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 Obama 1
10/28/2016 Objectives Persistent postpartum To describe bleeding patterns following delivery and early pregnancy loss bleeding To state 3 diagnostic possibilities for abnormal Case #1 post-pregnancy bleeding Naya calls your office. She is To develop an algorithm for evaluating now 7.5 weeks postpartum and she continues to have light abnormal post-pregnancy bleeding bleeding. She wants to know if this is normal. 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 50% 50% Test your knowledge 0% 0% 0% loss of blood the uterus losing part of oneself h shedding one’s lining birt relating to child from 2
10/28/2016 What is the average duration of Lochia postpartum bleeding? A. 42-56 days Lochia: postpartum vaginal discharge that contains blood, mucus, and uterine B. 21-28 days tissue C. 14-21 days D. 24-36 days 35% 28% 21% 16% 42-56 days 21-28 days 14-21 days 24-36 days http://singaporeschild.com.sg/postpartum-care-for-new-mums Duration of postpartum bleeding Persistent Postpartum Average duration ranges from 24 to 36 days bleeding Caution: several studies did not follow bleeding until cessation Case #1 Very little can be said about quantity of blood loss Naya calls your office. She is >10% of women experienced bleeding beyond 40 days now 7.5 weeks postpartum and she continues to have light Common for women to stop bleeding for 1+ days and bleeding. She wants to know if then resume bleeding this is normal. Fletcher et al, 2012; WHO, 1999. 3
10/28/2016 In what percentage of pregnancies does secondary postpartum hemorrhage occur? Persistent Postpartum A. Up to 2% bleeding B. 3-5% C. 7% D. up to 10% Case #1 - revised 58% Naya calls your office. She is 2 weeks postpartum and she is 18% 18% bleeding more heavily. She is 7% filling a pad every 1-2 hours. Up to 2% 3-5% up to 10% 7% Algorithm for secondary postpartum Postpartum hemorrhage hemorrhage Vaginal • Occurs in first 24 hours after delivery bleeding • Affects 2-5% of deliveries Primary Stable Unstable • Occurs between 24 hours and 12 weeks Obtain H&P Obtain pelvic Manage Transfer to after delivery and labs ultrasound blood loss OR (CBC, coags) with Doppler • Affects 0.8-2% of deliveries Secondary Consider Surgical differential management diagnosis 4
10/28/2016 Placental site sub-involution Differential Diagnosis Large patent uteroplacental arteries that failed to Retained products of Coagulopathy undergo normal process of conception involution Arterial-venous Uterine atony Delayed or inadequate malformation (AVM) remodeling of vessels Placental site sub- during 3rd trimester involution Pseudoaneurysm Persistence of low- resistance dilated vessels Endomyometritis Gestational with increased flow trophoblastic disease Abnormal placentation Occurs most often in second week postpartum Weydert et al 2006; Petrovich et al 2009 Pseudoaneurysm Arterial-venous malformation (AVM) Pseudoaneurysm does not have Can be congenital or acquired all 3 layers of the arterial wall Usually follows a history of previous Extraluminal collection of blood uterine trauma with turbulent flow that Abnormal communication between communicates with parent vessel artery & vein occurs during healing through defect in arterial wall process Can be asymptomatic, may U/S: multiple tubular or “spongy” thrombose or rupture or cause anechoic or hypoechoic areas hemorrhage within the myometrium of a normal Reported after pelvic surgery, endometrium; use of spectral vascular trauma, and uterine Doppler very helpful Vijayakumar et al 2013 curettage Baba et al 2014; Nanjundan et al 2011. 5
10/28/2016 CASE #1 - REVISED History: Uncomplicated NSVD 2 weeks ago, started bleeding heavily this morning, no infectious symptoms Persistent Exam: Vital signs wnl, perineal laceration well-reapproximated, Postpartum active bleeding from the cervix, 8 week sized uterus (non-tender) bleeding CBC & coags wnl Pelvic ultrasound 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. How long do dogs bleed after birth? A. Up to 2 weeks Managing B. Up to 4 weeks miscarriage C. Up to 6 weeks D. Up to 8 weeks E. Up to 12 weeks Case #2 47% Sonia calls your office. She was just diagnosed with a miscarriage and started 23% bleeding. She wants to know 11% 10% how long to expect bleeding. 9% What do you tell her? s s s s s k k k k e k e e e e e e e e e w w w w w 2 4 6 8 2 o o o o 1 t t t t o p p p p t U U U U U p 6
10/28/2016 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 35% 22% 22% 20% Test your knowledge (part II) 1% s s s s s a y a y a y a y y a d d d d d 3 7 0 4 1 1 1 2 Bleeding after early pregnancy failure Bleeding after EPF: (EPF) some finer details Median duration Management of EPF trial reports that a substantial Expectant Medical Surgical of bleeding number of women continued to bleed at 2 weeks (days) 43% of women who had medical treatment Early 30% of women in the surgical treatment pregnancy 12 (7-15) 11 (7-15) 8 (4-14) failure For women with a pregnancy loss prior to 6 wks GA: Embryonic Length of bleeding with loss was similar to usual 12 (7-16) 11 (7-15) 9 (4.8-14) demise menstrual length Bleeding associated with loss slightly longer (0.4 Incomplete days) 10 (7-13.3) 9 (6-14) 7 (4-12) abortion Davis et al, 2007; Promislow et al 2007. Trinder et al 2006 (MIST trial) 7
10/28/2016 Decline of serum HCG after spontaneous How long does it take for the B-HCG level to complete abortion trend to undetectable following early pregnancy failure? A. 7 days B. 14 days C. 21 days Initially a steep decline D. It depends…. Less steep decline if initial value < 500 57% mIU/mL 24% 18% 0% Barnhart K et al Obstet Gynecol 7 days 14 days 21 days It depends…. 2004 Expected percentage decline in serum hCG levels 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? Barnhart K et al Obstet Gynecol 2004 8
10/28/2016 Differential Diagnosis Managing Retained products of miscarriage Coagulopathy conception Arterial-venous Endomyometritis malformation Case #2 - revised Abnormal Sonia calls your office. She Pseudoaneurysm placentation was diagnosed with a miscarriage; she opted for Gestational medical management. She is Trauma trophoblastic disease now bleeding heavily. How do you manage her? Algorithm for evaluating bleeding Spectrum of after EPF normal ultrasound Vaginal findings bleeding Stable Unstable Obtain H&P Obtain pelvic Manage Transfer to and labs ultrasound blood loss OR (CBC, coags) with Doppler Consider Surgical differential management diagnosis 9
10/28/2016 Endometrial thickness Ultrasound & retained POCs Endometrial thickness alone does not predict Normal appearance of cavity after spontaneous who will require D&C abortion is variable and Even when EMS > poorly described 30mm Ultrasound associated with high false positive rate of retained POCs Endometrial thickness is greater in women Endometrial thickness is who require D&C after poor predictor of need Poor test for predicting medical abortion or for surgical intervention medical management need for D&C of SAB Reeve et al, 2008; Reeves et al, 2009. Are there other So how do we use studies to assess ultrasound? for retained POCs? Hyperechoic endometrial mass or solid component in endometrium Retained Saline sonogram POCs Heavy or Hysteroscopy prolonged bleeding 10
10/28/2016 Objectives Managing miscarriage To describe bleeding patterns following delivery and early pregnancy loss To state 3 diagnostic possibilities for abnormal Case #2 - revised post-pregnancy bleeding Sonia calls your office. She was diagnosed with a To develop an algorithm for evaluating miscarriage; she opted for abnormal post-pregnancy bleeding medical management. She is now bleeding heavily. How do you manage her? How soon does the next menses occur after early pregnancy failure? A. 2 weeks B. 4 weeks C.5 weeks Thank you D.6 weeks E. 8 weeks 0% 0% 0% 0% 0% 2 weeks 4 weeks 5 weeks 6 weeks 8 weeks 10 11
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