OBSTETRIC HAEMORRHAGE.pptx

Obstetric Haemorrhage

1. Dr Unnikrishnan P MD,DA,PDCC,MBA Asst Professor SCTIMST, TRIVANDRUM,KERALA, INDIA OBSTETRIC HAEMORRHAGE

2. Why this session.. Better to know each others priorities; especially in emergencies Non anesthetic and anesthetic priorities in obstetric hemorrhage Hidden corners in this subject

3. Why we should be prepared Severe bleeding is the single most significant cause of maternal death worldwide. More than half of all maternal deaths occur within 24 hours of delivery Rapid loss ; gravid uterine blood flow at term is 600-900ml/minute When uterine atony occurs, more than one unit of blood is lost every minute.

4. Postpartum Haemorrhage PPH is commonly defined as a blood loss of 500 ml or more within 24 hours after birth, while severe PPH is defined as a blood loss of 1000 ml or more within the same timeframe.

5. How the body prepares …. Blood volume increase (1000-2000mls) and increased red blood cell mass. Hypercoagulable state (increased clotting factors, including fibrinogen). Involution of uterus following delivery has a ‘tourniquet effect” on the spiral arteries of the gravid uterus.

6. Beware of underestimation difficulties in quantifying amniotic fluid SBP changes when more than 25-40% of the blood volume is lost in pregnancy Pregnancy causes increased susceptibility to DIC.

7. Causes of Primary PPH • Tone: Atonic uterus (The most common, accounting for 70% of PPH) • Tissue: Retained products (10%) • Trauma: Genital tract trauma (20%) • Thrombin: Coagulopathy , e.g. DIC (1%) Others : Pre-existing coagulation problems, thrombocytopaenia , women taking anticoagulannts

8. What made me an under performer? Over-stretched uterus : multiple gestation, macrosomia , polyhydramnios Tired uterus : high parity, prolonged labor , prolonged oxytocin use. Sick uterus as seen in chorioamnionitis

9. Recommendations for PPH prevention Uterotonics during the third stage of labour Oxytocin is the recommended uterotonic drug for the prevention of PPH in caesarean sections controlled cord traction surveillance of uterine tonus through abdominal palpation

10. Danger signs Tachycardia In APH, signs of fetal distress Take extra caution if obesity, pre- eclampsia , dark skin or beta-blockade [we may miss] blood loss of 1000ml (or less with signs of haemorrhagic shock such as tachycardia, tachypnoea , oliguria and, in extremis, hypotension and altered cognitive function) should make us start resuscitation as for major obstetric haemorrhage

11. Drugs in Postpartum Haemorrhage .

12. OXYTOCIN stimulates the force and frequency of uterine contraction. immediate effect and a half-life of 5 to 12 minutes The main preservative - chlorobutanol - has a negative inotropic effect on the cardiac muscles. iv bolus of 5 -10 IU f/b 30 to 40IU in 500mls 0.9% Saline may be commenced at a rate of 125ml.hr-1 [ 10 IU/h] for 4 hours  

13. OXYTOCIN Oxytocin given as a bolus IV or fast IV infusion produces a vasodilatation and subsequent hypotension and reflex tachycardia, flushing has been associated with pulmonary edema , SAH, arrhythmias, and anaphylactic reactions.

14. Ergometrine Increases both the force and the frequency of uterine contraction probably via alpha-adrenergic receptors, tryptaminergic receptors, or both. constriction of arteries and veins  raises the BP coronary vasoconstriction, nausea and vomiting dosage of 0.2 mg im . Contraindicated in women with hypertension, h/o IHD, preeclampsia

15. Ergometrine in combination with oxytocin ( Syntometrine:ergometrine 500 mcg combined with oxytocin 5 units ) in the prevention and treatment of PPH. rapid onset of action of oxytocin combined with the sustained myometrial response of ergometrine higher incidence of the side-effects

16. Prostaglandin F 2 Alpha (e.g. Carboprost ) 250mcg is given by im injection. This may be repeated at 15 minute intervals to a maximum of eight doses [ 2mg] . Adverse effects include bronchospasm , pulmonary hypertension, hypoxia, flushing, nausea and vomiting. should be avoided in patients with asthma Intramyometrial administration has a more rapid onset but is an ‘off-label’ use

17. Other Prostaglandins Misoprostol , the prostaglandin E1 analogue 800-1000 mcg given rectally - severe PPH shivering and pyrexia as side effects-up to 12 hours cheap, easy to administer, long shelf life of several years. Hemabate 250mcg (s/e: diarrhoea,)

18. Non-pharmacological Management of Postpartum Hemorrhage .

19. Non-pharmacological Management of Postpartum Hemorrhage .

20. Uterine massage, external aortic compression Uterine massage : rubbing of the uterus achieved through the manual massaging of the abdomen In CS anesthetist also should be keen to check whether the myometrium is contracting effectively or not Mechanical compression of the aorta, if successful, slows blood loss

21. Placenta if a placenta is not expelled within 30 minutes after the delivery of a baby, the woman should be diagnosed as having a retained placenta If the placenta is not expelled spontaneously  CCT and IV/IM oxytocin (10 IU) [ dont use ergometrine,PGE2 ⍺ ] If the placenta is retained and bleeding occurs  manual removal of the placenta Prophylactic antibiotics [ ampicillin single dose]

22. Uterine tamponade used to gain hemostasis and determine whether further surgical measures will be needed Inserting a Sengstaken -Blakemore esophageal catheter [Or Foleys catheter; too small (30cc)] into the uterus and inflating it with normal saline immediately postpartum. uterine atony as well as placenta accreta . If PPH is arrested  left in situ for at least 6 hours Failure to achieve haemorrhagic control  laparotomy .

23. Compression sutures B-Lynch sutures – require hysterotomy for insertion- so most useful in the control of PPH following CS By opposing the anterior and posterior walls of the uterus, blood flow is reduced. Modified techniques which do not require hysterotomy may reduce the need for hysterectomy but should only be used by a skilled surgeon Do temporizing measures, till she/he comes!

24. A stitch in time saves nine .

25. Internal iliac ( hypogastric ) & uterine artery ligation diminish the pulse pressure of blood flowing to the uterus less familiarity, less successful than previously thought Bilateral uterine artery ligation is quicker and easier to perform Fails  hysterectomy should be performed promptly

26. Uterine Artery Ligation .

27. Uterine Artery Ligation .

28. Uterine artery balloon occlusion / Catheter arterial embolization need for a trained interventional radiologist and a fully equipped x-ray department 24 hours a day. Feasible in certain centres ; under LA usually with anesthesia support Embolization obviates the need for a laparatomy Can place a prophylactic catheter in high risk patient

29. Hysterectomy most definitive treatment. procedure is technically difficult due to the enlarged uterus, engorged vessels, and oedematous tissues should not be delayed until the patient is unstable and deteriorating quickly

30. Hysterectomy Large bore IVA- Crystalloid/colloid-blood products. Warmer/ warm IVFs An arterial line Vasopressors full blood count, clotting values, electrolytes monitor urine output Conversion to general anesthesia Intravenous anesthetics ; ketamine all volatile agents worsen uterine atony

31. Other Treatments .

32. Factor VIIa most commonly from excessive bleeding. “off-label” use as a bolus in doses ranging from 60 to 120mcg/kg, effects were seen in as little as ten minutes Disadvantages: short half-life (two hours) and the high cost ; $ US 1400 per milligram Adverse effects : DIC, thrombosis, MI

33. Tranexamic acid tranexamic acid is advised in cases of refractory atonic bleeding or persistent trauma-related bleeding [for Rx] 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.[ 15mg.kg-1 IV]

34. Intra-operative cell salvage has been considered relatively contraindicated because of the fear of amniotic fluid contamination and embolism started after the majority of the amniotic fluid has been suctioned A leucocyte depletion filter should be used prior to re-infusion of the salvaged blood to remove additional contaminants contains only red cells with essentially no clotting factors or platelets

35. Management of Obstetric Haemorrhage .

36. Initial management abdominal pain

37. Initial management abdominal pain

38. Initial management abdominal pain

39. Initial management Once 3500ml of warmed crystalloid preferred (2000ml) and/or colloid (1000ml) have been infused, further resuscitation should continue with blood. Dilution is dangerous Give O negative blood (immediate) or group specific blood (20 minutes) until crossmatched red blood cells are available (40-60minutes).

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42. Transfusion practice Packed red blood cells and FFP are given in a ratio of between 1:1 and 1:2  avoid dilution of clotting factors and development of a coagulopathy . Check Hb and clotting avoid the vicious cycle of hypothermia, acidosis and coagulopathy in the massive transfusion patient ‘massive transfusion packs’???

43. Guide to use of blood products .

44. Guide to Blood Component Therapy .

45. Correction of electrolyte imbalance may be necessary; this may include hyperkalaemia (secondary to high concentrations of potassium in transfused blood) Hypocalcaemia ( chelated by the citrate found in transfused FFP)

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47. Points to ponder Haemodynamic compromise and coagulopathy should be addressed prior to surgery whenever possible Detection of concealed haemorrhage is vital. Regional anaesthesia may be contra-indicated due to maternal coagulopathy and risk of neuraxial haeamatoma as well as haemodynamic compromise

48. Points to ponder volatile agents cause uterine relaxation and excessive concentrations should be avoided, especially in the case of uterine atony Consider upgrading monitoring (arterial +/- CVP) if situation allows but DO NOT DELAY URGENT SURGERY to facilitate insertion

49. When there are two patients consideration must be given to assessment and optimisation of foetal well being Often maternal resuscitation will improve fetal condition. Where there is conflict, maternal life should be prioritised over fetal life. The patient should be placed in a head down position with left lateral tilt or uterine displacement Paediatric support

50. Disseminated intravascular coagulopathy abruption, infection or fetal demise- high chance

51. . APH - Placenta previa

52. APH - Placenta previa Target is expel Placenta [& baby] and make the uterus contract If patient is not actively bleeding, not hypotensive  EDB/SAB/GA IOP-DANGERS: placental nick @ uterine incision, LUS implantation site-wont contract efficiently, P accreta especially if previous CS So large bore iv access, 4 PRBCs in all such cases

53. Oh.....its not coming.... Eliminate volatile agent if bleeding continues-N 2 O+OPIOID If the placenta does not separate easily, a placenta accreta may exist. massive blood loss and the need for cesarean hysterectomy should be expected Blood..blood.. Blood..blood

54. Uterine Inversion abdominal pain, profuse hemorrhage and shock occurs when fundal pressure and inappropriate traction on the cord is applied during the third stage of labor in the presence of atonic uterus with open cervix Bleeding from the placental site is exaggerated because of restricted venous outflow from the uterus

55. Mechanism Lorem

56. Mechanism degree of blood loss is related to the time the uterus remains inverted Initial vasovagal reflex  hypotension and bradycardia inverted uterus  exert traction on the sympathetic nerves  neurogenic shock

57. Unique problem for the anesthesiologist Rx hypovolemia patient is often in severe pain  need anesthesia for replacing the uterus if manual replacement is not possible and the cervix has already begun to contract, have to provide analgesia and rapid uterine relaxation with a volatile inhaled anesthetic or nitroglycerine (GTN) in a hypovolemic patient !!!

58. Unique problem for the anesthesiologist rapid intravenous fluids and vasopressors may be required to maintain or improve the arterial blood pressure. GA with a potent inhalation anesthetic relaxes the uterus, use of higher than usual concentrations of potent volatile inhalation agents are often necessary for optimum uterine relaxation risk of cardiovascular system depression

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60. Nitroglycerine rapid onset of action (30-40 seconds) in combination with a shortlived effect of approximately one minute. Doses of 50-200 mcg have been used successfully to achieve relaxation without causing significant hypotension or other unwanted side effects.

61. An can change her postpartum recovery creates uterine relaxation in a much shorter time than would otherwise be achieved if an anesthesiologist were relying on the uptake of inhaled anesthetics . The short duration of action obviates the need for reversal may avoid the need for GA If epidural anaesthesia was used for labor  small increments of intravenous nitroglycerine and epidural LAs

62. Sublingual GTN Onset : within 30-45 seconds ; lasts for up to 5 min It has been reported that the administration of 800mcg of has resulted in complete relaxation and reduction of a partially re-inverted uterus within approximately 30 seconds. Available as 0.5 mg [e.g. : GTN Sorbitrate 0.5 mg buccal tab,Abbot ]

63. Stop and take a U- turn Once the uterus is replaced, all medications that were administered to produce uterine relaxation should be stopped and uterotonic agents should be administered

64. MANUAL REMOVAL OF PLACENTA Activate ED, if in situ / SA : block height at or above T6 to cold is necessary for maternal comfort 0.5 mg/kg of ketamine GA with high dose volatile agents  anesthesia+uterine relaxation Sublingual or intravenous administration of nitroglycerin may provide uterine relaxation, which facilitates manual removal of a retained placenta [500-800 microgm ] uterotonic agents are administered to decrease bleeding

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66. Anesthetic technique for the repair of genital trauma vulvar hematomas: LA + iv opioids extensive lacerations and drainage of vaginal hematomas: aspiration prophylaxis  50% N 2 O / low dose Ketamine retroperitoneal hematoma  GA

67. Subsequent management IN OBSTETRIC HEMORRHAGE rebound hypercoagulation and the risk of thromboembolism . blood transfusion  further increases risk of thromboembolic disease in pregnant patient. Graduated compression stockings , pharmacological thromboprophylaxis [initiated as soon as practical]  

68. Title Lorem

69. THANK YOU .