Obstetric Haemorrhage

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

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

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

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 F2 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

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

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

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

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

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
crystalloidpreferred (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).

40. • .

41. • .

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)

46. • .

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

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-N2O+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

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

59. .
• .

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

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

65. .
• .

66. Anesthetic technique for the
repair of genital trauma
vulvar hematomas: LA + iv opioids
extensive lacerations and drainage of
vaginal hematomas: aspiration
prophylaxis 50% N2O / 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
.