Chapter 194. Peripartum Hemorrhage

• Severe hemorrhage happens in about 6.7/1,000 deliveries:
  • Seventeen percent of maternal deaths are due to hemorrhage in the United States
  • Maternal hemorrhage is the leading cause for maternal death in developing countries

See following table.

• Trivial bleeding:
  • Occurs in about 6% of pregnancies
  • Usually secondary to cervicitis. Important to exclude more serious scenarios
  • No bleeding is trivial in the pregnant patient until serious causes have been excluded
• Placental abruption:
  • Occurs in 10% of pregnancies
  • May occur at any gestational age
  • Known risk factors:
    • Hypertension
    • Smoking
    • Advanced maternal age
    • Cocaine
    • Trauma
    • PROM
    • History of previous abruption
  • May be complicated by:
    • Amniotic fluid embolism
    • Uterine rupture
    • Coagulopathy
  • IUGR, fetal malformations are common
  • Presents with:
    • Vaginal bleeding (often concealed)
    • Uterine tenderness
    • Increased uterine activity
  • Ultrasound exam often diagnostic but may miss small abruptions
  • Tocolytic therapy in preterm patients is controversial
  • FHR monitoring is essential
  • Mode of delivery is determined by:
    • Condition of mother
    • Condition of fetus
  • Labor and vaginal delivery:
    • If coagulation studies normal, epidural analgesia is not contraindicated
    • Place two large IVs
    • Monitor hemodynamic status closely
  • Cesarean section:
    • Often emergent
    • General anesthesia in most cases
    • Aggressive volume resuscitation is a must; large-bore venous access may necessitate central venous cannulation
    • If necessary, place an arterial line to guide therapy
    • Uterine atony, rapidly developing coagulopathy may worsen hemorrhage
    • Consider postdelivery ICU admission of unstable patients
• Placenta previa:
  • Prior uterine trauma is often associated
  • Painless vaginal bleed is often first sign
  • Up to 10% may have associated abruption
  • Diagnosed by ultrasonography
  • MRI may be helpful if uterine wall invasion is suspected
  • Avoid vaginal examination
  • Expectant management with admission to hospital
  • Optimal tocolytic is still debated:
    • MgSO4 worsens maternal hypotension
  • IUGR is common
  • Always abdominal delivery
  • All patients should be evaluated on arrival
  • Place at least one large-bore IV
  • Send labs, type, and crossmatch (2 U PRBC)
  • Start volume resuscitation if indicated
  • Double setup if vaginal examination is necessary
  • Cesarean section:
    • Increased risk of bleeding even during elective case
    • Place second IV before start
    • Order a minimum of 4 U PRBC in actively bleeding patients
    • Consider general anesthesia for patients presenting with significant hypovolemia

• In case of uncertainty as the source of hemorrhage in a patient with known placenta previa it may become necessary to perform a vaginal examination
• The patient is prepped and draped as for a Cesarean section with a team ready to perform an emergency abdominal delivery should the hemorrhage become threatening
• An obstetrician then performs the vaginal examination
• An anesthesiologist is always present, ready to induce GA in case of ...