Anaesthetic Management in
Obstetric Haemorrhage
Dr B.Srikanth
II nd yr PG
Dept. Of Anaesthesia
Introduction
• Obstetric hemorrhage is a common cause of maternal
morbidity and mortality and remains one of the
leading causes of maternal death.
• Major hemorrhage occurs in approximately 3.7 per
1000 births.
• World Health Organization statistics shows that
it complicates up to 10.5% of births, and
up to 50% of maternal deaths are attributable to
its effects.
• Diagnosis of major obstetric haemorrhage
- a challenge
Because
- Blood loss may be concealed
- can be difficult to quantify due to dilution with
amniotic fluid.
- the physiological changes of pregnancy
may mask the normal clinical signs of hypovolemia.
• The blood flow to the placenta is approximately
700-900 ml/min at term and hence bleeding can
be rapid and may quickly become life threatening.
Physiologic Alterations in pregnancy
• Cardiovascular
– Heart Rate (increases by 25%);
– Blood Pressure ( SBP decreases by 8%, DBP by 20%)
– Blood Volume (increases by 35%);
– Cardiac Output( increases by 40%)
– Venous stasis ( aorto caval compression)
– Systemic Vascular Resistance (decreases by 15-20%)
• Haematologic
– Hb - Decreased by max 2 g/dL
– Relative Leukocytosis
– Gestational Thrombocytopenia
– Procoagulant State [increased Fibrinogen; Protein S]
• Pulmonary
– Reduced Residual lung volume , ERV & FRC
– Increased Inspiratory reserve volume, TV & inspiratory
capacity
– No change in VC & TLC
• Urinary System
– Increased GFR [approaches upto 150%]
– Protein Excretion
• Drugs
– Serum Albumin ( decreased), so more free form of drug is
available.
– so dosage of drug to be given is less.
Obstetric hemorrhage
• Classification
1. Early pregnancy
- Abortions
- Ectopic pregnancy
2. Late pregnancy
- Antepartum hemorrhage
- Postpartum hemorrhage
• Antepartum hemorrhage (APH)
- bleeding from the vagina after 24 weeks gestation
- incidence is between 2–5% of all pregnancies.
Causes are
– Placenta Previa
– Placental Abruption
– Spontaneous uterine rupture
– DIC
– Trauma
Postpartum hemorrhage
Primary PPH Secondary PPH
• occurs during the first 24 • occurring between 24 hours
hours after delivery to 6 weeks
• Causes • Causes
- Uterine atony - retained products of
- Abnormal placentation conception
1. placenta accreta - - puerperal sepsis
2. placenta increta
3. placenta percreta
- Uterine inversion.
• Ectopic pregnancy
results when fertilized ovum implants outside
the Endometrial lining of Uterus.
• Ruptured ectopic pregnancy is one of cause for
obstetric hemorrhage which may lead to massive
loss of blood.
• one of the leading cause of maternal death during
1st trimester.
• Most ectopic related maternal deaths are due to
hemorrhage.
Disseminated Intravascular
Coagulation
• Incidence is 0.1% of all Pregnancies
• Causes
– Placental Abruption
– HELLP syndrome
– Intra-uterine Foetal Death
– Acute fatty Liver of Pregnancy
– Amniotic Fluid Embolism
APPROACH TO A PATIENT OF OBSTETRIC
HEMORRHAGE
• The management principles include
- early recognition
- prompt resuscitation
- treatment of the underlying cause.
• The management strategy will be determined by both
maternal and fetal considerations.
• Maternal resuscitation will improve fetal condition.
• Immediately assess severity of hemorrhage based on the
clinical signs of the patient.
Staging scheme for assessment of
obstetric hemorrhage
% of blood Findings Severity of
loss shock
<15% - 20% None None
20% - 25% Tachycardia ( <100 bpm) Mild
Mild hypotension
Peripheral vasoconstriction
25% - 35% Tachycardia ( 100- 120 bpm) Moderate
Hypotension ( SBP 80-100mmHg)
Restlessness
Oliguria
>35% Tachycardia ( > 120 bpm) Severe
Hypotension ( SBP <60mmHg)
Altered conciousness
Anuria
Sequelae of hemorrhage
• Decreased tissue perfusion ( hypovolemia)
• Decreased tissue oxygenation
• Metabolic acidosis
• Decreased organ perfusion & failure
Management of hemorrhage
• Assess and secure the airway
• Improve oxygenation
• Iv fluid resuscitation
• Treat the underlying cause
MANAGEMENT contd….
• High flow oxygen should be administered and if
antepartum, the patient placed in a full left lateral position
to reduce aorto-caval compression and to aid uterine
perfusion.
• Two wide bore intravenous cannulae (at least 16 G)
should be sited and blood taken for urgent blood count,
clotting studies and cross-match.
• The mainstay of hemorrhagic shock is
intravenous fluid resuscitation and transfusion.
• All fluids that are administered during resuscitation should
be warmed and if possible the rapid infusion devices are
beneficial.
• The choice of fluid for initial resuscitation
- crystalloid
- colloid
- blood & blood products
• Fully cross matched Whole Blood is ideal.
Guidelines for management of Hemorrhagic shock
• Hemorrhagic shock with volume loss >20% is best managed by
Blood replacement.
• Hemorrhagic shock with volume loss <20% is managed by
Crystalloids or Colloids.
• In practice crystalloids can be given 3 - 4 times the
volume of blood lost, where as colloids & Blood replaced in
1:1 ratio.
• In significantly hemodynamically compromised women,
Group O negative blood if available than either type
specific or fully cross-matched blood, should be
considered.
• If bleeding continues after the initial resuscitation steps
- then immediate transfer the patient to the operating
theatre
- examination should be performed under anaesthesia.
• Invasive monitoring may assist with resuscitation.
• Senior help should be requested including
obstetricians and paediatricians if a viable fetus is
in-situ.
• The haematology service should be alerted as to the
possible need for massive transfusion and the advice of
a haematologist is often useful.
• Blood should be commenced early if bleeding
continues to avoid dilutional coagulopathy.
Management of Massive
Haemorrhage
• Preparation
– Identify patients at risk
– 2 Large bore IV access
– Blood should be available [Type specific or O
neg]
– Avoid Aorto caval compression
– supplemental highflow O2
– Foetal monitoring
• Search for evidence of DIC
- Peripheral blood smear
- PT, PTT, Platelet counts, Fibrinogen level; D-
dimer level
- Specific clotting factor analysis
- Bedside coagulation testing (TEG)
Volume Replacement
• Immediate aggressive volume replacement
– Crystalloid & colloid until blood is available [warm fluids]
• Consider Packed Red Blood Cells, once blood loss is >
2,000mL
– Anticipate the need early
• Unmatched type specific or Type O-ve blood if available
should be considered
• Avoid dilutional coagulopathy ( by giving excess crystalloids
& colloids)
ANAESTHETIC MANAGEMENT
• The main aims of management are
- rapid resuscitation is to restore tissue oxygen delivery
- correcting hemostatic disorders.
• Appropriate levels of monitoring (especially invasive arterial
blood pressure monitoring) should be considered and instituted
early.
• If anaesthesia is required for examination or for any surgical
intervention in hemodynamically compromised patient
- general anaesthesia is usually indicated.
• Hemodynamic compromise and coagulopathy should be
addressed prior to surgery whenever possible although surgical
control may be required to enable the effective resuscitation.
• Patient should be placed in the Trendelenburg position
• Regional anaesthesia may be contra-indicated due to maternal
haemodynamic compromise, coagulopathy and risk of
neuraxial haeamatoma.
• In addition, surgery may be lengthy with the potential for
further patient deterioration.
• Rapid sequence induction is indicated, following aspiration
prophylaxis (e.g. ranitidine & metoclopramide ).
• Induction of general anaesthesia in a severely hypovolemic
patient may cause a catastrophic fall in cardiac output.
• So Ketamine, Etomidate & Midazolam are the suitable
induction agents than thiopentone or propofol ( Because they
produce further fall in BP )
• If time and the patient’s condition allow, direct arterial
monitoring may be established, both as a guide to response
and for ongoing blood sampling to guide transfusion therapy.
• Central venous access may be required, however this is not
imperative and can wait until the situation is under control and
should not interfere with prompt resuscitation.
• Central venous access may be necessary for inotrope and
vasopressor infusion and for central venous pressure
monitoring to help to guide fluid management.
• Minimally invasive haemodynamic monitoring devices (e.g.
oesophageal Doppler monitoring) may be useful in the
management of major obstetric haemorrhage.
- These devices may helpful in fluid management in the
anaesthetised patient.
• Intraoperative blood loss can be calculated approximately by
- measuring blood volume in suction container.
- visually estimating the blood in surgical gauge & pads.
• Fully soaked gauge ( 4 4)
holds about 10-15 ml of blood.
• Where as fully soaked pad
holds about 100-150 ml of blood.
• Most accurate measurement of blood loss can be obtained by
measuring surgical gauge & pads are weighed before and after
usage. ( 1gm = 1ml of blood)
• Blood and fluid losses during operation are replaced in
accordingly.
• Attention to fluid balance is important because
over-transfusion and dilution before achieving surgical
hemorrhage control is associated with worse outcomes.
Transfusion practice
• Care must be taken to avoid dilutional coagulopathy with
excessive crystalloid or colloid.
• A significant PPH generally requires the early use of blood
products.
• Recent research in transfusion medicine has pointed
towards early transfusion of fresh frozen plasma (FFP), and
targeted use of platelets.
• Packed red blood cells and FFP are given in a ratio of
between 1:1 and 1:2 in an effort to avoid dilution of clotting
factors and development of a coagulopathy.
• Regular measurements of haemoglobin and clotting factors
are recommended to guide transfusion requirements.
• Thromboelastography (TEG) and thromboelastometry (ROTEM)
are viscoelastic whole blood testing devices that evaluate the
haemostatic capacity of blood.
• Their use has been reported in the management of blood product
replacement in major obstetric hemorrhage.
• It is important to avoid the vicious cycle of
- hypothermia,
- acidosis and
- coagulopathy
in the massive transfusion patient.
• Massive transfusion defined as
transfusion of blood more than patient’s blood volume in less
than 24 hrs. (or)
transfusion of more than 10% blood volume in less than 10
mins.
• Maintain Normothermia of patient by
- by giving Warmed fluids
- by the use of devices
such as forced air warmers.
• Correction of electrolyte imbalance may be
necessary this may include
- hyperkalemia (secondary to high
concentrations of potassium in transfused blood)
- hypocalcaemia (chelated by the citrate
found in transfused FFP).
INTRAOPERATIVE CELL SALVAGE
• Cell salvage technique is useful in both anticipated and
unanticipated massive haemorrhage
- this can reduce the exposure to allogeneic blood
transfusion (and its associated risks) and is cost-effective.
• Cell salvage is usually started after the majority of the
amniotic fluid has been suctioned
- to decrease the risk of amniotic fluid embolism.
• A leucocyte depletion filter should be used prior to re-
infusion of the salvaged blood to remove additional
contaminants that the washing process may not clear.
• Cell salvaged blood contains only red blood cells with
essentially no clotting factors or platelets.
ADDITIONAL DRUGS
• Recombinant factor VIIa
- expensive therapy that may be considered in obstetric
haemorrhage.
- primarily used as a treatment of uncontrolled
haemorrhage in the trauma setting
- causes a thrombin burst & promoting clotting in open
vessels.
- Its effectiveness is markedly diminished by hypothermia
and acidosis
so effective resuscitation towards normal
physiology is a prerequisite of its use.
- potential for thrombotic complications.
• It is typically given in a dose of 90mcg/Kg.
• Antifibrinolytics are a useful adjunct in the
pharmacological management of massive
transfusion and PPH.
Tranexamic acid is a potentially useful drug
that is widely available.
It can decrease bleeding and reduce the need
for further transfusion without many major side
effects.
• The initial dose is a slow IV bolus of 1g followed
by a further 1g 4 hours later.
Uterotonic agents
• The mainstay of conservative treatment is administration of uterotonic
drugs.
• Drugs that should be considered include:
Oxytocin
- Slow intravenous bolus of 5 IU, repeated if required
- Give slowly
- if given rapidly causes vasodilation and is harmful in the
haemodynamically unstable patient
- Following bolus dose, commence infusion @ 10 IU/h for 4 hours
Ergometrine
- Typical dose of 500 mcg can be given either slow Iv or
Intramuscularly
- Causes nausea and vomiting and may precipitate severe
hypertension
- Avoid in pre-eclampsia
• Prostaglandin F2 Alpha (e.g. Carboprost)
- 0.25 mg dose can be given intramuscularly, repeated to a total dose
of 2 mg
- Side effects include: hypertension, pulmonary hypertension and
bronchospasm
- Avoid in asthmatic patients
- Intramyometrial administration has a more rapid onset
• Misoprostol
- A prostaglandin E1 analogue
- Useful in combination with the other uterotonic agents
- Can be used rectally, orally or sublingually
- The recommended dose is 800 mcg
SUBSEQUENT MANAGEMENT
• After controlling the acute situation, attention should be paid to
the possibility of rebound hypercoagulation and the risk of
thromboembolism.
• Pregnant women are physiologically hypercoagulable and those
women who have received blood products have a further
increase in the incidence of thromboembolic disease.
• Graduated compression stockings should be worn.
• Pharmacological thromboprophylaxis initiated as soon as
possible.
Thank you
