53. MOH Flashcards
You are asked to assess a 24-year-old woman who is in labour and has
had a significant antepartum haemorrhage. What are the causes of major
obstetric haemorrhage?
Major haemorrhage occurs in 6.7/1000 deliveries and may be defined as
(multiple definitions exist, pick one or two):
Acute loss of 40% of circulating volume (∼2 litres at term).
Loss of 50% of circulating volume in under 3 hours.
Loss of one total blood volume in 24 hours.
Antepartum haemorrhage:
- Placental abruption.
Occurs in 1%–1.5% of pregnancies and is responsible
for 20%–25% of antepartum haemorrhages.
Blood loss may be concealed and DIC may occur. - Placenta previa.
Occurs in 0.5%–1% of pregnancies and is responsible for
15%–20% of antepartum haemorrhages. - Uterine rupture. Blood loss may be concealed and associated with severe
abdominal pain. - Cervical or vaginal lesions.
- Unknown aetiology.
Primary postpartum haemorrhage:
- Uterine atony. Most common cause of bleeding (80% of PPH) and
more likely with uterine over distension,
uterine fatigue (prolonged or augmented labour) or
obstruction due to retained products. - Trauma to the birth canal
- Coagulopathy
- Uterine inversion
- Uterine rupture
- Placenta accreta.
Latest Mbrrace
In 2017-19, 191 women died during or up to six weeks after the end of pregnancy,
from causes associated with their pregnancy, among 2,173,810 women giving birth
in the UK.
8.8 women per 100,000 died during pregnancy or up to six weeks after childbirth
or the end of pregnancy. There is no statistically significant difference in maternal
mortality compared to 2010-12.
Heart disease remains the leading cause
of death, followed by epilepsy and stroke.
Sepsis and thrombosis and thromboembolism (blood clots) are the
third and fourth most common causes of maternal death during or up to six weeks after the end of pregnancy
Secondary postpartum haemorrhage
Retained products of conception
Sepsis
How would you manage this lady with a massive antepartum
haemorrhage for emergency caesarean section?
Initial resuscitation with ABC and anaesthetic assessment:
Oxygen via non-rebreathing mask and bag at 15 litres per minute.
Left lateral position and head down.
Two large bore (14G) cannulae and rapid infusion to maintain circulating
volume (crystalloid or colloid until blood available).
Blood for FBC, Coagulation screen, 6 unit cross-match.
Transfuse blood when available (uncrossed O negative blood should be
available if needed).
Call for senior anaesthetic and obstetric help.
Inform haematology of situation and involve consultant haematologist if
coagulopathy present. FFP, cryoprecipitate, platelets and other clotting
factors may be required.
Anaesthetic management:
Consider upgrading monitoring (arterial and central access) when the
situation allows.
Anti-reflux medication may be given if the situation allows.
Maintain left tilt or uterine displacement.
Pre-oxygenation.
Rapid sequence induction and intubation using suxamethonium with cricoid
pressure. If shocked, some authors recommend etomidate or ketamine as
induction agents instead of thiopentone.
Endotracheal intubation and ventilation.
Maintain anaesthesia with volatile agent. If shocked, continue 100%
oxygen.
Continue resuscitation intra-operatively via warming devices. Maintain Hb
>8.0 g/dl and maintain circulating volume.
Correct coagulopathy.
Cell salvage has been successfully used to reduce homologous blood
requirements. Separate suction should be used for amniotic fluid.
Post-operative stabilisation may be best performed in a critical care setting.
Specific managements:
Uterine atony:
Bimanual massage.
Oxytocin. 5iu slow i.v. bolus followed by infusion. May precipitate
hypotension.
Ergometrine. 250–500 mcg by i.m. injection. Nausea and vomiting are
very common.
Carboprost (hemabate). 250 mcg by deep intramuscular or
intramyometrial injection.
Misoprost
Coagulopathy:
Maintain PT <1.5 times normal. 4 units FFP is first line and should be
repeated as required.
Maintain platelets > 75×109/l.
Maintain fibrinogen level >1.0g/l. If not corrected by FFP will require 10 units cryoprecipitate.
Tranexamic acid – antifibrinolytic.
Persistent non-surgical bleed may be managed with recombinant
activated factor VII (NovoSeven).
Surgical management of persistent bleeding:
Radiological management of persistent bleeding:
Uterine packing
Uterine artery ligation
B-lynch sutures
Hysterectomy
Embolisation of pelvic vessels may prevent the need for hysterectomy.
Recombinant activated factor VII
Recombinant activated factor VII (NovoSeven) was initially developed for
conditions of factor VII deficiency or inhibition.
The first step in the coagulation cascade is the activation of factor VII by
tissue factor.
Recombinant activated factor VII was first reported in the
management of major traumatic haemorrhage in 1999 (Israeli army) and
various case reports of successful use in obstetric haemorrhage have been
published.
However, some concern still exists regarding thrombotic complications.
Dosing should follow haematology guidance (40–100 mcg/kg).
Failure of NovoSeven has been associated with profound coagulopathy and acidosis
Carboprost
Carboprost is a prostaglandin F2 receptor agonist (15-methylprostaglandin
F2).
It causes uterine contraction.
The major side effects are bronchospasm
(contra-indicated in asthma), hypoxia, flushing, nausea and vomiting
