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Maternal Mortality-Obstetrical Hemorrhage PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Maternal Mortality - Obstetrical Hemorrhage” by Dr. Adiel Fleischer.

This medical PowerPoint presentation is about obstetrical hemorrhage, excessive bleeding that occurs during or after childbirth. It is a potentially life-threatening complication that can occur in both vaginal and cesarean deliveries.

Tags : Maternal Mortality, Obstetrical Hemorrhage, childbirth, Obstetrics and Gynecology, Obstetrics and Gynecology PowerPoint presentation

Published on : Jun 20, 2023 | Views : 1617 | Downloads : 2

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Maternal Mortality - Obstetrical Hemorrhage - Dr. Adiel Fleischer Chief Maternal Fetal Medicine NS-LIJ Health System
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Maternal Mortality-All pregnancies-
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Prepare Handle Maternal Mortality Peripartum Hemorrhage (PPH) Predict - Obstetrical Hemorrhage -
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Maternal Mortality - Obstetrical Hemorrhage - Identify Patients at Risk Multidisciplinary “Hemorrhage protocol” Clinical management of PPH
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Maternal Mortality - Obstetrical Hemorrhage - 1.-Identify pat. at risk -Pl previa/accreta Anticoagulation Rx Coagulopathy Overdistended uterus Grand multiparity Abn labor pattern Chorioamnionitis Large myomas Previous history of PPH
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Maternal Mortality - Obstetrical Hemorrhage - 1.- Prepare for PPH 2.- Optimize patient’s hemodynamic status 3.- Timing of Delivery 4.- Surgical planning 5.- Anesthesia /I.V. access/ invasive monitoring 6.- Modify obsterical management 7.- Increased postpartum/postop surveillance Patients at risk Pre-delivery management
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Maternal Mortality - Obstetrical Hemorrhage - 1.- Prepare for PPH -Nursing -Anesthesia - Surg assistance - Others (I.R.) Drugs/Equipment -Methergine -Hemabate -Cytotec -Colloids - Blood/Bl.products -Surg. Instruments -Hemostatic ballons ( Cook, S-B, Foley) Personel
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Maternal Mortality - Obstetrical Hemorrhage - 1.- Prepare for PPH 2.- Optimize patient’s hemodynamic status 3.- Timing of Delivery 4.- Surgical planning 5.- Anesthesia /I.V. access/ invasive monitoring 6.- Modify obsterical management 7.- Increased postpartum/postop surveillance Patients at risk Pre-delivery management
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Maternal Mortality - Obstetrical Hemorrhage - 2.- Optimize hemodynamic status 1.- Acute isovolemic hemodilution 2.- Acute hypervolemic hemodilution 3.- Autologous donation 4.- Preoperative transfusion
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Maternal Mortality - Obstetrical Hemorrhage - Acute hemodilution Decreases pre-op Hb concentration Lower RBC’s loss For same blood volume lost - Transfusion rates - Final Hct’s
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Maternal Mortality - Obstetrical Hemorrhage - 1.- Acute isovolemic hemodilution Withdraw 2-4u. of Blood  Replace the volume with crystaloids  Lower the pre-op Hct  Replace the blood at end of surgery 2.- Acute hypervolemic hemodilution Admin 1500-2000cc Crystaloids  Hemodilution (Lowers pre-op Hct)
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Maternal Mortality - Obstetrical Hemorrhage -
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Maternal Mortality - Obstetrical Hemorrhage - - Acute isovolemic/hypervolemic hemodilution After hemodilution
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Maternal Mortality - Obstetrical Hemorrhage -
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Maternal Mortality - Obstetrical Hemorrhage - Optimize hemodynamic status 1.- Acute isovolemic hemodilution 2.- Acute hypervolemic hemodilution 3.- Autologous donation 4.- Preoperative transfusion
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Maternal Mortality - Obstetrical Hemorrhage - 1.- Prepare for PPH 2.- Optimize patient’s hemodynamic status 3.- Timing of Delivery 4.- Surgical planning 5.- Anesthesia /I.V. access/ invasive monitoring 6.- Modify obsterical management 7.- Increased postpartum/postop surveillance Patients at risk Pre-delivery management
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Maternal Mortality - Obstetrical Hemorrhage - 3.- Timing of Delivery - Placenta previa - Prev classical Prev myomectomy Tumor previa Avoids uterine rupture Avoids significant hemorrhage Schedule C/S - 36-37wks after Amnio for FLM - >37 wks if Amnio not possible
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Maternal Mortality - Obstetrical Hemorrhage - 1.- Prepare for PPH 2.- Optimize patient’s hemodynamic status 3.- Timing of Delivery 4.- Surgical planning 5 .- Anesthesia /I.V. access/ invasive monitoring 6.- Modify obsterical management 7.- Increased postpartum/postop surveillance Patients at risk Pre-delivery management
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Maternal Mortality - Obstetrical Hemorrhage - 4.- Surgical planning Realistic assessment of a significant PPH episode Wants to avoid TAH ? (religious/cultural) Inability to transfuse ? (Jehovah’s witness, etc) Desires subsequent pregnancies ? Tolerates poorly large hemodynamic shifts Bleeding  TAH More Surgery/Embolization More Tranfusion. TAH
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Maternal Mortality - Obstetrical Hemorrhage - 1.- Prepare for PPH 2.- Optimize patient’s hemodynamic status 3.- Timing of Delivery 4.- Surgical planning 5 .- Anesthesia /I.V. access/ invasive monitoring 6.- Modify obsterical management 7.- Increased postpartum/postop surveillance Patients at risk Pre-delivery management
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Maternal Mortality - Obstetrical Hemorrhage - 4.- Anesthesia / I.V. Access Obtain Anesthesia consult - Type of anesthesia - Need for invasive monitoring (A line, S-G monitoring, etc)
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Maternal Mortality - Obstetrical Hemorrhage - Identify Patients at Risk Multidisciplinary “Hemorrhage protocol” Clinical management of PPH 1.- How/Who triggers the “H.P.” 2.- Identify “The response team” 3.- Transfusion protocol 4.- Define the logistics involved 5.- Conduct drills 6.- Post-op care
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Maternal Mortality - Obstetrical Hemorrhage - Identify Patients at Risk Multidisciplinary “Hemorrhage protocol” Clinical management of PPH 1.- How/Who triggers the “H.P.” RN’s, CNM’s, PA’s, MD’s Labor & Delivery Postpartum floor Antepartum floor E.D. Code “H” Operator Response Team
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Maternal Mortality - Obstetrical Hemorrhage - Identify Patients at Risk Multidisciplinary “Hemorrhage protocol” Clinical management of PPH 2.- The “Response Team” Nursing Anesthesia Ob surgery (MFM, Gyn Onc, Ob-Gyn,) Intervention Radiology Urology Hematology
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Maternal Mortality - Obstetrical Hemorrhage - Identify Patients at Risk Multidisciplinary “Hemorrhage protocol” Clinical management of PPH 3.- Transfusion Protocol -Immediate release of O neg Blood if required - How fast can Crossmatched blood be made available - Physical transport of Blood  O.R. and samples O.R.  Lab/Blood Bank
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Maternal Mortality - Obstetrical Hemorrhage - Identify Patients at Risk Multidisciplinary “Hemorrhage protocol” Clinical management of PPH 4.- Logistics Hospital specific - Define responsibilities
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Maternal Mortality - Obstetrical Hemorrhage - Identify Patients at Risk Multidisciplinary “Hemorrhage protocol” Clinical management of PPH 5.- Drills - Conduct Drills 3-4 x/year - Evaluate the performance - Review the results with the entire team
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Maternal Mortality - Obstetrical Hemorrhage - Identify Patients at Risk Multidisciplinary “Hemorrhage protocol” Clinical management of PPH 6.- Postoperative care Insures a smooth transition from the O.R./L&D to the apropriate level of care unit  In most hospitals L&D/Postpartum units not ideal for these patients
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Maternal Mortality - Obstetrical Hemorrhage - Identify Patients at Risk Multidisciplinary “Hemorrhage protocol” Clinical management of PPH Diagnosis - Early shock - Severity of Shock Treatment - Insure hemostasis - Adequate replacement
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Maternal Mortality- Obstetrical Hemorrhage - Significant PPH Etiology Uterine atony Placenta previa/accreta Cervico-vag tears Uterine rupture Coagulopathy* * Any major hemorrhage  Coagulopathy  Bleeding
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Maternal Mortality- Obstetrical Hemorrhage - - Uterine massage  I.V. fluids Empty bladder Oxytoxic Agents Methergine 0.2mg Carboprost 250μg Cytotec 800-1000μg Significant PPH  Hemostasis  Hemostasis Surgery/Embolization
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Maternal Mortality- Obstetrical Hemorrhage - Local matress sutures Hemostatic baloons U.A.E. Conserv Rx of Pl accreta  TAH B-Lynch procedure Uterina a. ligation Stepwize devascularization Uterine repair U.A.E.  TAH Significant PPH Ut Atony/Tears Pl previa/accreta Failed Medical Rx
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Maternal Mortality- Obstetrical Hemorrhage - Five cases of massive life threatening postpartum hemorrhage were managed by the use of the “B-Lynch surgical technique. Christopher B-Lynch Br J Ob Gyn 1997
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Maternal Mortality- Obstetrical Hemorrhage - - Decreases Blood Flow by  48% - Controls Severe P.P.H. in  50% of cases Clark et al Ob-Gyn 1985 Hypogastric artery ligation
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Maternal Mortality- Obstetrical Hemorrhage - O’Leary,J J Reprod Med 1995 Uterine artery ligatiaon Over a 30 yr period 256 Ut artery ligation were performed for PPH. -Successful 256 cases - Failed 10 cases
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Maternal Mortality- Obstetrical Hemorrhage - Stepwise uterine devascularization was performed for 103 patients to control intractable postpartum hemorrhage not responding to clasic management S.A. AbdRabbo Am J Ob Gyn 1994
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Maternal Mortality- Obstetrical Hemorrhage - S.A. AbdRabbo Am J Ob Gyn 1994
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Maternal Mortality- Placenta Accreta - Biochemical markers - Placenta previa - Previous C/S - Adv maternal age  Sonographic markers Clinical Risk Factors  Suspect Placenta accreta
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Maternal Mortality- Placenta Accreta - Attempt Placental removal  Hemorrhage Cesarean Section -Local sutures Uterine artery ligation Embolization TAH Classic management
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Maternal Mortality- Placenta Accreta - - Significant blood loss - MOF (ARDS, DIC, ARF ) Injury to other organs -Bladder, Urether Need for Hysterectomy Classic management
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Maternal Mortality- Placenta Accreta - A survey of members of SPO identified 109 cases of placenta accreta. - Antepartum Dg suspected in 50%. - Management Surgical 93% Conservative 7% Maternal Mortality 8 (7%) Maternal Morbidity Transfusions 90% Massive transfusion (>10u.) 40% Serious infections 28%
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Maternal Mortality- Placenta accreta - Objective A group of patients suspected of having Pl. accreta and managed conservatively was compared with a similar group of patients that deliverd during the same time interval but were managed in a traditional fashion Jurczak,A Fleischer,A et al ACOG-2005
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Maternal Mortality - Placenta Accreta - Conservative approach Amnio at 37wks gestation for FLM Day of C/S catheters are placed in the abd. aorta Intraop : - Sono maps the position of the Placenta -Uterine incision just above placental edge (High transverse incision) Jurczak,A Fleischer,A et al ACOG-2005
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Maternal Mortality - Placenta Accreta - Selective embolization of the uterine arteries under fluoroscopic guidance (20-25 min) Delivery of infant: - Leave placenta intact - Insure hemostasis of uterine incision Conservative approach Jurczak,A Fleischer,A et al ACOG-2005
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Maternal Mortality - Placenta Accreta - Succesful embolization Attempt made to remove placenta Leave placenta in situ Remove placenta  Pl accreta  Pl accreta Conservative approach Jurczak,A Fleischer,A et al ACOG-2005
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Maternal Mortality -Placenta Accreta - Conservative  A total of 17 patients with the presumptive Dg of Placenta accreta were managed in this fashion. Traditional  A total of 18 ptients were managed by removing placenta first then insuring hemostasis . Jurczak,A Fleischer,A et al ACOG-2005
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2 wks P-Partum
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6mo PP
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Group 1. n=13 Embolized; Placenta left Group 2. n=2 Group 3. n=2 Entire Pl  6pat Part of Pl  7pat Embolized; Placenta removed (No Pl accreta) Not Embolized Ut incision through Pl Bleeding  TAH Maternal Mortality -Placenta Accreta - Jurczak,A Fleischer,A et al ACOG-2005
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*2 pat Medical reasons for tranfusion **attempt for vaginal removal of placenta 2mo PP Maternal Mortality -Placenta Accreta - Jurczak,A Fleischer,A et al ACOG-2005
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Maternal Mortality -Placenta Accreta - Objective A retrospective comparison of a new “conservative” approach to the classic management of Placenta accreta Kayem et al Ob-Gyn 2004
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Maternal Mortality -Placenta Accreta - Conservative  A total of 20 patients had their Placenta left in situ after Dg of Pl accreta. UAE not done routinely Traditional  A total of 13 ptients were managed by removing placenta first then insuring hemostasis . Kayem et al Ob-Gyn 2004
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Maternal Mortality -Placenta Accreta - Kayem et al Ob-Gyn 2004 *p< 0.05
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Intraoperative management 1.-Map exact position of placenta  Make high transverse uterine incision to avoid cutting through placenta 2.- Deliver fetus  Rapid hemostasis of uterine incision (clamps, sutures) TAH Dg uncertain Avoid TAH Definitive Rx UAE Remove pl Leave Pl in situ UAE Do not remove pl Maternal Mortality -Placenta Accreta -
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Maternal Mortality -Placenta Accreta - Wants to avoid TAH (religious/cultural) Inability to transfuse (Jehovah’s witness, etc) Desires subsequent pregnancies Significant Bladder involvment Tolerates poorly large hemodynamic shifts (IHSS, Eisenmenger syndrome etc) Conservative approach
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Follow-up management 1.- Ultrasound exams  Vascularity 2.- HCG titers (If  consider Mtx) 3. Daily Temps, Other S&S of infection 4.- Bleeding 5.- Coagulation profile Maternal Mortality -Placenta Accreta -
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Follow-up management If Intervention necessary for - Bleeding - Infection - DIC Proceed directly to TAH Maternal Mortality -Placenta Accreta -