Sign in

Review Note

Last Update: 03/27/2025 09:39 PM

Current Deck: ACG Part 2::Obstetrics

New Card (Unpublished)

Currently Published Content

Front
Back

No published tags.

Pending Suggestions

Field Change Suggestions:
SS_OB 1.34 Discuss the anaesthetic management of problems that may arise with labour and delivery, including the following situations:
- Antepartum haemorhage / PPH 
Definition: Royal College of Obstetricians and Gynaecologists (RCOG) has defined major APH as bleeding of 50-1000mL with no signs of shock, and massive APH as bleeding 1000 mL and/or bleeding of any volume with clinical signs of shock
Causes: placenta praevia, placental abruption, uterine rupture and bleeding from the vulva, vagina or cervix, although a cause is often not found

Antepartum Haemorrhage / Postpartum Haemorrhage
  • Gravid uterus receives 12% of CO, and when haemorrhage occurs, it can be extremely rapid.
  • Fetus is at greater risk from maternal hemorrhage than the mother.
  • Hypotension reduces uteroplacental blood flow, and severe anaemia will further reduce oxygen delivery.
  • Fetal mortality may be as high as 35%.
Causes of antepartum haemorrhage
  • Placental abruption – usually associated with pain; small bleeds may be treated conservatively.
  • Placenta praevia/accreta – usually small painless bleed, may be catastrophic.
  • Uterine rupture – fetal distress is almost universal; normally painful.
Causes of postpartum haemorrhage (PPH)
  • Tone (90%) – uterine atony/inversion.
  • Trauma (20%) – perineum/vaginal wall/cervix/uterus.
  • Tissue (10%) – retained placenta/products of conception.
  • Thrombin (<1%) – coagulation abnormalities.
PPH
  • >500ml blood loss during puerperium.
  • Severe PPH is >1000ml blood loss.
Risk factors for PPH
  • Tone – prolonged labour, precipitate labour, dysfunctional labour, grand multiparity, multiple pregnancy, polyhydramnios, macrosomia, fibroids, intrauterine infection, uterine relaxing agents (e.g., magnesium, tocolytics, GA).
  • Trauma – operative delivery, assisted delivery, cervical/vaginal lacerations.
  • Tissue – retained placental tissue, abnormal placentation.
  • Coagulopathy – pre-eclampsia, HELLP syndrome, placental abruption, FDIU (>4 weeks), amniotic fluid embolism, sepsis, drugs (aspirin/heparin), bleeding disorders (von Willebrand disease, ITP, thrombocytopaenia, DIC).
Clinical features
  • CVS – tachycardia, hypotension, cold peripheries, pallor, sweating.
  • CNS – reduced LOC, dizziness, weakness, restlessness.
  • Resp – reduced SpO2, SOB, dyspnoea.
  • UO – reduced.
Investigations
  • Visual estimation of blood loss – often unreliable and usually underestimates loss.
  • ECG – sinus tachycardia.
  • FBE – low Hb, high Hct, low platelets.
  • Coags – coagulopathy, low fibrinogen, high PT/APTT/INR.
  • ABG – acidosis, high lactate, reduced calcium.
Management
  • Call for help.
  • Airway:
    • Intubate and ventilate if for GA.
    • Do not perform regional technique if patient is hypovolaemic.
  • Breathing:
    • Give supplemental oxygen.
  • Circulation:
    • Left lateral if antenatal.
    • 2 large bore IV access.
    • Bloods – crossmatch blood, FBE, coags, POC viscoelastic tests.
    • Warm all resuscitation fluids.
    • Use group-specific or O negative blood while waiting.
    • Level 1 warmer and rapid infusion device.
    • Monitor Hct and Hb.
    • Restore normovolaemia.
    • Monitoring of mother and fetus; consider invasive monitoring.
    • Correct coagulopathy in association with TEG/ROTEM.
  • Communication is vital:
    • Mobilise porters.
    • Notify theatre staff.
    • Request cell saver with separate suction for amniotic fluid.
    • Alert blood bank, haematologist, and neonatologist.
  • Other:
    • Uterotonics.
    • Continue care in HDU/ICU.
References
GC notes

Terms of Service | Privacy Policy | Imprint (German)

Copyright © AnkiCollab. Website Template Designed & Developed by Quixlab 2018