Obstetric Hemorrhage

Classification

• Antepartum hemorrhage– Placenta previa– Placental abruption

• Postpartum hemorrhage– Uterine atony– Genital tract laceration

Cunningham PG, Leveno KJ, Bloom SL. Williams Obstetric. 22nd edition. E-book.

Cunningham PG, Leveno KJ, Bloom SL. Williams Obstetric. 22nd edition. E-book.

Predisposing or Worsening Conditions

• Abnormal placentation• Trauma during labor and delivery• Small maternal blood volume• Other factors• Uterine atony• Coagulation defects

Cunningham PG, Leveno KJ, Bloom SL. Williams Obstetric. 22nd edition. E-book.

Antepartum Hemorrhage

• Placenta previa• Placental abruption• Vasa previa

Cunningham PG, Leveno KJ, Bloom SL. Williams Obstetric. 22nd edition. E-book.

Placenta Previa• Placenta is located over or very near to internal ostium• Classification:

– Total– Partial– Marginal– Low-lying

• Etiology– Advancing maternal age– Multiparity– Prior caesarean delivery– smoking

• Vasa previa vessels instead of placentaCunningham PG, Leveno KJ, Bloom SL. Williams Obstetric. 22nd edition. E-book.

Cunningham PG, Leveno KJ, Bloom SL. Williams Obstetric. 22nd edition. E-book.

Incidence

• More common in multiparity patient with age >30 yo

• In several general hospital in Indonesia 1,7% – 2,9%

Chalik TMA. Perdarahan pada Kehamilan Lanjut dan Persalinan dalam Ilmu Kebidanan. 4th ed. Jakarta: PT Bina Pustaka Sarwono Prawirohardjo

Pathophysiology

• Isthmus widening, cervix effacement and dilatation detachment of implanted placenta laceration bleeding

• Lower segment of uterine has minimal muscular element minimal contraction slowly ends bleeding

• Progressive forming of lower segment of uterine new laceration recurrent bleeding

Chalik TMA. Perdarahan pada Kehamilan Lanjut dan Persalinan dalam Ilmu Kebidanan. 4th ed. Jakarta: PT Bina Pustaka Sarwono Prawirohardjo

Diagnosis

• Clinical findings:– Painless hemorrhage, especially after second

trimester• Radiology: sonography, MRI (not common)• Digital exploration is only permissible in

operating room

Cunningham PG, Leveno KJ, Bloom SL. Williams Obstetric. 22nd edition. E-book.

Complication

• Anemia or shock• Placenta accreta, increta, and percreta• Rupture of cervix and lower segment of

uterine• Malposition of the fetus• Preterm birth• Solutio placenta, postpartum hemorrhage, DIC

Chalik TMA. Perdarahan pada Kehamilan Lanjut dan Persalinan dalam Ilmu Kebidanan. 4th ed. Jakarta: PT Bina Pustaka Sarwono Prawirohardjo

Management

• Those in whom the fetus is preterm and there is no indication for delivery

• Those in whom the fetus is reasonably mature• Those in labor• Those in whom hemorrhage is so severe as to

mandate delivery despite fetal immaturity

Cunningham PG, Leveno KJ, Bloom SL. Williams Obstetric. 22nd edition. E-book.

Management (2)

• Blood transfusion• Close observation of mother and fetus• MSAFP• Mg sulfate• Steroid• USG, color Doppler, MRI

Chalik TMA. Perdarahan pada Kehamilan Lanjut dan Persalinan dalam Ilmu Kebidanan. 4th ed. Jakarta: PT Bina Pustaka Sarwono Prawirohardjo

Delivery

• Partial/ marginal placenta previa induction of labor

• Total placenta previa sectio caesarea

Cunningham PG, Leveno KJ, Bloom SL. Williams Obstetric. 22nd edition. E-book.

Prognosis

• Nowadays, the prognosis for women with placenta previa is better due to early detection

• Preterm birth is still unavoidable

Chalik TMA. Perdarahan pada Kehamilan Lanjut dan Persalinan dalam Ilmu Kebidanan. 4th ed. Jakarta: PT Bina Pustaka Sarwono Prawirohardjo