction Uterine massage after placenta delivery

22 Blood loss ml % PPH Symptoms Slight tachycardia, palpitations, drowsiness Tachycardia, cold & sweating, malaise Uneasy, oligouria, BP Colapse, anuria, BP 40-60

23 Rule of 30 30% blood loss > moderate shock HR increase > 30 bpm Respiratory rate > 30/min Systolic BP down 30 mm Hg Urinary output < 30 ml/hour Haematocrit drop > 30% & to be kept at an absolute value of > 30

24 Shock index Shock Index = HR / Systolic BP Normal = Shock index > 0.9 indicates state of shock that needs urgent resuscitation

25 PPH - causes Remember the 4 T s! Tone - uterine atony 70% Tissue - retained placenta 20% Tears - vagina/cervix 10% Thrombin - coagulopathy <1%

26 PPH - treatment Call for help I.v. access (2 green/gray i.v. bores) ABC, monitor BP, pulse, respiration Bimanual compression of uterus Misoprostol, Oxytocin, PG Hb, platelets, blood for transfusion Surgical procedures

27 Tone - 70% Bimanual compression of the uterus

28 Uterotonic drugs

29 Algorithm for management of Atonic PPH HAEMOSTASIS H Ask for Help A Assess (vital parameters, blood loss) and resuscitate E Establish etiology + Ensure availability of blood M Massage uterus O Oxytocin infusion + Prostaglandins i.v. / i.m. / per rectal / intra-myometrial

30 Tissue - 20% Manual removal Placenta Cleavage Plane

31 Repair of cervical laceration

32 HAEMOSTASIS S Shock Garment & Shift to theatre exclude Tissue or Trauma / Bimanual compression T Tamponade Balloon or uterine packing A Apply compression sutures B-Lynch or modified S Systematic Pelvic devascularisation Uterine/Ovarian/Quadruple/Internal iliac I Interventional Radiologist If appropriate uterine artery embolisation S Subtotal / Total abdominal hysterectomy

33 Uterine balloon tamponade

34

35 Maternal mortality due to PPH CONFIDENTIAL ENQUIRY INTO MATERNAL DEATHS TOO LITTLE TOO LATE Too Little (IV fluids, oxytocics, BLOOD, Clotting factors) Too Late (PG, resuscitation - blood replacement, decision for surgery + to get senior surgeon & anaesthetist involved)

36

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