산과적 출혈

Obstetrical Hemorrhage Antepartum Hemorrhage Postpartum Hemorrhage Postpartum Hemorrhage Placental abruption Placenta previa Uterine atony Retained placental fragments Placenta accreta, increta, and percreta Inversion of uterus Genital tract lacerations Puerperal hematoma Rupture of uterus

Placental Abruption

Placental Abruption

Risk Factors Increased age & parity Preeclampsia Chronic hypertension Preterm ruptured membranes Cigarette smoking Cocaine abuse Prior abruption Uterine leiomyoma

Pathology Hemorrhage into the decidua basalis Decidual hematoma due to split Separation, compression, destruction of the placenta adjacent to it Rupture of decidual spiral artery Retroplacental hematoma Disrupt more vessels to separate more placenta

Pathology Concealed hemorrhage Effusion of blood behind the placenta but its margin still remain adherent Completely separated placenta with attached membrane Blood gains access to the amniotic cavity Fetal head is so closely applied to the lower segment

Pathology Chronic placental abruption Fetal-to-maternal hemorrhage Hemorrhage with retroplacental hematoma arrested completely without delivery Fetal-to-maternal hemorrhage Bleeding is almost always maternal Traumatic abruption may cause fetal bleeding

Pathology

Clinical Diagnosis Classical sign Ultrasonography Pain, shock, uterine rigidity, absent fetal heart sounds Ultrasonography Negative findings do not exclude potentially life-threatening placental abruption

Clinical Diagnosis Signs and symptoms Vaginal bleeding Uterine tenderness or back pain Fetal distress Hypertonus Idiopathic preterm labor Dead fetus

Complication Consumptive coagulopathy Mainly intravascular induction of coagulation Overt hypofibrinogenemia (< 150 mg/dL) Elevated fibrinogen-fibrin degradation product (> 100 ㎍/ml) Thrombocytopenia after repeated transfusion

Complication Renal failure Acute tubular necrosis Massive hemorrhage & coexisting acute or chronic HT Decreased cardiac output Intrarenal vasospasm Impaired renal perfusion Prompt fluid & electrolyte replacement Prevent life threatening renal dysfunction

Complication Uteroplacental apoplexy (Couvelaire Uterus) Widespread extravasation of blood into the uterine musculature Seldom interfere with uterine contraction Not indicated for hysterectomy

Couvelaire Uterus

Management Gestational age and status of the mother and fetus Tocolytic therapy is contraindicated Oxytocin If no rhythmic contraction superimposed, standard dose of oxytocin is given Fetus distressed -> cesarean section Fetus dead -> vaginal delivery preferred

Management

Placenta Previa

Risk Factors Advancing maternal age Multiparity Prior cesarean delivery Smoking (placental hypertrophy) Defective vascularization of the decidua Associated with placenta accreta

Clinical Findings Sudden painless hemorrhage near the end of the second trimester or after Initial bleeding Usually not profuse Cease spontaneously, but recur Coagulation defects : rare

Diagnosis Sonography MRI

Management Placenta previa with preterm fetus Cesarean section Active bleeding이 없는 한 계속 임신을 유지 일단 출혈이 멈추고 태아가 건강하면 퇴원 Cesarean section Lower segment transverse uterine incision Poor contractile nature Hemostasis Oversewing Gauze packing -> remove transvaginally

Management Hysterectomy is needed occasionally Especially in associated with placenta accreta Perinatal morbidity & mortality Prematurity is the major cause

Postpartum Hemorrhage Definition Loss of 500 ml or more After completion of the third stage Actual loss = two times of estimated loss

Predisposing Factors Bleeding from placental implantation site Hypotonic myometrium – uterine atony Retained placental tissue Succenturiate lobe Accreta, etc. Trauma to the genital tract Coagulation defects Intensify all of the above

Uterine Atony Predisposing factors Overdistended uterus Large fetus Multiple fetuses Hydramnios Distension with clots Anesthesia Halogenated agents

Uterine Atony Predisposing factors Exhausted myometrium Rapid labor Prolonged labor Oxytocin stimulation Chorioamnionitis Previous uterine atony

Diagnosis Laceration에 의한 출혈과 감별하여야 한다 Atony와 laceration이 동시에 있을 수 있다

Complications 신부전, 간염, 수혈에 따른 부작용 Sheehan 증후군 발생기전은 불명확하지만 뇌하수체 전엽의 괴사가 있는 경우가 있다. 증상 수유불능, 무월경, 유방위축 액와모 및 치모 감소 갑상선기능저하, 부신피질기능저하 등

Management 분만 3기의 출혈 자궁저를 문질러 자궁을 수축시킨다 (vigorous fundal massage). 태반분리의 징후가 보이면 자궁저를 압박하면서 태반을 만출시킨다. 태반분리가 안되고 계속 출혈이 있으면 자궁내에 손을 넣어 태반을 분리시킨다.

태반만출

Manual Removal of Placenta

Management 태반만출후 출혈 Fundal Massage OxytocinMethylergonovine 0.2mg IM or IV Prostaglandin Bimanual compression Obtain help ! Transfusion Exploration Inspect cervix & vagina

Bimanual Compression

태반부착 이상 분류 유착태반 (accreta) 감입태반 (increta) 관통태반 (percreta)

태반부착 이상 원인 Ddecidua basalis의 전부 혹은 일부 소실 섬유화층 (Nitabuch layer) 미발달 Subplacental sonolucent or "hypoechoic retroplacental zone" 전치태반 이전의 제왕절개 이전의 소파수술 다산부

Placenta Percreta

Inversion of Uterus 원인 처치 태반만출시 제대를 과도한 힘으로 당길 때 이완된 자궁의 저부를 과도하게 압박할 때 유착태반 처치 정맥로 확보 및 수혈 자궁이완후 도수정복(manual reduction) 안되면 자궁 절제

Uterine Inversion

Inverted Uterus

Manual Reduction

질 및 자궁경부 열상 2 cm 정도의 경부열상 자궁수축이 잘 되면서 계속 출혈이 있을 때 경부열상이 있을 때 분만시 불가피하고 후유증도 없다. 자궁수축이 잘 되면서 계속 출혈이 있을 때 질상부 및 경부열상 또는 잔류태반 확인 경부열상이 있을 때 후복막 혹은 복강내 출혈이 의심되면 개복 지나친 경부열상 봉합 경부협착이 생길 수 있다.

Repair of Cervical Laceration

Vulvar Hematoma

Rupture of Uterus 파열 (rupture) 개열 (dehiscence) 자궁강과 복강의 완전히 통하여 태아가 복강내로 탈출된다. 대량출혈이 있어 치명적이다. 개열 (dehiscence) 증상이 없는 수가 있고 자궁벽이 서서히 벌어지고 자궁강과 복강이 통하지는 않는다.

Cause of Uterine Rupture Uterine injury or anomaly sustained before current pregnancy Surgery involving the myometrium Cesarean section or hysterotomy Previously repaired uterine rupture Myomectomy incision Deep cornual resection Metroplasty

Cause of Uterine Rupture Uterine injury or anomaly sustained before current pregnancy Coincidental uterine trauma Abortion with instrumentation Sharp or blunt trauma (accident, bullet, knife) Silent rupture of previous pregnancy Congenital anomaly

Cause of Uterine Rupture Uterine injury or abnormality during current pregnancy Before delivery Persistent, intense contraction Labor stimulation Intraamniotic instillation Perforation by internal pressure catheter External trauma External version Uterine overdistension

Cause of Uterine Rupture Uterine injury or abnormality during current pregnancy During delivery Internal version Difficult forceps delivery Breech extraction Fetal anomaly distending lower segment Vigorous uterine pressure Difficult manual removal of placenta

Cause of Uterine Rupture Uterine injury or abnormality during current pregnancy Acquired Placenta increta or percreta Gestational trophoblastic neoplasm Adenomyosis Sacculation of entrapped retroverted uterus

Sacculation of Entrapped Retroverted Uterus

제왕절개후 자궁파열 0.2-0.8 %의 빈도 고전적 제왕절개 하부횡절개 파열의 가능성이 훨씬 높다. 진통 개시 전에 3분의 1이 파열된다. 출혈이 심하다. 하부횡절개 파열보다는 개열의 가능성이 높다. 진통 개시 전에는 파열이 되지 않는다. 개열이 분만진행에 지장을 초래하지 않는다.

제왕절개후 자연분만 Vaginal Birth After Cesarean 사망률이나 이환율의 차이가 없다. 분만방법, oxytocin 사용여부, 이전의 제왕절개 이유, 반흔종류 등과 개열발생빈도는 연관성이 없다. 수술에 따른 열성이환율이 오히려 적다. 단, 파열시는 산모나 태아에게 치명적일 수 있다.

손상이 없었던 자궁의 파열 증상 예후 흉통, 복통, 호흡곤란 등 이상한 증상 진통중 갑작스런 복통 (칼에 찔리거나 총상을 입은 것 같은 통증) 자궁수축이 중단되고 수축에 의한 통증의 소실 하혈 예후 즉시 치료하지 않으면 산모 및 태아에 치명적 태반박리와 모체의 대량실혈

Hypovolemic Shock Fluid and blood replacement Prompt and adequate refilling of intravascular compartment Crystalloid solution Transfusion Hematocrit < 25 vol% or hemoglobin < 8 g/dL Imminent surgery, acute operative blood loss, acute hypoxia, vascular collapse Likelihood of additional blood loss

Hypovolemic Shock Blood and component replacement Fresh Compatible Whole Blood Packed red blood cells Platelets Fresh-frozen plasma Cryoprecipitate Autologous transfusion Hemoglobin substitutes

Hypovolemic Shock Dilutional coagulopathy Stored whole blood is deficient in factors V, VIII, XI Packed RBC do not contain all soluble clotting factors and platelets Multiple transfusion cause thrombocytopenia

Consumptive Coagulopathy Significance Platelet & clotting factor -> bleeding tendency Ischemic tissue damage <- fibrin deposition & microcirculatory blockage Microangiopathic hemolysis

Consumptive Coagulopathy Clinical evidence Excessive bleeding by modest trauma Spontaneous bleeding from gums, or nose Continuous oozing on incision site Laboratory evidence Hypofibrinogenemia Fibrin and fibrinogen derivatives Thrombocytopenia PT or aPTT: Prolonged due to low fibrinogen or FDP, or both

Fetal death & delayed delivery Pathogenesis Rarely develop within 1 month of fetal death Mediated by thromboplastin from the dead fetus Fetal death in multiple pregnancy Selective termination Delayed delivery following death of one twin

Fetal death & delayed delivery

Fetal death & delayed delivery Pregnancy termination Oxytocin Laminaria Prostaglandins Intraamnionic hypertonic saline Dangerous Coagulation defects may be induced or enhanced

Amnionic fluid embolism Clinical picture In the late stage of labor or immediate postpartum Gasping air Seizure or cardiorespiratory arrest DIC, massive hemorrhage, and death

Amnionic fluid embolism Pathogenesis Anaphylactoid syndrome of pregnancy Amnionic fluid itself is innocuous, even when infused in large amounts Physiologic barrier가 깨어지는 경우가 흔히 있다 Clinical picture가 embolic phenomenon과 다르다 Endogenous mediator release

Amnionic fluid embolism Diagnosis 과거에는 pulmonary bed에서 amnionic fluid debris를 발견하면 확진 Amnionic fluid embolism이 아닌 경우에도 발견된다 Characteristic signs and symptoms Treatment Cardiopulmonary resuscitation Perimortem cesarean