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
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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