Guide How a postpartum hemorrhage signs and symptoms

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality through the world.  The obstetrician must have a thorough understanding of normal delivery – related blood loss , physiologic responses to hemorrhage, the most have a thorough understanding of normal delivery- related blood loss , physiologic responses to hemorrhage, the most common etiologies of  postpartum hemorrhage, and appropriate therapeutic interventions.

NORMAL BLODD LOSS: 

Normal delivery- related blood loss depends upon delivery type.  The average blood loss for a vaginal delivery,  cesarean section, and cesarean hysterectomy.

PHYSILOGICAL RESPONSE TO HEMORRHAGE:

 The pregnant patients can be able to adapt to hemorrhage more effectively than her nonpregnant counterpart   due to hemodynamic changes that accompany pregnancy. These changes were include increased red cell mass, increased in the plasma volume, and also increased a cardiac output.

ETILOGIES OF POSTPARTUM HEMORRHAGE: 

The etiologies of postpartum hemorrhage can be categorized as early occurring within 24 hours of delivery –and late­-those occurring from 24 hours until 6 weeks post delivery.

UTERINE RUPTURE:

 Uterine rupture represents a potential catastrophic event for both mother and fetus and may result in a significant hemorrhage if the placental implantation site is involved. While prior cesarean section remains the most common risk factor for uterine rupture, other risk factors include multiparity, fetal malpresentation, obstructed labor, multi gestation, prior hysterectomy/myomectomy, uterine manipulation, and mid to high-operative vaginal delivery.

Hypertensive emergencies

   Hypertensive disorder  are the most common medical complications of pregnancy the spectrum of the disease ranges from mildly elevated  blood pressures with minimal clinical significances , to severe hypertension and multiorgan dysfunction. Understanding the disease and its impact on pregnancy is utmost importance, as hypertensive disorders remain a major cause of maternal and prenatal morbidity and mortality worldwide.

GESTATIONAL HYPERTENSION: gestational hypertension is the elevation of blood pressure during the second half of pregnancy or in the first 24 hours postpartum, without proteinuria and without symptoms Normalization of blood pressure occurs in the postpartum period, usually within 10 days. Treatment is generally not warranted since most patients will have mild hypertension.

The classic triad of hypertension, proteinuria and symptoms defines the syndrome of preeclampsia. Symptoms of preeclampsia include headache, visual changes, epigastric or right upper quadrant pain, and shortness of breath. Preeclampsia should be instructed to immediately report any of the symptoms listed below.

                                                      

·         Nausea and vomiting

·         Persistent, severe headache

·         Right upper quadrant or epigastric pain

·         Scotomata

·         Blurred vision

·         Decreased fetal movement

·         Rupture of membranes

·         Vaginalbleeding

·         Regular uterine contractions

PATHOPHYSIOLOGYL: 

The hypertensive changes seen in preeclampsia are attributable to intense vasoconstriction thought to be due to increase vascular reactivity. The underlying mechanism responsible for increased vascular reactivity is presumed to be dysfunction in the normal interactions of vasodilatory and vasoconstrictive substances.

MANAGEMENT OF SEVERE PREECLAMPSIA: 

Any patient with serve preeclampsia should be admitted and initially observed in a labor and delivery unit. Initial workup should include assessment for fetal well being, monitoring of maternal blood pressure and symptomatology as well as laboratory evaluation. Laboratory assessment should include hematocrit, platelet count, serum creatinine, aspartate aminotransferase, and 24-hour urine collection for total protein excretion. An ultrasound for fetal growth and amniotic fluid index should also be obtained candidates for expectant management should be carefully selected .

HYPERTENSIVE EMERGENCIES

On rare occasions, pregnant women may present with life-threatening clinical conditions that require immediate control of blood pressure, such as hypertensive encephalopathy, acute left ventricular failure, acute aortic dissection or conditions characterized by increased levels of circulating catecholamines. Patient   at the high risk of these complications include those with underlying cardiac disease, chronic renal disease, hypertension requiring multiple drugs to achieve control, superimposed in the second trimester, and abruption placenta in association with disseminated intravascular coagulation.

Obesity in the Obstetric intensive care patient

               Obesity should be of particular interest and importance to those providing health care to women because age-adjusted rates of obesity of females of all races significantly exceed those for males. African-American women with severe obesity incur the greatest numbers of years of life lost of obesity- related premature mortality .The complications of obesity and its relation to the obstetric intensive care patient cannot be overemphasized.

             Obesity had been defined and described in variety of colorful ways. Terms such as severe, massive, morbid and grotesque appear in published literature to describe different degrees of obesity. Unfortunately, standardized definitions are lacking. The term overweight refers to an excess of body weight compared to set standards, with the excess weight coming from muscle, bone, fat and body water. Obesity, however, is defined as an excess of body fat frequently resulting in impairment of health. Therefore, rarely, an individual could be overweight but not obese. Obesity is usually caused by an excess of caloric intake versus expenditure.

Medical complications of obesity

               Sudden death, Stroke, Coronary artery disease, Hypertension, Thromboembolic disease, Diabetes mellitus, Dyslipidemias, Carcinoma, Dyslipidemias, Carcinoma, Colon, Gallbladder, Ovary, Endometrium, Breast, Cervix, Compromised obstetric outcome, Anesthetic complications, Dermatological diseases, Acanthosis nigricans, Gragilitas cutis inguinalis, Gout , Osteoarthritis, digestive Diseases, Cholelithiasis, Hiatal hernia , pulmonary function impairment, Obstructive sleep apnea/pulmonary, Hypertension, Asthma, Hepatic steatosis, Endocrine abnormalities, Menstrual disorders, Infertility, Polycystic ovary disease, Psychosocial disorders, depression, mood, and anxiety disorders

PATHOPHYSIOLOGY: 

Perinatal outcome is compromised among pregnancies complicated by obesity. The Obese pregnant woman and fetus are at risk of a variety of complications during pregnancy. These include increased risks of hypertension, preeclampsia, diabetes (insulin –dependent and gestational), labor abnormalities, cesarean delivery, and congenital malformations. The neonate born to the obese mother has also been noted to be at significantly increased risk of adverse outcome including low Apgar Scores, intrauterine growth restriction, preterm delivery, low birth weight, macrosomia/large for gestational age , and intensive care requirement.

Obesity and Perinatal outcome-Maternal Risks
·         Obstetric (direct) mortality:Aspiration, Hemorrhage, Thromboembolism, Stroke.
·         Dysfunctional labo
·         Cesarean section
·         Failed vaginal birth after cesarean (VBAC)
·        Cesarean section operative and anesthetic morbidities :-Increased blood loss, Increased                       endometritis, Prolonged  operative time, failed epidural placement, Respiratory
      complications, Wound infection, Thromboembolism
·         Medical complications: - Chronic hypertension, Diabetes, preeclampsia,
·         Prolonged hospitalization
·         Urinary tract infection

INTRAPARTUM MANAGEMENT: - 

The Intrapartum management of the obese patient in labor is truly a team effort. The obstetrical physician, the labor and delivery nurse, and the obstetric anesthesiologist physician, the labor and delivery nurse, and the obstetric anesthesiologist from the primary components of the team. Medical Consultants who have evaluated the patient for given medical complications may be notified of the patient’s admission to labor and delivery for additional management input.

The Diagnosis and treatment of Thromboembolic Disease in Pregnancy 

         Hemorrhage and thrombosis are major contributors to both Perinatal and maternal morbidity and mortality. That they do not occur more often is remarkable, given the paradoxical challenges presented to a woman’s hemostatic system during the antepartum and postpartum period. During early placentation, syncytiotrophoblasts penetrate maternal uterine vessels to establish the primordial uteroplacental circulation. Subsequently, endovascular extravilllous crytotrophoblasts invade uterine spiral arteries orchestrating a morphological transformation of these vessels to facilitate high volume, Low resistance blood flow into the intervillous space.

The Regulation of Hemostasis - Risk factors

Cesarean delivery and postpartum endomyometritis lower the levels of proteins and cause tissue injury while increased parity promotes venous stasis. Not surprisingly each of these factors increases the risk of venous Thromboembolic. Cesarean delivery alone is associated with a ninefold increase in the risk of venous Thromboembolic compared to vaginal delivery. Other clinical risk factors unrelated to pregnancy include trauma, infection, obesity, nephritic syndrome, age greater than 35, bed rest, orthopedic surgery, and a prior history of venous Thromboembolic. Smoking and prior superficial venous thrombosis are additional independent risk factor for venous Thromboembolic during pregnancy and the postpartum period.

PELVIC THRMBOSES

Septic pelvic thrombophlebitis is an uncommon and controversial complication of pelvic infection. It is more common after cesarean than vaginal delivery but has also been reported after gynecologic procedure. Thrombus formation in the pelvic veins is likely to result from inflammatory cytokine induction of tissue factor expression in the endothelium of pelvic vessels. Physical finding are non specific. Multiple infected embolic may result from fibrinolysis. The typical presentation is a patient who develops spiking fevers that persist despite adequate antibiotic coverage. MRI or CT imaging may aid in the diagnosis. Although these techniques may be specific a nonocclusive thrombus in the iliofemoral veins may remain undetected. Clinical response was considered both therapeutic and diagnosis with defervescence expected in 48 to 72 hours and the recommended duration of treatment ranging from 7 to 10 days to full 6 weeks of anticoagulation.

SURGERY AND THROMBOLYTIC THERAPY

surgical embolectomy should be reserved for life threatening setting. Massive PE with hemodynamic instability should be the only indication for thrombolytic therapy in pregnancy given the high risk that these agents will induce abruption.

Cardiac disease in pregnancy

Cardiac disease complicates less than one percent of all pregnancies. Circulatory stress of pregnancy may unmask a previously unrecognized cardiac condition and can cause rapid deterioration. Understanding cardiovascular adaptations in pregnancy and postpartum are crucial in the management of such patients. Cardiac lesions are classified into congenital and acquired categories and can be further divided in to cyanotic and acyanotic grouphs. Cyanotic (right to left shunt) lesions are the most critical, and pregnancy is contraindicated in such patients due to high maternal mortality.

GENERAL PRINCIPLES OF MANAGEMENT

Specific management is described with each condition

  

Antepartum

All cardiac patients require meticulous follow up during pregnancy
Attention should be paid to subtle changes in exercise capacity and symptoms

  Postpartum

       Increase in stroke volume
      1.    Reflex bradycardia
      2.   These changes persist for 1-2 weeks after delivery

Fetal echocardiogram is indicated in the presence of congenital heart disease in mother. periodic fetal growth assessments, antepartum fetal surveillance starting at 30-34 weeks.

Labor and Delivery

  Avoid fluid overload

 Labor in left lateral decubitus position

 Supplemental oxygen

 Multidisciplinary management in consultation with anesthesiologist and cardiologist

COMMON CONGENITAL CARDIAC LESIONS

             Secundum Atrial Septal defect is the most common defect seen in pregnancy

             Systolic ejection murmur at left sternal border and wide fixed spilt second heart sound

             Partial right bundle branch block, right axis deviation, and sometimes right ventricular hypertrophy

             Patients with a large defect and significant left to right shunt may develop Atrial arrhythmias and congestive heart failure in pregnancy   

Maternal sepsis

Sepsis, severe sepsis, and septic stock are a continuum in the systemic response to infection. The obstetrics patient is particularly vulnerable to sepsis because of the association between pregnancy and infectious complications such as pyelonephritis, chorioamnionitis, endometritis, wound infection, necrotizing fasciitis, and cholecystitis. Overall, gram-negative aerobic bacilli used to be the predominant organisms associated with sepsis. How-ever, the incident of infection with gram-positive organisms in patients with sepsis has increased and may now equal that of gram-negative infections.

PATHOGENESIS

Sepsis is has been viewed as uncontrolled inflammatory response to infection. The immunological response in patient with sepsis may even be biphasic, with an anti-inflammatory phase following an initial overwhelming response. The cardiovascular manifestations of sepsis re the results of alternations in peripheral vascular tone and cardiac function. The decrease in vascular tone affects both the arterial and venous system and is believed to be due to an increase in smooth muscle relaxants such nitric acid. Micro vascular changes such as endothelial cell swelling, fibrin deposition, and aggregation of circulating cell as contribute to the abnormal blood flow seen in patient with sepsis.

General Treatment Guidelines for Sepsis

  
•              Broad spectrum antibiotics

•             Aggressive fluid replacement guided by CVP or pulmonary artery catheter

•             Blood product as needed

•             Vasopressors and inotropes

•             Removal of infection source

•             Ventilator support

•             Supportive care

•             Immunological therapy

•             Delivery as last resort

The effect of pregnancy on the critically ill patient vice versa, is discussed elsewhere. Pregnant septic  patient risk for utero-placental insufficiency and preterm labor. The decision for continuous fetal heart rate monitoring and and/or tocolysis should take in to account the gestational age and patient’s condition.  A non reassuring fetal heart rate pattern or contractions frequently resolve with correction of maternal hypoxemia and acidosis short-term duration.