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Postpartum Hemorrhage
Case Presentation Definition Epidemiology Preventative Measures Etiology Management Replacement Therapy What Can We Do As Anesthesia Assistants? Case summary
Case Review
Healthy 32 yr old G3P2 22 weeks pregnant for induction of labour of fetus with a fetal anomaly Mallampati IV Vaginal delivery with retained placenta Heavy bleeding Systolic BP ~60mmHg Transferred to OR Dx: Postpartum Hemorrhage
DEFINITION
Blood loss >500mL for a vaginal delivery Blood loss >1000mL for a caesarian section 10% decrease in hematocrit Requires a blood transfusion Primary PPH is within 24 hours after birth Secondary PPH is 24 hours to 6 weeks after birth Primary PPH involves heavier bleeding and is more likely to result in maternal morbidity and mortality
Blood volume increases by 50% Red blood cells only increase 20-30% Uterine blood flow is 600ml/min Hypercoaguable state Upper airway edema Decrease in FRC Oxygen consumption increase by 20%
EPIDEMIOLOGY
Major cause of maternal death worldwide PPH can occur in 10-18% of all births 3% of vaginal deliveries will result in severe PPH 25% of all maternal deaths are caused by severe hemorrhage
PREVENTATIVE MEASURES
Active management of the third stage of labour Oxytocin with delivery of baby Prophylactic oxytocin decreases PPH by 40% Deliver placenta with controlled cord traction and inspect for completeness Palpate uterus and inspect lower genital tract
ETIOLOGY
Remember the 4 Ts: 1. Tone 2. Tissue 3. Trauma 4. Thrombin
1. TONE
Uterine Atony Boggy uterus Most common cause of PPH 70% of all PPH
(polyhydramnious,
fever)
(NTG, Volatile
2. TISSUE
Retained products Abnormal placenta (placenta accreta, increta or percreta) Previous uterine surgery
3. TRAUMA
Lacerations of cervix, vagina, perineum or C/S incision site Hematomas Uterine rupture Uterine inversion
Precipitous delivery Operative delivery Assisted delivery (forceps, vacuum) Previous uterine surgery Fundal placenta
4. THROMBIN
Pre-existing
Acquired in pregnancy
Pre-eclampsia HELLP Amniotic fluid embolus
MANAGEMENT OF PPH
Communication!!!! Call for HELP!! Determine etiology (four Ts) Vital signs Large bore I.Vs Blood work Oxygen OR
Dont Panic!
2. Uterine Massage
Inspect placenta for completeness Manually remove remainder of placenta Abnormal placenta
Suture any lacerations Inspect uterus for inversion Correction of uterine inversion- done under GA
Fresh frozen plasma Platelet transfusion Cryoprecipitate Hematology consult Replace specific coagulation factors
Surgical Intervention
Interventional Radiology
REPLACEMENT THERAPY
Volume replacement options Blood loss is usually underestimated May be asymptomatic until blood loss reaches 25-35% Any patient who is at risk for PPH should be cross-matched upon arrival to hospital
Be aware Team work Oxygen Help transport to the OR Monitors I.V. access Retrieve Ergot and Hemabate from the fridge Blood work
(contd)
RSI Difficult airway equipment Prime the Level 1 rapid infuser Check and hang blood Warming mechanisms (Hotline, blankets) Point of care testing Put in/assist with an arterial line, CVP Be prepared for anything!
Case Review
Healthy 32 yr old G3P2 1 CS, 1 SVD 22 weeks pregnant for induction of labour Mallampati IV Retained placenta Heavy bleeding Systolic BP ~60mmHg Transferred to OR
(contd)
Case Review
GA RSI with Glide scope 2 18g I.V.s and arterial line inserted Placenta manually removed Uterotonics given Bakri balloon and vaginal packing inserted
(Contd)
Case Review
Interventional Radiology Surgical Hysterectomy Total EBL 10L Total blood products given: PRBC 21, platelets 6, Cryo 10, FFP 12 N/S 1 litre R/L 4 litres, Voluven 1.5 litres
(Contd)
Case Review
ICU admission PCV 10/5, Fi02 0.40 ABG 7.49/31/193/24/10 HgB 84, platelets 122, INR 1.0 Normal electrolytes Pt extubated the following morning
(contd)
Case Review
Transferred out of ICU Minimal pain medication required Discharged home 3 days later
Patient awareness?
(contd)
Tissue
Trauma
Questions?
References
1.
Chestnut D. Obstetric Anesthesia. 3rd edition. Philadelphia: Elsevier Mosby; 2004. University of Toronto Department of Anesthesia. CME Module 8: Clinical Management of Post Partum Hemorrhage. [online]. 2008 [cited April 5, 2009];[16 screens]. Available from URL: http://www.anesthesia.utoronto.ca/edu/cme/courses/m08/m08p04.htm Anderson J, Etches D. Prevention and Management of Postpartum Hemorrhage [online]. March 2007 [cited April 19, 2009]; Available from URL: http://www.aafp.org/afp/20070315/875.html Schurmans N, MacKinnon C, Lane C, Etches D. Prevention and Management of Postpartum Haemorrhage. SOGC Clinical Practice Guidelines [serial online] 2000 April [cited April 19, 2009]; 88:[11 screens]. Available from: URL: http://www.sogc.org/guidelines/public/88E-CPG-April2000.pdf World Health Organization. Prevention of Postpartum Haemorrhage by Active management of Third Stage of Labour: MPS Technical Update. Geneva: World Health Oraganization, 2006.
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References (contd)
6.
Garcia J. Postpartum Hemorrhage [online]. December 2001 [cited April 14, 2009]; Available from URL: http://www.fammed.washington.edu/network/sfm/Didactic%20Handout s/Postpartum%20hemorrhage%2012-01.ppt Dunn PF. Clinical Anesthesia Procedures of the Massachusetts General Hospital. 7th Edition. Boston: Lippincott Williams and Wilkind;2007. Up To Date [online] 2009 [cited April 25, 2009]; Available from URL: http://www.uptodate.com/online/content/image.do?imageKey=obst_pix /uterin5.htm&title=Uterine%20artery%20ligation Smith S. Uterine Fibroid Embolization. American Family Physician. [online] 2000 [cited April 24, 2009]; Available from URL: http://www.aafp.org/afp//AFPprinter/20000615/3601.html Ciliberto C. Physiological Changes Associated with Pregnancy [online]. 1998 [cited May 20, 2012]; Available from URL: http://www.nda.ox.ac.uk/wfsa/html/u09/u09_003.htm
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