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

Current Deck: ACG Part 2::Obstetrics

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SS_OB 1.34 Discuss the anaesthetic management of problems that may arise with labour and delivery, including the following situations:
- PPH 

Definitions:
PPH as per ACOG = PPH as being 1000 ml within 24 h, with or without associated clinical signs of hypovolaemia
WHO defines PPH as 500 ml blood loss
  • Primary PPH within 24hrs of delivery
  • Secondary PPH between 24hrs and 12 weeks post delivery
Causes:
  • Common:
    • Tone (80%) 
    • Trauma and injury to the genital tract
    • Tissue: retained invasive placenta
    • Thrombin and coagulopathy
  • Uncommon:
    • uterine inversion
    • extragenital bleeding
  • Endometritis or retained products of conception are the most common causes of secondary PPH
Assessing blood loss:
  • Early recognition and prompt intervention avoids haemorrhagic shock, DIC and death
  • Visual estimation often inaccurate and underestimates loss
  • Quantitative blood loss measurement best if available (gravimetric or photometric)
Preparation:
  • Identify those at high risk during antenatal period
  • Match patient to unit capable of meeting clinical needs
  • Rapid transfer of a patient to a consultant-led unit in case of haemorrhage in the community or birthing centres
  • If abnormal placentation - structured MDT planning for delivery (reduces blood loss, rate of emLSCS, use of blood products)
  • Identify those who may refuse blood products early and given counselling
  • Optimise anaemia
  • Maternity units should have massive haemorrhage algorithms, crisis organisation and resource allocation focussing on the SMI themes of readiness, recognition, response and reporting
Clinical management:


Other: Coags - POC testing TEG/ROTEM, activate MHP, IX and treat, Temperature warming and monitoring, Extracorporeal membrane oxygenation (ECMO) may offer life-saving support for patients who fail to recover from reversible cardiocirculatory failure

Tone (80% of primary PPH’s):
  • Usually active management of the third stage of labour (AMTSL) is a process in which expulsion of the placenta and membranes is achieved proactively with early cord clamping, controlled cord traction (CCT) and the use of uterotonic drugs
    • Reduces incidence of PPH by 70% compared to expectant management (spontaneous delivery of placenta)
    • Delayed cord clamping has significant benefits for the neonate (so may not be used)

Blood transfusion:
  • Should be protocolised at each obstetric unit
  • Fixed transfusion strategies with a high ratio of platelets and fresh frozen plasma (FFP) clotting products to packed red blood cells (e.g. 1:1:1) are often used in massive transfusion protocols. Dilution of fibrinogen is a concern if large volumes of products with a low concentration of fibrinogen are used such as FFP.
  • Red cells
    • Should eb clinical decision, no reliable lab tests
    • The use of cell salvage may also be prudent in some cases at risk of major haemorrhage, but no benefit has been demonstrated from its routine use and it may increase the risk of maternal alloimmunisation
  • Plasma and fibrinogen
    • Inadequate provision of coagulation products, particularly fibrinogen was highlighted as a concern in recent MBRRACE
    • The risk of coagulopathy increases with bleeding >2000 ml. 
    • Coagulopathy varies depending on the aetiology of haemorrhage and may be dilutional, consumptive or attributable to DIC
    • Haemorrhage causes by amniotic fluid embolism, uterine rupture or placental abruption may be associated with early onset DIC
    • FFP should be considered early for conditions with a suspected coagulopathy, such as placental abruption or amniotic fluid embolism, or where treatment has been delayed. The coagulation target should be to maintain PT and APTT at less than 1.5 normal.
    • A target of at least 2 g L-1 fibrinogen is required to maintain haemostasis during haemorrhage. Human fibrinogen concentrate or cryoprecipitate may be used as a fibrinogen source
    • Fibrinogen concentrations decrease more rapidly than other coagulation factors, and this is often a predictor of progression to severe PPH
  • Platelets:
    • If low may indicate a consumptive process and be associated with a coagulopathy. A platelet transfusion trigger of 75 x 10^9 is recommended as a transfusion trigger during haemorrhage
  • TXA
    • The World Maternal Antifibrinolytic Trial (WOMAN) showed that by giving TXA, deaths from bleeding were reduced by 20% and the greatest benefit was seen when TXA was given within 3 h of childbirth
    • The dose of TXA recommended by the WHO is a 1 g fixed dose given over 10 min with a second dose if bleeding continues after 30 min
Surgical interventions:
  • Bimanual compression as temporising measure
  • Intrauterine balloon catheters such as the Bakri, Rusch and Foley catheters may be used to achieve uterine tamponade, and is effective in 97% of cases of PPH in resource poor settings
  • Haemostatic compression sutures are most commonly used at Caesarean delivery to arrest haemorrhage, particularly in the setting of refractory uterine atony
  • Ligation of the uterine and utero-ovarian arteries can reduce uterine bleeding by obtunding myometrial blood flow. 
  • Cross-clamping of the aorta may be used as a temporising measure to control bleeding in the setting of massive haemorrhage.
  • Peripartum hysterectomy is the definitive last resort to control obstetric haemorrhage and is associated with significant morbidity. The recent MBRRACE report acknowledges that hysterectomy should be resorted to sooner rather than later, especially in cases of accreta or uterine rupture
Interventional radiology:
  • Selective arterial occlusion using balloons may be used to stem blood flow to the common internal iliac artery or the aorta to either prevent or treat PPH
  • The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) has resulted in better outcomes than standard therapy without REBOA, but has also been associated with serious complications including ischaemia
  • Selective radiological embolisation of the uterine artery may be used to treat haemorrhage. 
  • Complications including ischaemia, thrombosis and arterial rupture have also been reported.
Major obstetric haemorrhage BJA 2022 

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