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I have no disclosures Evaluating post-pregnancy bleeding Sara - - PowerPoint PPT Presentation

May 15, 2023 355 likes •468 views

10/28/2016 Is this too much bleeding? I have no disclosures Evaluating post-pregnancy bleeding Sara Whetstone, MD, MHS My task over the years hasn't just been Catastrophic to stop the bleeding Postpartum Hemorrhage Barack

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10/28/2016 1

Is this too much bleeding?

Evaluating post-pregnancy bleeding

Sara Whetstone, MD, MHS

I have no disclosures

–Barack Obama

“My task over the … years hasn't just been to stop the bleeding…”

Catastrophic Postpartum Hemorrhage

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10/28/2016 2

Objectives

To describe bleeding patterns following delivery and early pregnancy loss To state 3 diagnostic possibilities for abnormal post-pregnancy bleeding To develop an algorithm for evaluating abnormal post-pregnancy bleeding

Persistent postpartum bleeding

Case #1

Naya calls your office. She is now 7.5 weeks postpartum and she continues to have light

  • bleeding. She wants to know if

this is normal.

Test your knowledge

What does the term ‘lochia’ mean?

  • A. loss of blood
  • B. from the uterus

C.losing part of oneself D.relating to childbirth

  • E. shedding one’s lining
loss of blood from the uterus losing part of oneself relating to child birt h shedding one’s lining

0% 0% 50% 50% 0%

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10/28/2016 3

Lochia

Lochia: postpartum vaginal discharge that contains blood, mucus, and uterine tissue

http://singaporeschild.com.sg/postpartum-care-for-new-mums

What is the average duration of postpartum bleeding?

  • A. 42-56 days
  • B. 21-28 days
  • C. 14-21 days
  • D. 24-36 days
42-56 days 21-28 days 14-21 days 24-36 days

28% 35% 16% 21%

Duration of postpartum bleeding

Average duration ranges from 24 to 36 days Caution: several studies did not follow bleeding until cessation Very little can be said about quantity of blood loss >10% of women experienced bleeding beyond 40 days Common for women to stop bleeding for 1+ days and then resume bleeding

Fletcher et al, 2012; WHO, 1999.

Persistent Postpartum bleeding

Case #1

Naya calls your office. She is now 7.5 weeks postpartum and she continues to have light

  • bleeding. She wants to know if

this is normal.

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10/28/2016 4 Persistent Postpartum bleeding

Case #1 - revised

Naya calls your office. She is 2 weeks postpartum and she is bleeding more heavily. She is filling a pad every 1-2 hours.

In what percentage of pregnancies does secondary postpartum hemorrhage occur?

  • A. Up to 2%
  • B. 3-5%
  • C. 7%
  • D. up to 10%
Up to 2% 3-5% 7% up to 10%

18% 18% 7% 58%

Postpartum hemorrhage

Primary

  • Occurs in first 24 hours after delivery
  • Affects 2-5% of deliveries

Secondary

  • Occurs between 24 hours and 12 weeks

after delivery

  • Affects 0.8-2% of deliveries

Algorithm for secondary postpartum hemorrhage

Vaginal bleeding Stable Obtain H&P and labs (CBC, coags) Obtain pelvic ultrasound with Doppler Consider differential diagnosis Unstable Manage blood loss Transfer to OR Surgical management

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10/28/2016 5 Differential Diagnosis

Retained products of conception Uterine atony Placental site sub- involution Endomyometritis Abnormal placentation

Coagulopathy Arterial-venous malformation (AVM) Pseudoaneurysm Gestational trophoblastic disease

Placental site sub-involution

Large patent uteroplacental arteries that failed to undergo normal process of involution Delayed or inadequate remodeling of vessels during 3rd trimester Persistence of low- resistance dilated vessels with increased flow Occurs most often in second week postpartum

Weydert et al 2006; Petrovich et al 2009

Arterial-venous malformation (AVM)

Can be congenital or acquired Usually follows a history of previous uterine trauma Abnormal communication between artery & vein occurs during healing process U/S: multiple tubular or “spongy” anechoic or hypoechoic areas within the myometrium of a normal endometrium; use of spectral Doppler very helpful

Vijayakumar et al 2013

Pseudoaneurysm

Pseudoaneurysm does not have all 3 layers of the arterial wall Extraluminal collection of blood with turbulent flow that communicates with parent vessel through defect in arterial wall Can be asymptomatic, may thrombose or rupture or cause hemorrhage Reported after pelvic surgery, vascular trauma, and uterine curettage

Baba et al 2014; Nanjundan et al 2011.

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10/28/2016 6 Persistent Postpartum bleeding

Case #1 - revised

Naya calls your office. She is 2 weeks postpartum and she is bleeding more heavily. She is filling a pad every 1-2 hours.

CASE #1 - REVISED

History: Uncomplicated NSVD 2 weeks ago, started bleeding heavily this morning, no infectious symptoms Exam: Vital signs wnl, perineal laceration well-reapproximated, active bleeding from the cervix, 8 week sized uterus (non-tender) CBC & coags wnl Pelvic ultrasound

How long do dogs bleed after birth?

  • A. Up to 2 weeks
  • B. Up to 4 weeks
  • C. Up to 6 weeks
  • D. Up to 8 weeks
  • E. Up to 12 weeks
U p t
  • 2
w e e k s U p t
  • 4
w e e k s U p t
  • 6
w e e k s U p t
  • 8
w e e k s U p t
  • 1
2 w e e k s

47% 23% 10% 11% 9%

Managing miscarriage

Case #2

Sonia calls your office. She was just diagnosed with a miscarriage and started

  • bleeding. She wants to know

how long to expect bleeding. What do you tell her?

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10/28/2016 7

Test your knowledge (part II)

What is the average duration of bleeding after early pregnancy failure?

  • A. 3 days
  • B. 7 days
  • C. 10 days
  • D. 14 days
  • E. 21 days
3 d a y s 7 d a y s 1 d a y s 1 4 d a y s 2 1 d a y s

1% 22% 20% 35% 22%

Bleeding after early pregnancy failure (EPF)

Median duration

  • f bleeding

(days)

Expectant Medical Surgical Early pregnancy failure 12 (7-15) 11 (7-15) 8 (4-14) Embryonic demise 12 (7-16) 11 (7-15) 9 (4.8-14) Incomplete abortion 10 (7-13.3) 9 (6-14) 7 (4-12)

Trinder et al 2006 (MIST trial)

Bleeding after EPF: some finer details

Management of EPF trial reports that a substantial number of women continued to bleed at 2 weeks 43% of women who had medical treatment 30% of women in the surgical treatment For women with a pregnancy loss prior to 6 wks GA: Length of bleeding with loss was similar to usual menstrual length Bleeding associated with loss slightly longer (0.4 days)

Davis et al, 2007; Promislow et al 2007.

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10/28/2016 8

How long does it take for the B-HCG level to trend to undetectable following early pregnancy failure?

  • A. 7 days
  • B. 14 days
  • C. 21 days
  • D. It depends….
7 days 14 days 21 days It depends….

0% 57% 24% 18%

Decline of serum HCG after spontaneous complete abortion

Initially a steep decline Less steep decline if initial value < 500 mIU/mL

Barnhart K et al Obstet Gynecol 2004

Expected percentage decline in serum hCG levels

Barnhart K et al Obstet Gynecol 2004

Managing miscarriage

Case #2

Sonia calls your office. She was just diagnosed with a miscarriage and started

  • bleeding. She wants to know

how long to expect bleeding. What do you tell her?

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10/28/2016 9 Managing miscarriage

Case #2 - revised

Sonia calls your office. She was diagnosed with a miscarriage; she opted for medical management. She is now bleeding heavily. How do you manage her?

Differential Diagnosis

Retained products of conception Endomyometritis Abnormal placentation Trauma Coagulopathy Arterial-venous malformation Pseudoaneurysm Gestational trophoblastic disease

Algorithm for evaluating bleeding after EPF

Vaginal bleeding Stable Obtain H&P and labs (CBC, coags) Obtain pelvic ultrasound with Doppler Consider differential diagnosis Unstable Manage blood loss Transfer to OR Surgical management

Spectrum of normal ultrasound findings

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10/28/2016 10 Endometrial thickness

Endometrial thickness alone does not predict who will require D&C

Even when EMS > 30mm

Endometrial thickness is greater in women who require D&C after medical abortion or medical management

  • f SAB

Poor test for predicting need for D&C

Reeve et al, 2008; Reeves et al, 2009.

Ultrasound & retained POCs

Normal appearance of cavity after spontaneous abortion is variable and poorly described Ultrasound associated with high false positive rate of retained POCs Endometrial thickness is poor predictor of need for surgical intervention

Are there other studies to assess for retained POCs?

Saline sonogram Hysteroscopy

So how do we use ultrasound?

Hyperechoic endometrial mass or solid component in endometrium

Heavy or prolonged bleeding

Retained POCs

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10/28/2016 11 Managing miscarriage

Case #2 - revised

Sonia calls your office. She was diagnosed with a miscarriage; she opted for medical management. She is now bleeding heavily. How do you manage her?

Objectives

To describe bleeding patterns following delivery and early pregnancy loss To state 3 diagnostic possibilities for abnormal post-pregnancy bleeding To develop an algorithm for evaluating abnormal post-pregnancy bleeding

Thank you

How soon does the next menses occur after early pregnancy failure?

  • A. 2 weeks
  • B. 4 weeks

C.5 weeks D.6 weeks

  • E. 8 weeks
2 weeks 4 weeks 5 weeks 6 weeks 8 weeks

0% 0% 0% 0% 0%

10