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PowerPoint Discussion of How to Evaluate and Manage Intrapartum and Antepartum Hemorrhage
Severe obstetric hemorrhage is an important cause of maternal and perinatal mortality and morbidity worldwide. The incidence of obstetric hemorrhage is increasing because of recent changes in obstetric demographics. Obstetric hemorrhage can develop before delivery, in labor, or immediately postpartum. A list of important causes of obstetric hemorrhage is summarized in Table 3-1 . In order to be prepared to deal with obstetric hemorrhage, it is important that all obstetric units develop mechanisms and action plans that identify patients at risk by color coding of medical records during the antepartum period, in labor, and postpartum ( Table 3-2 ). This chapter discusses evaluation and management of obstetric hemorrhage associated with placenta previa, abruptio placentae, uterine rupture, and placenta accreta/percreta.
| Antepartum/Intrapartum |
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| Postpartum |
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Placenta Previa
Placenta previa is a major cause of painless vaginal bleeding during the late second trimester and in the third trimester. The incidence of bleeding increases with advanced gestational age secondary to cervical effacement or dilation in association with increased uterine activity. The incidence of placenta previa is approximately 0.5% of all gestations. This incidence is increasing because of increased rates of cesarean section and advanced maternal age during pregnancy. Risk factors for placenta previa are summarized in Table 3-3 .
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Placenta previa can be marginal, partial, or complete ( Fig. 3-1 ). Vaginal bleeding prior to delivery is more likely and more severe in cases of total previa.
Placenta previa is associated with increased maternal and perinatal morbidities particularly in those with total previa, previous cesarean section, and multifetal gestation. Maternal morbidity includes the need for blood transfusions and hysterectomy, whereas both perinatal mortality and morbidities are increased secondary to premature delivery ( Figs. 3-2 and 3-3 ).
Case 1: Placenta Previa
A 38-year-old G2P2 with two previous cesarean sections (one was for arrest of dilation at term and the second was elective repeat at 39 weeks’ gestation). She had normal prenatal care except for painless vaginal bleeding at 30 weeks’ gestation, requiring hospitalization. Ultrasound examination revealed total placenta previa covering at least 4 cm of the internal cervical os. In addition, there was no evidence of placenta accreta. Vital signs were stable, and the patient received corticosteroids for fetal lung maturation. She was observed for 3 days during which vaginal bleeding stopped; her hematocrit at time of discharge was 29%. At 33 4/7 weeks’ gestation, she was hospitalized again with a second episode of painless vaginal bleeding for which she received another course of corticosteroids. She was observed in the hospital for 4 days during which bleeding subsided. She was again discharged home with a hematocrit of 26%. The plan was for elective cesarean section at 37 weeks’ gestation. Two weeks later (at 36 1/7 weeks’ gestation) she presented with profuse vaginal bleeding with uterine contractions for which she required blood transfusions and emergency cesarean section with delivery of a 2600-g live infant with Apgar scores of 3 and 6 at 1 and 5 minutes, respectively. During cesarean section she continued to have bleeding from the lower uterine segment with ultimate cesarean hysterectomy. She required transfusions of 5 units of packed red blood cells and 2 units of fresh frozen plasma. Postoperatively, she was monitored for 2 days in the intensive care unit, and was discharged home with her infant 7 days after admission. The pathology report of the hysterectomy specimen revealed no evidence of placenta accreta.
Discussion
Early detection of total placenta previa, particularly in patients with previous cesarean section is critical because it allows for interventions that will lessen the risks of adverse maternal and fetal outcomes as was evident in this case. Common errors in management include failure to appreciate the clinical significance of repetitive vaginal bleeding, the significant drop in maternal hematocrit with the need for blood transfusions, and failure for continued hospitalization for close monitoring and timely delivery. This patient with previous cesarean section with total and central previa (covering 4 cm of internal os) was at very high risk for antepartum bleeding, preterm delivery, and the need for hysterectomy (see Figs. 3-2 and 3-3 ). As expected, she had two episodes of painless vaginal bleeding prior to 34 weeks’ gestation. It was appropriate to administer corticosteroids because of the concern about the need for preterm delivery. Of concern was the fact that she was discharged home after the second episode of vaginal bleeding with a hematocrit of 26%. During the second hospitalization, the patient should have received 2 units of packed red blood cells (PRBCs) to keep her hematocrit at least 30%. In addition, she should have remained hospitalized for close monitoring of vaginal bleeding and uterine activity for timely delivery. During hospitalization, the patient should have been counseled about the need for preterm delivery and potential hysterectomy. In addition, the blood bank should have been notified to have 2 to 4 units of crossmatched PRBCs available in case she required urgent delivery.
Because the physician did not appreciate the significance of repetitive vaginal bleeding in a patient with previous cesarean section and central previa, the patient was discharged home with a plan for elective section at term, which led to a life-threatening emergency to both fetus and mother. This case highlights the need to develop protocols for surveillance and management of pregnant women with total placenta previa.
Abruptio Placentae
Abruptio placentae is defined as premature separation of the placenta after 20 weeks’ gestation. Placental separation can be clinically revealed ( Fig. 3-4A and B ), in which case the patient presents with painful vaginal bleeding with or without contractions or it could be concealed (occult) separation (see Fig. 3-4C and D ), in which case blood accumulates behind the placenta, and there is no vaginal bleeding. Placental abruption is revealed in approximately 75% of cases and concealed in 25%. The abruption could also be partial or complete. The exact incidence of abruptio is unknown; however, there are several risk factors for abruptio placentae ( Table 3-4 ). In general, the majority of patients with abruptio present with moderate to severe pain that can be intermittent or constant. In case of anterior placenta, the pain is usually abdominal (mid to fundal), whereas with posterior placental location, the pain is usually in the back. In moderate to severe placental abruption, uterine activity and fetal heart rate monitoring demonstrate one or more of the findings listed in Table 3-5 .
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| Uterine Activity | Fetal Heart Rate |
|---|---|
| •High frequency–low amplitude | •Absent accelerations |
| •Increased resting tone | •Decreased variability |
| •Uterine irritability | •Variable/late decelerations |
| •Tetanic contractions | •Bradycardia |
Pregnancies complicated by moderate to severe abruptio placentae are associated with substantial maternal and perinatal complications ( Table 3-6 ). These complications are more frequent in those with placental separation affecting more than 50% of the placenta, and in those with concealed abruptio. In these cases, the blood loss can be at least 1000 mL at the time of presentation. Therefore, moderate to severe placental abruption should be considered a life-threatening emergency to both mother and fetus ( Table 3-7 ).
Case 2: Abruptio Placentae
The patient is a 22-year-old G2P0 with normal prenatal care except for history of smoking cigarettes (one pack/day). At 34 weeks’ gestation she presented to triage area because of abdominal pain and pink vaginal discharge. Physical examination revealed a blood pressure of 115/70 mm Hg, and pulse of 94 to 98. Vaginal examination revealed cervix 2 cm dilated, 40% effaced, vertex presentation at −2 station with no evidence of vaginal bleeding. Uterine activity monitoring revealed irritable contractions, and the fetal heart rate (FHR) tracing demonstrated a normal baseline with moderate variability, and occasional decelerations ( Fig. 3-5A ). She was given a fluid bolus for hydration and discharged home after 1 hour of observation despite the fact that she was still having uterine irritability and occasional decelerations. Four hours later she presented back to triage area because of continued abdominal pain and mild vaginal bleeding. On arrival, her BP was 115/76 mm Hg, and the heart rate was 106 to 115 beats per minute (bpm).
A cervical exam revealed cervix 3 to 4 cm dilated, 70% effaced with mild vaginal bleeding. There was again uterine irritability with recurrent decelerations (see Fig. 3-5B ) for which she had position change and maternal oxygen (10 L/min). Approximately 50 minutes later, she was transferred to the labor and delivery area for close monitoring. Cervical exam was 4 cm dilated, 70% effaced, with vertex at zero station. Internal fetal scalp electrode was placed and the amniotic fluid was blood tinged. Subsequent monitoring revealed uterine tachysystole with repetitive decelerations (see Fig. 3-5C and D ). Abruptio placentae was suspected, and blood was sent for complete blood count (CBC), coagulation studies, and for crossmatch. Because of progressive cervical change and concern about coagulopathy, the plan was conservative. The FHR tracing was getting worse with continued decelerations and absent beat-to-beat variability with drop of baseline to a rate of 120 (see Fig. 3-5E and F ) and finally to 100 when emergency cesarean was done with delivery of a 2190-g infant with Apgar scores of 0, 0, and 1 at 1, 5, and 10 minutes, respectively (see Fig. 3-5G ). Cord arterial gases revealed a pH of 6.80, P co 2 of 100, HCO 3 of 16, and a base deficit of 19.8. The infant subsequently died 2 days later. At the time of cesarean section there was 60% abruption.
Initial blood tests results on admission revealed a hematocrit of 28%, platelet count of 144,000, prolonged prothrombin time, and fibrinogen of 114 mg/dL. Subsequent blood tests revealed the presence of disseminated intravascular coagulopathy for which she received 4 units of PRBCs and 4 units of fresh frozen plasma (FFP). The patient was discharged home 4 days after surgery.
Discussion
Early diagnosis, prompt management, and timely delivery are key to improve maternal and perinatal outcomes in patients with abruptio placentae. Maternal and perinatal outcomes in abruptio placentae are usually dependent on one or more of the following: gestational age at onset, degree of placental separation, type of abruptio (revealed or concealed), maternal and/or fetal conditions at time of presentation, and presence or absence of associated conditions such as severe hypertension-preeclampsia, cocaine overdose, or uterine rupture with extrusion of the fetus into the uterine cavity. In the last case, the placental separation can be complete (100%), which results in either fetal-neonatal death and/or significant neonatal hypoxia-acidosis after 10 minutes of placental separation. In addition, maternal and perinatal morbidities and mortality are substantially increased in those with one or more of the factors listed in Table 3-7 .
Common errors in the management of abruptio placentae include failure to appreciate the clinical significance of signs and symptoms such as constant abdominal (anterior placenta) or back pain (posterior placenta), in association with either uterine irritability and/or changes in FHR tracing, acute changes in maternal vital signs, and failure to appreciate the amount of blood loss (both revealed or concealed). Other common errors include failure to obtain the appropriate laboratory tests or serial monitoring of blood tests (CBC, fibrinogen, prothrombin time, platelet count), failure to obtain blood and blood products and administer these products in a timely fashion, and failure to accomplish timely delivery.
Abruptio placentae that is severe enough to kill the fetus, and those with concealed abruptio and/or separation of more than 50% are usually associated by more than 1000 mL of blood loss at the time of presentation. In addition, disseminated intravascular coagulation (DIC) is present in approximately 35% of cases. These patients are usually hypovolemic despite the fact their initial blood pressure can be normal and the pulse is slightly elevated. These patients should receive empirically 4 units of PRBCs and FFP as needed in preparation for or during delivery. In patients with severe hypertension-preeclampsia in association with abruptio, a normal blood pressure indicates hypovolemic shock and should be managed by aggressive fluid and blood infusions being guided by heart rate, urine output, and results of CBC and coagulation tests. Vaginal delivery is recommended when the fetus is dead. If labor is not well established, induction of labor should be initiated by artificial rupture of the membranes and oxytocin if needed. During induction, patient should receive serial monitoring of coagulation studies, vital signs, urine output, and amount of bleeding. Hypovolemia and coagulopathy should be treated promptly with crystalloids, blood, and blood products. Emergency cesarean section is recommended when the fetus is viable (≥24 weeks’ gestation) in association with nonreassuring FHR tracing (see Table 3-5 ).
This patient, with a history of cigarette smoking, presented to the triage area with signs and symptoms suggestive of possible abruptio placentae (abdominal pain, uterine irritability, occasional variable decelerations). She was managed as ruled out preterm labor, observed for only 1 hour, and was discharged home despite the presence of uterine irritability and persistent FHR decelerations. During this visit she should have been monitored for a longer time with uterine activity and FHR. Four hours later she came back with similar complaints in association with vaginal bleeding, advanced cervical dilation, maternal tachycardia, and more frequent uterine contractions and recurrent decelerations.
At that time a diagnosis of abruptio placentae should have been made and blood obtained for CBC, crossmatch, and coagulation studies with plan for emergency cesarean section. Even when the diagnosis of abruptio placentae was considered an hour later, and in the presence of nonreassuring FHR tracing, the plan was to attempt vaginal delivery. During the observation period, there was progressive separation of the placenta with increased hypoxia and acidosis as reflected by changes in FHR tracing (staircase to fetal death tracing). This delay in delivery ultimately resulted in neonatal death secondary to severe hypoxia and acidosis. In addition, it resulted in the woman developing DIC and for the need of transfusion of several units of PRBCs and FFP.
This case highlights several errors in diagnosis and management of abruptio placentae by both the managing physician and the nursing staff. The physician did not appreciate the importance of the changes in uterine activity and FHR tracing, and the nurses failed to communicate to the physician their concern about these changes. In the setting of severe placental abruption in association with nonreassuring FHR tracing, both neonatal survival and intact neonatal survival are progressively reduced if delivery was achieved beyond 20 minutes ( Fig. 3-6 ). This case underscores the importance of developing protocols for surveillance and management of patients with suspected abruptio placentae including mechanisms to improve education, training, and methods of communication among all obstetric providers working in emergency department, obstetric triage, and labor and delivery units.
