2. OBSTETRIC HAEMORRHAGE
Worlds leading cause of maternal mortality
Major obstetric haemorrhage complicates up to
10.5% of all births
In India obstetric haemorrhage contributes to
22.34% of all maternal deaths
3. Obstetric haemorrhage is can be classified as
Antepartum haemorrhage
defined as bleeding from vagina after 24 wks. of
gestation and before delivery
Post partum haemorrhage
defined as blood loss within 24hrs of delivery
which is more than 500ml following vaginal delivery
,more than 1000ml following caesarean section
5. PLACENTA PREVIA
placenta previa is present when the placenta implants in
advance of the foetal presenting part
incidence of placenta previa is approximately 1 in 200
pregnancies
total placenta previa ---completely covers the cervical os
partial placenta previa--- covers part, but not all of the cervical
os
marginal placenta previa ---lies close to, but does not cover the
cervical os
7.
The most characteristic event in placenta previa is
painless hemorrhage.
This usually occurs near the end of or after the
second trimester.
The initial bleeding is rarely so profuse as to prove
fatal.
It usually ceases spontaneously, only to recur.
Placenta previa may be associated with placenta
accreta, placenta increta or percreta.
Coagulopathy is rare with placenta previa.
8. DIAGNOSIS
should always be suspected in women with uterine
bleeding during the latter half of pregnancy.
appropriate evaluation, including sonography
examination of the cervix is never permissible unless the
woman is in an operating room with all the preparations
for immediate cesarean delivery, because even the
gentlest examination of this sort can cause torrential
hemorrhage.
safest method is transabdominal sonography.
MRI
At 18 weeks, 5-10% of placentas are low lying. Most
‘migrate’ with development of the lower uterine segment
10. ANAESTHETIC MANAGEMENT
For Double Set-Up examination
Rarely performed
performed in the operating room
full preparation for cesarean section which includes
maternal monitors,
insertion of two large-gauge intravenous
cannulae,
administration of a nonparticulate antacid
sterile prep , draping of the abdomen
Two units of packed red blood cells (PRBCs
11. FOR CAESAREAN SECTION
choice of anaesthetic technique depends on the
indication and urgency for caesarean section
and the degree of maternal hypovolemia
High risk of intra operative blood loss due to
obstetrician may cut into the placenta during
uterine incision
lower uterine segment implantation site does
not contract well
increased risk for placenta accreta
12.
A retrospective study with 350 cases of
placenta previa [ 60 % regional , 40 % GA ]
found
decraesed EBL with RA vs. GA
decrased transfusions needs with RA
no difference in hypotension
N Parekh et al Br J Anaesth 2000;84;725
13. PREOPERATIVE PREPARATION
patient evaluation, resuscitation, and
preparation for operative delivery all proceed
simultaneously
careful assessment of the parturient's airway
and intravascular volume
Two large-gauge intravenous catheters
four units of PRBCs
Blood administration sets
fluid warmers
equipment for invasive monitoring
14. Rapid-sequence induction of general anesthesia
is the preferred technique
avoid sodium thiopental
propofol should not be used in hypovolemic
patients
Ketamine (0.5 to 1.0 mg/kg) and etomidate (0.3
mg/kg) are the best induction agents for
bleeding patients
patients with severe hypovolemic shock,
intubation may require only a muscle relaxant
15. MAINTENANCE
nitrous oxide and oxygen with a low concentration
of a volatile halogenated agent
concentration of nitrous oxide can be reduced (or
omitted) in cases of foetal distress
Oxytocin (20 U/L) immediately after delivery
lower uterine segment implantation site does not
contract as well as the fundus
All uterine relaxants should be eliminated if
bleeding continues
best to eliminate the volatile halogenated agent after
delivery
substitute nitrous oxide (70%) and an intravenous
opioid
16. ABRUPTIO PLACENTA
Placental abruption is defined as separation of
the placenta from the decidua basalis before
delivery of the foetus
Incidence 1 in 100 pregnancies
Risk factors
hypertension
advanced age and parity
tobacco use
cocaine use
trauma
premature rupture of membranes
a history of previous abruption
18. OBSTETRIC MANAGEMENT
definitive treatment is delivery of the fetus and
placenta
degree of abruption is minimal
the fetus shows no signs of distress
Maternal haemodynamics stable
Hospitalisation
Foetal HR monitoring
Serial ultra sonography
Maternal haemodynamic monitoring
Delivered after foetal lung maturation
19. ANAESTHETIC MANAGEMENT
Preoperative preparation
airway assessment
Assessment of volume status
Maternal Haemodynamic monitoring
FHR monitoring
Two large bore IV catheters
Blood for cross matching , haematocrit ,
coagulation
Maintain supplemental oxygen
Left uterine displacement
20. FOR LABOUR AND NORMAL DELIVERY
Epidural analgesia can be given only if
coagulation studies are normal
no intravascular volume deficit
Vincent et al.[36] observed that epidural anesthesia
significantly worsened maternal hypotension, uterine blood
flow, and fetal PaO2 and pH during untreated hemorrhage (20
mL/kg)
21.
22. CAESAREAN SECTION
General anaesthesia is preferred for most of the
cases
Regional anaesthesia can be given for a patient
with stable haemodynamics ,good intravascular
volume ,minor abruption, NO foetal distress
Ketamine and etomidate are inducing agents of
choice
Rapid sequence induction is preferred
Large doses of ketamine may increase uterine
tone during early gestation
So dose of ketamine should be limited to single
dose of 1mg/kg
23.
Aggressive volume resuscitation with both
crystalloids and colloids
Blood transfusion
Central venous catheter and arterial catheter may be
necessary
High risk for uterine atony and coagulopathy
Oxytocin 20U/L infused immediately after the
delivery
Coagulation abnormalities may require FFP
Recover quickly and completely after delivery
prolonged hypotension, coagulopathy, and massive
blood volume/product replacement, are best
monitored in a multidisciplinary intensive care unit.
24. UTERINE RUPTURE
Rupture of the gravid uterus can be disastrous to
both the mother and foetus
It may be of two types
uterine scar dehiscence
complete uterine rupture
Scar dehiscence
foetal distress less common
no excessive haemorrhage
rarely requires emergency section
Uterine rupture
foetal distress
massive haemorrhage
requires emergency caesarean section
27. ANAESTHETIC MANAGEMENT
Preoperative evaluation , resuscitation and
preparation of OT simultaneously
GA is often required
RA can be given in haemodynamically stable
patients , who already have a epidural catheter
,absence of foetal distress
Aggressive volume replacement
maintenance of urine output
Invasive hemodynamic monitoring
28. VASAPREVIA
Occurs rarely 1 in 2000 to 3000 deliveries.
Vasa previa is associated with a velamentous insertion of the
cord where foetal vessels traverse the foetal membranes ahead
of the foetal presenting part.
Highest foetal mortality rates 50% to 75%
No threat to the mother
Early diagnosis and treatment are essential to reduce the
chance of foetal death
Requires immediate delivery by caesarean section
Neonatal resuscitation, neonatal volume replacement
Choice of anaesthetic technique depends on the urgency of
caesarean section
29. POST
PARTUM HAEMORRHAGE
Major cause of maternal morbidity and mortality
Types
Primary postpartum haemorrhage occurs
during the first 24 hours after delivery
secondary postpartum haemorrhage occurs
between 24 hours and 6 weeks postpartum
Causes
Uterine atony
Genital trauma
Coagulopathy
Placental abnormalities
30.
31. UTERINE ATONY
Risk factors
Multiple gestation
Macrosomia
Polyhydramnios
High parity
Chorioamnionitis
Precipitous labor
Augmented labor
Tocolytic agents
High concentration of a volatile agents
Prolonged labor
32. OXYTOCIN
first-line drug for the prophylaxis or treatment of uterine atony
Endogenous oxytocin is a 9-amino acid polypeptide produced
in the posterior pituitary
exogenous form is a synthetic preparation
20 U of oxytocin to a litre of NS or RL started as infusion
Bolus administration of oxytocin causes peripheral
vasodilation, hypotension
Weis et al.[53] administered oxytocin 0.1 U/kg intravenously to
pregnant women in the first trimester. They noted that heart rate
increased, MAP decreased by 30%, and total peripheral
resistance decreased by 50%
Secher et al.[54] noted that bolus intravenous administration of 5
or 10 U of oxytocin increased pulmonary artery pressures in
pregnant women
cardiovascular changes are short lived (less than 10 minutes).
33. prostaglandin E2
vaginal or rectal suppository 20mg every 2hrly
causes bronchodilation
decreased SVR and blood pressure
increased heart rate , cardiac output
prostaglandin F2-alpha
increases cardiac output
increases systemic and pulmonary artery pressures
Increased PaCO2 and decreased PaO2
alterations of ventilation/perfusion ratios
bronchospasm
15-Methyl prostaglandin F2-alpha (carboprost)
preferred for the treatment of refractory uterine atony
250 μg administered intramuscularly or intramyometrially
Bronchospasm
disturbed ventilation/perfusion ratios
increased intrapulmonary shunt fraction
hypoxemia.
34. Misoprostol
800 -1000 mcg rectally
prostaglandin E1 analogue
effective treatment for postpartum haemorrhage
unresponsive to oxytocin and ergometrine
Ergot alkaloids
0.2mg iv every 2-4 hrs
Ergonovine and methylergonovine
restricted to postpartum use
rapidly produce tetanic uterine contraction
act on alpha-adrenergic receptors
Cause vasoconstriction, hypertension, Pulmonary
artery pressure , Pulmonary oedema
35. GENITAL TRAUMA
Most common injuries at childbirth are lacerations and
hematomas of the perineum, vagina, and cervix
Pelvic hematomas are three types:
vaginal, vulvar, and retroperitoneal
signs and symptoms
restlessness,
lower abdominal pain,
a tender mass above the inguinal ligament
vaginal bleeding
abrupt hypotension
Ileus
unilateral leg oedema
urinary retention
haematuria
36. ANAESTHETIC MANAGEMENT OF GENITAL
TRAUMA
For vulval haematomas and small lacerations
Local infiltration and a small dose of intravenous opioid
For extensive lacerations and vaginal haematomas
pudendal nerve block – technically may not be feasible
neuraxial blockade – may cause hypotension
MAC – most preferred
N2O ,O2 with inhalational agents
low dose ketamine
For retroperitoneal haematoma
laparotomy with general anaesthesia
rapid sequence induction
difficult intubation to be anticipated
37. RETAINED PLACENTAL PRODUCTS
Retained placental fragments are a leading cause of both early
and delayed postpartum hemorrhage
OBSTETRIC MANAGEMENT
manual removal and inspection of the placenta
After removal of the placenta, uterine tone should be
enhanced with oxytocin
38. ANAESTHETIC MANAGEMENT OF RETAINED
PLACENTAL PRODUCTS
If epidural catheter is in situ additional local
anaesthetic drug can be given
Subarachnoid block can be given if patient is
haemodynamically stable
Nitrous oxide analgesia
Low dose ketamine
GA can be given with rapid sequence induction
Methods to facilitate uterine relaxation
halogenated inhalational agents
nitroglycerine
40. Placenta accreta vera is defined as adherence to the
myometrium without invasion of or passage through
uterine muscle
Placenta increta represents invasion of the myometrium
Placenta percreta includes invasion of the uterine serosa
or other pelvic structures
Risk factors
previous uterine trauma
previous caesarean section
low lying placenta
Diagnosis
antepartum diagnosis is rare
difficulty in removal placenta
ultrasonography
MRI
transvaginal colour dopler
41.
Obstetric management
uterine curettage, followed by over-sewing of the bleeding
placental bed.
Balloon occlusion
embolization techniques
postpartum hysterectomy – definitive
Anaesthetic management
preoperative diagnosis of placental abnormalities
identifying patients with high risk for placenta accreta
preparation for hysterectomy
availability of blood products
42. UTERINE INVERSION
Turning inside out of all or part of the uterus
Occur in 1 In 5000 to 1 in 10,000 pregnancies
Risk factors
uterine atony
inappropriate fundal pressure
umbilical cord traction
uterine anomalies.
An abnormally implanted placenta
(i.e., placenta accreta)
Obstetric management
Early replacement of the uterus is the best treatment
Once the uterus has been replaced.
Oxytocin (20 U/L) should be infused initially,
additional drugs (15-methyl prostaglandin F2-alpha)
may be needed
43. ANAESTHETIC MANAGEMENT OF UTERINE
INVERSION
uterine tone precludes immediate replacement,
uterine relaxation is needed before successful replacement can be
performed
Ideal technique should have
rapid uterine relaxation
no side effects
short duration
restoration of uterine tone after replacement of the uterus
GA with inhalational agents most preferred
Equipotent doses of all volatile halogenated agents produce a
similar degree of uterine relaxation
Endotracheal intubation is mandatory
Other modes
terbutaline, magnesium sulfate, organic nitrates
44. INVASIVE TREATMENT FOR OBSTETRIC
HAEMORRHAGE
Includes
angiographic arterial embolization
balloon occlusion
surgical arterial ligation
hysterectomy
Embolization
local anaesthesia
complications are few
preservation of fertility is likely
Can be done in presence of a coagulopathy
Requires rapid access to angiographic facility
Requires skilled radiologist
Logistic problems
45. Bilateral surgical ligation
uterine, ovarian, and internal iliac arteries
preservation of fertility
damage to other pelvic structures (ureter)
vascular anatomy is variable
lower extremity ischemia
postpartum hysterectomy
definitive treatment for postpartum haemorrhage
Tissues are oedematous and congested
Amount of blood loss is more
multicentre review showed that the average blood
loss for emergent cases was 2526 mL, with an
average transfusion requirement of 6.6 units of blood
46.
47. ANAESTHETIC MANAGEMENT
obstetrician requires good skeletal muscle relaxation and a quiet operative
field
Choice of technique
Regional anaesthesia
Risk of hypotension
The operative time for caesarean hysterectomy is more
patient may have fatigue and restlessness.
Intraperitoneal manipulation, dissection, and traction result in pain,
nausea, and vomiting.
hyperemic pelvic viscera with engorged, edematous vasculature
require careful dissection facilitated by a quiet operative field
If RA is given then
Maintenance of a T-4 sensory level
prophylaxis against nausea and vomiting
judicious sedation
Most of the cases require GA for emergency obstetric hysterectomy
48. Regardless of the anaesthetic technique used
two large-gauge intravenous catheters
at least two units of packed PRBCs should be
immediately available.
Additional units should be available without
delay.
Vasoactive drugs (e.g., phenylephrine,
dopamine, epinephrine).
establish invasive monitoring.
A fluid warmer
equipment for rapid infusion of fluids
49. RECENT ADVANCES
Intra operative cell salvage
Chance of amniotic fluid embolism
Haemolytic disease in future pregnancies
Leukocyte depletion filter is useful
Separate suction for amniotic fluid advised
Thromboelastography
Useful guide in massive haemorrhage
Provides information regarding coagulation factors , platelet
function, fibrinogen levels , fibrinolysis
Rapid results
Can be done near the patient
50.
Role of tranexaemic acid
Antifibrinolytic
1gm IV stat dose
Followed by a second dose after 30 min if bleeding doesn’t stop
World maternal antifibrinolytic trail
Recombinant factor VIIa
useful in unresponsive massive haemorrhage
Coagulopathy has to be corrected prior
Prerequisites
platelet count >50,000
fibrinogen > 0.5gms /L
ph. >7.2
Dose – 90 mcgs/kg stat dose
followed by 120 mcg/kg if bleeding persists
Thromboembolic events can occur
High cost , lack of availability