Therapy for non-atonic conditions pps

Section VI Therapy for non-atonic conditions 215 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:58 Color profile: Generic CMYK printer profile Composite Default screen 23 BLEEDING FROM THE LOWER GENITAL TRACT A. Duncan and C. von Widekind INTRODUCTION In the first comprehensive English Language textbook on the subject, William Smellie, in his 1752 Treatise on the Theory and Practise of Mid - wifery 1 , correctly identifies the atonic uterus as a major cause of postpartum hemorrhage with his statement ‘This dangerous efflux is occasioned by every thing that hinders the emptied uterus from contracting’. Although he refers to vaginal pack - ing with Tow or linen rags (dipped in astringents such as oxycrate, red tart wine, alum or Sacchar-saturni), he does not specifically refer to bleeding from the lower genital tract. Because this omission was repeated in subsequent years by many standard textbooks and reviews of postpartum hemorrhage, it is not surprising that the present evidence base is poor, and a 2005 MESH search in PubMed of the National Library USA combining the terms ‘Postpartum hemorrhage’ AND ‘Lacerations’ OR ‘Rupture’ NOT ‘Uterine rupture’ came up with only 28 publications. Maternal deaths specifically from lower geni - tal tract bleeding as the cause of postpartum hemorrhage are rare in the developed world. The 2000–2002 United Kingdom Confidential Enquiries 2 reported only one death from this cause. World-wide, no accurate figures exist, but it is likely that the numbers are significant, particularly where there is significant co- morbidity and a poorly resourced maternity infrastructure 3 . CLASSIFICATION Possible sources of bleeding from the lower genital tract include: (1) Cervical tears; (2) Vaginal tears (above and below the levator ani muscle, see Figure 1); (3) Vulva and perineal tears; (4) Episiotomies. With the exception of cervical tears without vaginal extension, all of the above can lead to paravaginal hematomas, which in turn can be divided into those above and below the levator ani muscle (Figure 1). Infralevator hematomas include those of the vulva, perineum, para- vaginal space and ischiorectal fossa. Supra- levator bleeding is more dangerous, as it is more difficult to identify and control the source of bleeding, and blood loss into the retroperitoneal space can be massive. INCIDENCE In the UK, postpartum hemorrhage of more than 500 ml occurs in between 5 and 17% of all deliveries and postpartum hemorrhage of more than 1000 ml in 1.3% of deliveries. Cervical tears Minor cervical tears are common and are likely to remain undetected. However, bleeding which occurs despite a well-contracted uterus and which does not appear to be arising from the vagina or perineum is an indication for examining the cervix. Numerous cases have been described of women dying from hemorrhage due to a cervical tear, following operative vaginal delivery. Postpartum hematoma Because there is no agreed definition, there is no consensus as to the incidence. After 194 216 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:58 Color profile: Generic CMYK printer profile Composite Default screen 195 Bleeding from the lower genital tract Figure 1 Paravaginal hematomas. (a) The hematoma lies beneath the levator ani muscle; (b) the hematoma lies above the levator ani and is spreading upwards into the broad ligament. H, hematoma; LA, levator ani, U, uterus; P, pelvic peritoneal reflection 8 D /$ 3 + 8 E /$ 3 + 217 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:59 Color profile: Generic CMYK printer profile Composite Default screen spontaneous delivery, up to 50% of parturients develop a minor self-limiting infralevator/vulva hematoma 5 . In contrast, the formation of a sig - nificant postpartum hematoma is an uncommon but serious complication after delivery, with the reported incidence of around 1 in 500–700 deliveries 6 . Major pelvic (supralevator) hema - tomas are rare, with widely varying reported incidence of between 1 in 500 and 1 in 20 000 7 . Episiotomy An episiotomy can bleed heavily, and, although there are no data on the incidence of hemor - rhage from this cause alone, observational stud - ies suggest that the relative risk of postpartum hemorrhage is increased four to five times if an episiotomy is performed 8 . RISK FACTORS The major causes of postpartum hemorrhage are uterine atony, retained placental fragments, morbid adherence of the placenta and lower genital tract lacerations. Data from the North West Thames District of the UK (Table 1) reviewed the obstetric factors associated with a blood loss of more than 1000 ml and appor- tioned a relative risk to each factor 4 . Of these, assisted delivery (forceps or vacuum extrac- tion), prolonged labor, maternal obesity (and associated large baby) and episiotomy were most relevant to the risks of lower genital tract hemorrhage. It is worth noting that episiotomy, with a relative risk of 5, carried the same weight as a cause of postpartum hemorrhage as did multiple pregnancy and retained placenta. Rotational forceps are a particular risk factor for spiral vaginal tears 9 . Coagulation disorders, if present, are likely to significantly increase the risk of lower genital tract hemorrhage and hematoma and therefore should always be corrected where possible. If vaginal lacerations require repair in this situa - tion, the threshold for the use of a vaginal pack should be low. PREVENTION The three main areas in which risk can be reduced all require a proactive approach: (1) Antenatal co-morbidities such as anemia and diabetes should be treated so that women entering labor are as healthy as possible. (2) A consistent proactive approach is required in both the first and second stages of labor. Active monitoring (partogram) and early intervention are essential where progress is inadequate or cephalic-pelvic disproportion is diagnosed. Coagulation defects (includ- ing iatrogenic defects due to anticoagulat- ion) should be corrected where possible (see Chapter 25). (3) Postpartum, the early identification of excessive blood loss and a proactive approach to resuscitation/fluid replacement as well as identification of the source of bleeding and stopping it, are vital. Because operative delivery and episiotomy are both significant risk factors for postpartum hemorrhage from the lower genital tract, efforts to reduce the incidence of both are likely to reduce the risk of hemorrhage. Where operative vaginal delivery is required, however, then a proper technique as described in standard textbooks 10 will reduce the risk of vaginal and cervical tears. DIAGNOSIS Careful and well-documented observation after delivery is imperative as the seriousness of 196 POSTPARTUM HEMORRHAGE Antenatal Relative risk Intrapartum Relative risk Placenta previa Obesity 13 2 Emergency Cesarean section Assisted delivery Prolonged labor (> 12 h) Placental abruption Multiple pregnancy Retained placenta Elective Cesarean section Mediolateral episiotomy Pyrexia in labor 9 2 2 13 5 5 4 5 2 Ta bl e 1 Risk factors for postpartum hemorrhage and approximate increase in risk 4 218 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:20:59 Color profile: Generic CMYK printer profile Composite Default screen concealed or persistent low-grade blood loss can be underestimated. Bleeding, especially after instrumental vaginal delivery, that occurs despite a well- contracted uterus and that does not appear to be arising from the lower vagina or perineum is an indication for examination of the upper vagina and cervix. The characteristic feature of bleeding from upper vaginal and cervical tears is a steady loss of fresh red blood. Exclusion of upper vaginal and cervical tears requires examination in the lithotomy position with good relaxation, good light and proper assistance 7 . A tagged vaginal tampon to absorb blood loss from the uterine cavity and the use of flat-bladed vaginal retractors will assist in visualizing the vaginal walls. The cervix should always be examined where there is continuing bleeding despite a well- contracted uterus and also after use of all rotational forceps, which are associated with a significant increase in the risk of upper vaginal and cervical tears 11 . The method for doing this is to grasp the anterior lip with one ring forceps and to place a second ring forceps at the 2-o’clock position, followed by progressively ‘leap-frogging’ the forceps ahead of one another until the entire circumference has been inspected. TREATMENT Hemorrhage from the lower genital tract should always be suspected when there is ongoing bleeding despite a well-contracted uterus. Generally, high vaginal or cervical tears require repair under regional anesthesia in theater. The Scottish Obstetrics Guidelines and Audit Project (SOGAP) group provides detailed guidelines on the management of postpartum hemorrhage 12 . A summary of the ORDER protocol as described by Bonnar 13 is shown in Table 2, with additional boxes relating to hemorrhage from the lower genital tract. Perineal tear repair The technique has been well described else - where 14 . The principles include ensuring that the first suture is inserted above the apex of the tear or episiotomy incision, use of a continuous polyglactin/polyglycolic acid suture on a taper- cut needle, obliteration of dead spaces and taking care that sutures are not inserted too tightly. If dead spaces cannot be closed securely, then a vaginal pack should be inserted. Vaginal tear repair The technique for repair of superficial vaginal tears is similar to that of perineal repair, as described above. Use an absorbable, continuous interlocking stitch, which must start and finish beyond the apices of the laceration, and should where possible reach the full depth of the tear in order to reduce the risk of subsequent hematoma formation. For deeper tears, an attempt should be made to identify the bleeding vessel and ligate it. If there is any significant dead space or if the vagina is too friable to accept suturing, then packing is indicated (see below), because access to deeper tears is usually difficult in an inade- quately anesthetized patient. Thus, repair of such lacerations should be done in theater with adequate anesthesia. Lacerations high in the vaginal vault and those extending up from the cervix may involve the uterus or be the cause of broad ligament or retroperitoneal hematomas. The proximity of the ureters to the lateral vaginal fornices, and the base of the bladder to the anterior fornix, must be kept in mind when any extensive repair is undertaken in these areas. Poorly placed stitches can lead to genitourinary fistulas. Vaginal packing for at least 24 h is always wise under these conditions. Vaginal packing using gauze is the most common method to achieve vaginal tamponade. As with uterine packing, the technique of vaginal packing involves ribbon gauze inserted uniformly side-to-side, front-to-back and top- to-bottom. Vaginal packing using thrombin- soaked packs, as described for uterine packing, can also be considered 15 , especially where closure of all lacerations has not been possible. Because of the risk that the raw vaginal sur - face will bleed on removal of the pack, povidone iodine-soaked double lengths of 4.5 × 48 inch packs can be inserted inside sterile plastic drapes (this has been well described for the management of uterine hemorrhage, but the 197 Bleeding from the lower genital tract 219 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:21:00 Color profile: Generic CMYK printer profile Composite Default screen 198 POSTPARTUM HEMORRHAGE Failure to control bleeding Failure to control bleeding Failure to control bleeding O: ORGANIZATION /Call for help R: RESTORATION OF BLOOD VOLUME Blood and crystalloid transfusion 1. Inform Consultant Obstetrician Consultant anesthetist 2. Examine under anesthesia: Remove retained products Repair any tear Bimanual compression Prostaglandin F 2 intramyometrial and (250 µg maximum eight injections i.m.) Continue bimanual compression Continue resuscitation and monitoring D: DEFECTIVE BLOOD COAGULATION Correct as dictated by clotting studies First-line management Second-line management R: REMEDY THE CAUSE 1. Improve the tone Bimanual compression Oxytocin 10 units by slow i.v. injection Ergometrine 0.5 mg by slow i.v. injection Oxytocin infusion 40 units in 500 ml at 125 ml/h Prostaglandin F 2 intramuscular (Carboprost 250 µg i.m.) 2. If no better, consider lower genital tract bleeding and move to second-line management Under anesthetic (general or regional) 1. Repair cervix Circumferential examination with ring forceps Repair with interrupted figure-of-eight dissolvable suture 2. Repair vaginal tear if possible Epithelial repair with continuous dissolvable suture Individual figure-of-eight ligation of bleeding vessels Vaginal pack & catheter 24 h (+ antibiotic cover) Bleeding despite a well- contracted uterus is likely to be due to genital tract trauma E: EVALUATION OF RESPONSE If continuing bleeding from vaginal tear despite vaginal pack consider: 1. Alternative form of vaginal tamponade Blood pressure cuff in glove inflated to just above systolic pressure 26* Rüsch catheter or Sengstaken–Blakemore tube (aspiration channel for drainage of lochia) 2. If the cervical tear extends into the uterus, laparotomy and hysterectomy may be required 3. Angiographic embolization of bleeding vessels 4. Bilateral internal iliac artery ligation Ta bl e 2 Management of major postpartum hemorrhage (blood loss > 1000 ml or clinical shock) (see reference 13) 220 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:21:01 Color profile: Generic CMYK printer profile Composite Default screen principle is the same for vaginal packing) to allow for easy removal 16 . Generally, packs are left in place for 24–36 h before removal 17 .A urinary Foley catheter and broad-spectrum antibiotic cover should be given where packs are used. Balloon tamponade using Rüsch catheters 18 or Blakemore-Sengstaken 19 tubes, as described for treatment of uterine bleeding (see Chapters 28 and 29), can also be used. Pinborg and colleagues 20 described the successful use of the blood pressure cuff in two patients to control intractable vaginal bleeding following evacuation of vaginal hematoma that developed after spontaneous vaginal delivery. A blood pressure cuff was inserted into a sterile glove, which in turn was inserted into the vagina and the pressure then gradually increased to 120 mmHg, 10 mmHg above the systolic pressure, to stop the bleeding. Eight hours later, the pressure of the cuff was reduced by 10 mmHg/h and the cuff then taken out after 32 h. Both patients made an uneventful recovery. Cervical tear Any cervical tear extending above the internal os warrants laparotomy. Small, non-bleeding lacerations of the cervix do not need to be sutured. Any bleeding cervical tear, and certainly any tear longer than 2 cm, however, should be sutured by using an absorbable suture on a tapered (rather than a cutting) needle. A suitable method for suturing is shown in Figure 2. Both edges of the most caudal part of the laceration are grasped with a ring forceps and then sutured with an interrupted or figure-of- eight stitch. This is then held with a hemostat to bring down into view the next part of the tear, which is sutured in the same way, and so on until the apex is secured. The laceration should be observed for a few minutes after suturing, to ensure adequate hemostasis. The ring forceps can be replaced and left on for some time if oozing persists. Cervical and vaginal vault lacerations that continue to ooze despite treatment as detailed above or those that are associated with hema - tomas may be amenable to selective arterial embolization (see below). 199 Bleeding from the lower genital tract Figure 2 (a)–(c) Suturing cervical tear (b) (c) (a) 221 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 04 September 2006 17:20:15 Color profile: Generic CMYK printer profile Composite Default screen Hematoma management The literature on the management of para - genital hematomas is limited and no random - ized studies of the efficacy of various treatments exist 21 . Infralevator hematomas As always, initial management consists of resus - citation measures and analgesia followed by a period of observation. For hematomas that are less than 5 cm and not expanding, conservative treatment with ice packs, pressure dressing and analgesia is recommended 22 . The visible skin margin of the hematomas should be marked to help establish whether it is expanding. For hematomas that are expanding or more than 5 cm in size, surgical intervention is recom - mended. Where possible, the surgical incision should be made via the vagina to minimize visible scarring. Distinct bleeding points should be under-run with figure-of-eight dissolvable sutures. The presence of any residual bleeding or a hematoma cavity is an indication for insertion of a drain, a vaginal pack and a Foley catheter, all of which should be left in place for at least 24 h. Usually, however, no distinct bleeding point can be seen, in which case a drain and pack should be inserted 10 . Supralevator hematomas Approximately 50% of broad ligament hema - tomas present early with symptoms of lower abdominal pain, hemorrhage and in severe cases, shock. The other 50% present after 24 h. Broad ligament and retroperitoneal hematomas are ini - tially managed expectantly if the patient is stable and the lesions are not expanding 23 . Ultrasound, CT scanning and MRI may all be used to assess thesizeandprogressofthesehematomas.Close observation, intravenous fluid resuscitation, blood transfusion, vaginal packing or balloon/ blood pressure cuff tamponade and antibiotics are commenced as appropriate, but, if it is not possible to maintain a stable hemodynamic state, then active intervention is indicated, with options including the following: (1) Laparotomy ± total abdominal hysterectomy This is indicated where there is any possibility that a supralevator/broad liga - ment hematoma is due to a ruptured uterus or where a cervical tear appears to have extended up into the uterus. At laparotomy, if there is continuing bleeding from the upper vagina, then the anterior division of the internal iliac artery should be ligated in continuity, which will reduce the pulse pressure to the distal internal iliac artery branches (that supply the uterus and vagina) by 85% and the blood flow by about 50% 24 (see Chapters 32 and 34). A further vaginal pack should be inserted. (2) Selective arterial embolization Where there is continuing expansion of a supralevator hematoma without extension into the cervix or uterus, selective arterial embolization is seen as the treatment of choice 25 over inter - nal iliac artery ligation, which in itself has an uncertain chance of success 26 and involves imposing a laparotomy on an already unsta- ble patient. The blood supply to the upper vagina is from a rich anastomotic network of vessels, arising mainly from branches of the anterior trunk of the internal iliac artery (vaginal, uterine, middle rectal arteries) and the internal pudendal artery, which is the most inferior branch of the posterior trunk of the internal iliac artery. The technique of selective arterial embolization investigates these vessels by preliminary transfemoral arteriography, followed by embolization using Gelfoam (gelatin) pledglets. Pelage and colleagues 25 reported a series of 35 patients who underwent this procedure for unanticipated postpartum hemorrhage. Bleeding was controlled in all but one, who required hysterectomy 5 days later for re-bleeding. All women who had successful embolization resumed menstruation. The procedure, however, is not without risk and deaths have been reported due to sepsis and multiple organ failure 27 (see Chapter 44). SUMMARY In summary, bleeding from the lower genital tract should always be considered as a possible cause of primary postpartum hemorrhage where there is continuing bleeding despite a 200 POSTPARTUM HEMORRHAGE 222 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:21:06 Color profile: Generic CMYK printer profile Composite Default screen well-contracted uterus. Primary repair of vagi - nal or cervical tears with full-thickness sutures using a dissolving suture on a taper-cut needle, followed by insertion of a vaginal pack and catheter for at least 24 h will stem most bleed - ing. Urgent resort to laparotomy is necessary if there is a cervical tear extending beyond the internal cervical os up into the uterus, or if bleeding fails to settle despite an attempt at vaginal tamponade. Internal iliac artery ligation or selective arterial embolization should be considered where there is continuing expansion of a supralevator hematoma or upper vaginal bleeding despite the above measures. As always, regular assessments, clear documentation, a proactive approach and early intervention are vital to obtain a good outcome. References 1. Smellie W. A Treatise on the Theory and Practice of Midwifery, 1792 2. Millward-Sadler H. Why Mothers Die 2000–2002. The Confidential Enquiries into Maternal Deaths in the United Kingdom. London: Royal College of Obstetricians and Gynaecologists, 2004:227 3. Etuk S, Asuqo E. Effects of community and health facility interventions on postpartum haemorrhage. Int J Gynaecol Obstet 2000;70: 381–3 4. Stones R, Paxton C, Saunders N. Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993;48:15–18 5. Drife J. Management of primary postpartum haemorrhage. Br J Obstet Gynaecol 1997;104: 275–7 6. Hankins G, Zahn C. Puerperal haematomas and lower genital tract lacerations. In Hankins G, et al., eds. Operative Obstetrics. Connecticut: Appleton & Lange, 1995:57–72 7. Cheung TH, Chang A. Puerperal haematomas. Asia-Oceania J Obstet Gynaecol 1991;17:119–23 8. Combs C, Murphy E, Laros R. Factors associ - ated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77:69–76 9. Stones R, Paterson C, Saunders N. Risk factors for major obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol 1993;48:15–18 10. James D, Steer P, Weiner C, et al. High-risk Pregnancy Management Options, 2nd edn. London: WB Saunders, 1999:1187–204 11. Healy D, Quinn M, Pepperell R. Rotational delivery of the fetus: Kielland’s forceps and two other methods compared. Br J Obstet Gynaecol 1982;89:501–6 12. Management of Postpartum haemorrhage – A Clinical Practice Guideline for Professionals involved in Maternity Care in Scotland. Aberdeen: Scottish Programme for Clinical Effectiveness in Reproductive Health, 1998 13. Bonnar J. Massive obstetric hemorrhage. Baillieres Best Pract Res Clin Obstet Gynaecol 2000;14:1–18 14. Johanson R. Continuous vs. interrupted sutures for perineal repair. In Keirse M, Renfrew M, Neilson J, Crowther C, eds. Pregnancy and Childbirth Module. The Cochrane Pregnancy and Childbirth Database. London: BMJ Publishing Group, 1994 15. Bobrowski R, Jones T. A thrombogenic uterine pack for postpartum hemorrhage. Obstet Gynecol 1995;85:836–7 16. Wax J, Channell J, Vandersloot J. Packing of the lower uterine segment: new approach to an old technique? Int J Gynaecol Obstet 1993;43:197–8 17. Maier R. Control of postpartum haemorrhage with uterine packing. Am J Obstet Gynecol 1993; 169:317 18. Johanson R, Kumar M, Obhrai M, et al. Man- agement of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy. Br J Obstet Gynaecol 2001;108: 420–2 19. Katesmark M, Brown R, Raju K. Successful use of a Sengstaken-Blakemore tube to control massive postpartum haemorrhage. Br J Obstet Gynaecol 1994;101:259–60 20. Pinborg A, Bodker B, Hogdall C. Postpartum haematoma and vaginal packing with a blood pressure cuff. Acta Obstet Gynecol Scand 2000; 79:887–9 21. Ridgway LE. Puerperal emergency. Vaginal and vulvar haematomas. Obstet Gynecol Clin North Am 1995;22:275–83 22. Zahn C, Yeomans E. Postpartum haemorrhage: placenta accrete, uterine inversion and puerperal haematomas. Clin Obstet Gynaecol 1990;33:422 23. Lingam K, Hood V, Carty M. Angiographic embolisation in the management of pelvic haem - orrhage. Br J Obstet Gynaecol 2000;107:1176–8 24. Burchell R. Physiology of internal iliac artery ligation. J Obstet Gynaecol Br Commonwealth 1968;75:642–51 25. Pelage J, Le Dref O, Jacob D, et al. Selective arterial embolisation of the uterine arteries in the management of intractable postpartum haemorrhage. Acta Obstet Gynecol Scand 1999; 78:698–703 201 Bleeding from the lower genital tract 223 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:21:06 Color profile: Generic CMYK printer profile Composite Default screen 26. Evans S, McShane P. The efficacy of internal iliac artery ligation in obstetric haemorrhage. Surg Gynecol Obstet 1985;160:250–3 27. Ledee N, Ville Y, Musset D, et al. Management in intractable obstetric haemorrhage: an audit study on 61 cases. Eur J Obstet Gynecol Reprod Biol 2001;94:189–96 202 POSTPARTUM HEMORRHAGE 224 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:21:06 Color profile: Generic CMYK printer profile Composite Default screen [...]... effects of steroids have led some to use IVIg as a first-line therapy in pregnancy15,16 Others reserve this treatment for patients in whom steroid therapy is likely to be prolonged or in whom an unacceptably high maintenance dose is required (> 7.5 mg prednisolone daily) The conventional dose of IVIg is 0.4 g/kg/day for 5 days, although 1 g/kg/day for 2 days has been used successfully and may be more convenient11... antibiotic therapy (amoxicillin and clavulanic acid) is administered for 10 days FOLLOW-UP AFTER CONSERVATIVE MANAGEMENT During the postpartum period, all patients are seen weekly until complete resorption of the placenta Ultrasonography and clinical examination are performed to detect hemorrhage, pain or clinical signs of infection To improve clinical follow-up and to help choose antibiotic therapy in... predictable response is obtained in 80% of the cases The response to therapy usually occurs within 24 h (more rapid than with steroids) and is maintained for 2–3 weeks After an initial response, repeat single infusions can be used to prevent hemorrhagic symptoms and ensure an adequate platelet count for delivery Therapeutic options for those women with severely symptomatic ITP refractory to oral steroids... are conducted to establish whether the affected gene has been inherited Cells for karyotyping and as a source of DNA can also be obtained from amniotic fluid (amniocentesis) after 15 weeks’ gestation; here, the miscarriage rate is about 0.5–1% Fetoscopy to allow for fetal blood sampling is rarely performed; it can only be performed after about 16 weeks’ gestation and has a substantial risk of fetal death... levels remain low at 34–36 weeks in hemophilia carriers, treatment is necessary for delivery67 A FVIII/FIX plasma level of 40% is safe for vaginal delivery, and a level of 50% or greater is safe for Cesarean section Epidural anesthesia may be used if coagulation defects have been corrected67 Recombinant FVIII/FIX or DDAVP (for carriers of hemophilia A only) should be used Plasma-derived factor concentrate... problems in carriers of hemophilia occur postpartum Replacement therapy should be given immediately after delivery to mothers with uncorrected hemostatic defect Treatment options at this stage are the same as those during labor and delivery Supportive therapy to maintain hemostasis should be continued for 3–4 days after vaginal delivery and for 5–10 days after Cesarean section73 In the infant, intramuscular... used for 3 days, with the first dose being administered during labor Tranexamic acid is also used to manage prolonged mild intermittent secondary postpartum hemorrhage which is a common presentation of FXI-deficient patients84 FXI concentrate is needed for severely deficient women to cover vaginal delivery and also for Cesarean section The aim is to maintain the FXI level > 50% during labor and for. .. drugs should be avoided for postpartum analgesia ITP should not exclude women from consideration for peripartum thrombosis prophylaxis Prophylactic doses of low-molecular weight heparin are generally safe if the platelet count is greater than 50 × 109/l Following delivery, a cord blood platelet count should be determined in all cases Since the neonatal platelet count may decline for 4–5 days after delivery11,... the day of admission and should be started on UFH, aiming for an APTT ratio of 1.5–2.0 UFH should be reduced to 500 IU/h when contractions start, aiming for an APTT ratio < 1.5 and should be stopped at the second stage of labor or earlier if it appears that a Cesarean section may be required In the latter case, protamine sulfate may be needed for reversal of UFH if the APTT ratio remains > 1.5 Postpartum,... safety of antithrombotic therapy during pregnancy However, it appears reasonable to adopt one of the following three approaches: (1) Oral anticoagulants throughout pregnancy; (2) Replacing oral anticoagulants with UFH from weeks 6 to 12; (3) UFH throughout pregnancy In the first two regimens, heparin is usually substituted for the oral anticoagulant close to term The use of LMWH for anticoagulation in . Section VI Therapy for non-atonic conditions 215 Z:Sapiens PublishingA5211 - Postpartum HemorrhageMake-upPostpartum. profile Composite Default screen principle is the same for vaginal packing) to allow for easy removal 16 . Generally, packs are left in place for 24–36 h before removal 17 .A urinary Foley catheter and. all rotational forceps, which are associated with a significant increase in the risk of upper vaginal and cervical tears 11 . The method for doing this is to grasp the anterior lip with one ring forceps and