Major Obstetric Haemorrhage Flashcards
You are asked to review a 25-year-old patient who has just delivered in the birthing suite and is now actively bleeding following an initial estimated 1.2 L blood loss.
What is the definition of a “major obstetric haemorrhage”?
- There is no universally accepted definition, but it is often classified according to one of the following markers:
- Blood loss >1.5L (moderate as per RCOG is 1-2L, severe is >2L)
- A drop in Hb >4g/dL
- > 4 units of blood required for transfusion
What are the causes of obstetric haemorrhage?
Antepartum:
- Placental abruption (one third of cases).
- Placenta praevia (one third of cases).
- Other causes e.g. uterine rupture (one third of cases).
Postpartum (“Four Ts”):
* Tone – uterine atony.
* Trauma.
* Tissue – retained products/placenta.
* Thrombin – coagulopathic state.
How would you manage this patient?
This patient is actively bleeding and approaching the threshold for a major obstetric haemorrhage, hence she needs urgent assessment and intervention. Commonly several different teams are working to resuscitate while simultaneously controlling ongoing blood loss. The suggested management is listed below.
- Put out a major obstetric haemorrhage emergency call to include obstetric, anaesthetic and midwifery teams, blood bank and porters. Alert the consultant anaesthetist early if concerned, or according to local protocols.
- Carry out an urgent ABCDE assessment, apply 100% oxygen via a non-rebreathe mask and insert large bore intravenous access (at least 2 16G).
- Administer crystalloid fluid boluses until blood is available, and send urgent blood samples for full blood count, clotting (including fibrinogen) and cross-match. Serial haemocue or blood gases can be done to obtain values for Hb/lactate/calcium. Bedside measurement of clotting should be performed if available. Consider blood products after 2L of crystalloid has been given.
How would you manage this patient?
Continued…
- Administer warmed blood and blood products early using a rapid infuser and liaise with haematology in the case of ongoing major obstetric haemorrhage. Give FFP, cryoprecipitate and/or fibrinogen if indicated. Remember that FFP does not elevate fibrinogen very effectively (the concentration of fibrinogen in FFP is often <2 g/L). Fibrinogen is often low following major placental abruptions and amniotic fluid embolism.
- O-negative blood can be given if cross-matched blood is not available.
- Consider medical and surgical intervention early to treat the underlying cause of the bleeding, and further management of patient
should be done on the high dependency or intensive care unit.
What pharmacological agents can be used in the management of massive obstetric haemorrhage?
- Tranexamic acid IV (1g) over 10 minutes followed by an infusion if indicated.
- Calcium chloride (10 mL, 10%), but the dose can be directed by serial blood gas results.
- Uterotonic agents (if uterine atony is the cause):
- Oxytocin 5U IV followed by infusion of 40U over 4 hours.
- Ergometrine 500 mcg intramuscular (or slow IV over 15 minutes).
- Carboprost 250 mcg intramuscular (every 15 minutes to a
maximum of 2 mg). - Misoprostol 800mcg - 1 mg rectally.
The obstetric registrar suspects partially retained placenta as the cause of haemorrhage and wants to take the patient to theatre.
What are the concerns with regional anaesthesia in this patient?
- Regional anaesthesia in a hypovolaemic patient can lead to severe CVS instability due to sympathetic blockade causing vasodilation.
- Coagulopathy following major obstetric haemorrhage can increase the risk of epidural haematoma if neuraxial blockade is attempted.
What are the goals in the treatment of this patient?
- The goal in this patient is to gain control of the bleeding and ensure normal physiology, using the following indicators:
- Mean arterial pressure >70 mmHg.
- Urine output >0.5 mL/kg/hour.
- Haematocrit >0.3.
- Platelets >100 × 109 L−1.
- Fibrinogen >2 g/L.
- Ionized calcium >1.
- Temperature >36°C.
What are the options for surgical intervention in this patient?
- Evacuation of the uterus.
- Bimanual compression and uterine massage.
- Insertion of an intrauterine balloon (e.g. Bakri balloon).
- Internal iliac artery ligation.
- Uterine compression suture if the abdomen is open.
- Interventional radiology (arterial embolisation).
- Hysterectomy – last resort, and if possible, requires two consultant
obstetricians should concur that hysterectomy is needed. However, it should not be delayed if bleeding is immediately life threatening and a second consultant is unavailable.
