11. Antepartum haemorrhage

Question 1

You are called to the labour ward to see a 25-year-old P2+1 lady in labour
who has lost 700 ml of blood PV in labour. She looks pale and sweaty,
her pulse is 140, regular and thready and her BP is 105/55. What would
you do?

Answer 1

1. ABC.
2. Administer 100% oxygen via a non-rebreathing reservoir face-mask.

Establish intravenous access with two large-bore cannulae.

4 Commence fluid resuscitation with crystalloid/colloid (not dextrans).

O-negative blood initially (usually 2 units available on the ward) until
group-specific/fully cross-matched blood available (group specific takes
15 minutes).

Pressure bags and fluid warmer.

Head-down, left lateral tilt.

Call obstetrician, midwives and another anaesthetist (consultant if possible).
Inform haematologist.

Send blood for FBC, cross-match at least 6 units, coagulation screen, urea,
electrolytes and LFTs.

Regular repeated Hb, platelet and coagulation studies.

Consider FFP, cryoprecipitate and platelets.

There may be a major haemorrhage trolley on the delivery suite.

Joint assessment with obstetricians as to the urgency of surgery.

Adequate maternal monitoring (CVP and invasive BP useful if there is time).

Fetal monitoring.

Treat the cause.

Question 2

How would you assess the degree of blood loss?

Answer 2

The losses into the bed and onto pads could be estimated

and the degree of hypovolaemia estimated by using

physical signs such as
tachycardia,
BP,
capillary refill time,
skin colour and
level of consciousness.

There may be an underestimation of the degree of hypovolaemia due to hidden losses.

Question 3

What are the likely causes of her bleeding?

Answer 3

1. Placenta praevia
2. Placental abruption

Uterine rupture
Cervical or vaginal tear
Uterine atony
Coagulation or platelet problem

Question 4

Her previous pregnancy resulted in a caesarean section. Is this relevant?

Answer 4

Yes.

This increases the possibility of

placenta praevia overlying the old uterine scar and

increases the risk of uterine rupture.

There is also a higher incidence of placenta accreta
(adheres to the surface),
increta (invades uterine muscle)
or percreta (penetrates through uterine muscle),

all of which may lead to life-threatening haemorrhage,

necessitating a hysterectomy to stop the bleeding.

Question 5

How would you anaesthetise this lady?

Answer 5

Aspiration prophylaxis – sodium citrate.

Rapid sequence induction with cricoid pressure and left lateral tilt on the
operating table.

Equipment for a difficult intubation should be available.

Consultant anaesthetist ideally in attendance or
at least two pairs of ‘anaesthetic hands’.

Question 6

What measures are available to influence the degree of blood loss on the table?

Answer 6

Surgical
1. Bimanual uterine compression and packing
2. Aortic compression
3. Uterine or internal iliac artery ligation
4. Hysterectomy

Radiological
1. Arterial embolisation
2. Balloon occlusion of iliac vessels
(Need to be stable enough for potentially long X-ray procedure.)

Medical
1. Keep anaesthetic vapour concentration down
2. Ergometrine
3. Oxytocin
4. Carboprost (Hemabate(tm))– PGF2

Haematological
TXA
Correct coagulopathy – FFP, cryoprecipitate, platelets
Factor VIIa
Cell salvage

Question 7

WOMAN Trial

Answer 7

Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for post-partum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset

World Maternal Antifibrinolytic Trial

Question 8

You are called to the labour ward to see a 25-year-old P2+1 lady in labour
who has lost 700 ml of blood PV in labour.

She looks pale and sweaty, her pulse is 140, regular and thready and her BP is 105/55.

What would you do?

Answer 8

ABC.

Administer 100% oxygen via a non-rebreathing reservoir face-mask.

Establish intravenous access with two large-bore cannulae.