Haemorrhage and Pregnancy

OVERVIEW

• gravid uterus receives 15% of Q -> bleeding can be rapid!
• principle causes; abruption, placenta praevia, PPH
• baby more at risk than mum

Antenatal

• ABRUPTION – bleeding with pain
• PRAEVIA – small bleeds and painless
• UTERINE RUPTURE – painful or painless, fetal distress, no urine output

Postnatal

– >500mL significant

• UTERINE ATONY – associated with chorioamnionitis, prolonged labour, polyhydraminios, macrosomia, multiple gestations
• RETAINED PLACENTA or PRODUCTS
• GENITAL TRACT TRAUMA – vaginal/vault haematoma, retroperitoneal bleeding
• UTERINE INVERSION –
• ACCRETA – invasion into first 1/3 of myometrium
• INCRETA – invasion further into myometrium
• PERCRETA – invasion through myometrium into surrounding structures (bladder and bowel)

SUMMARY OF CAUSES

• TONE – rub down
• TRAUMA – uterus, vaginal or cervical laceration
• TISSUE – retained placenta, accreta
• THROMBIN – coagulopathy from multiple causes (AFE, retained products, intrauterine death, sepsis, PET, abruption)

CLINICAL FEATURES

History

• pain
• bleeding
• labour
• delivery; instrumental or not, explosive

Examination

• haemodynamics
• perfusion (be aware of the women with cold peripheries)
• abdominal examination

INVESTIGATIONS

• U/S
• Hb
• cross-match

MANAGEMENT

• MDT management (important issues = massive blood loss management, surgical technique, possible remote anaesthesia – radiology, anaesthetic technique)
• call for help
• O2
• left lateral tilt
• large bore IV access x 2
• fluids -> O negative if required
• invasive monitoring
• urinary catheter
• induce: etomidate 0.3mg/kg, ketamine 2mg/kg, thiopentone 4mg/kg
• paralysis: suxamethonium 2mg/kg
• CTG
• GA
• warm (patient and fluids)
• level one rapid infuser
• cell salvage an option
• correct coagulopathy with products/drugs (tranexamic acid, RBC’s, FFP, Cryo, Platelets, rFVIIa 100U/kg 20 min apart)
• 6U of blood (on floor)
• FBC + Coag’s
• uterotonics

-> rub down or bimanual compression
-> bimanual pressure
-> synto bolus -> infusion
-> ergometrine 0.5mg IM
-> carboprost (prostaglandin F2 alpha) 0.25mg intra-myometrially to maximum of 2mg

• embolisation
• preoperative internal iliac balloons
• clamping of iliacs
• Caesarian Hysterectomy (may want to leave placenta and use methotrexate -> if so no syntocinon!) -> consider with loss of 5 L of blood
• HDU or ICU
• notify:

1. Obstetrics
2. Haematologists
3. Radiologists
4. General and Urological surgeons
5. Blood bank
6. Neonatologists
7. Orderlies