Massive Obstetric Hemorrhage - Health Research at Fernandez ...
Massive Obstetric Hemorrhage - Health Research at Fernandez ...
Massive Obstetric Hemorrhage - Health Research at Fernandez ...
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<strong>Massive</strong><br />
<strong>Obstetric</strong><br />
<strong>Hemorrhage</strong><br />
Management Options<br />
Sunil T. Pandya<br />
PRERNA ANAESTHESIA<br />
& CRITICAL CARE SERVICES<br />
HYDERABAD
Greetings from<br />
HOSPITAL<br />
Hyderabad, India<br />
<strong>Health</strong> Care for Women & the Newborn<br />
Website : www.fernandezhospital.com
HOSPITAL<br />
Dedic<strong>at</strong>ed wholly to Women<br />
and the Newborn
5000<br />
4000<br />
3000<br />
2000<br />
1000<br />
0<br />
2830<br />
Deliveries<br />
<strong>Fernandez</strong> Hospital<br />
3080<br />
3342<br />
3874<br />
4408<br />
4715<br />
2003 2004 2005 2006 2007 2008<br />
Deliveries
Labour Epidural Analgesia<br />
Dedic<strong>at</strong>ed OCCU<br />
Dedic<strong>at</strong>ed acute Pain service<br />
PAC Clinic<br />
Anaesthesia Services<br />
Fellowship and post doctoral training courses
P<strong>at</strong>hology Lab<br />
Microbiology, Biochemical<br />
Hem<strong>at</strong>ology<br />
Supportive Departments<br />
<strong>Obstetric</strong> Medicine, Fetal Medicine<br />
Level III NICU, Labourist concept
<strong>Massive</strong><br />
<strong>Obstetric</strong><br />
<strong>Hemorrhage</strong><br />
“<strong>Obstetric</strong>s is Bloody Business”<br />
Cunningham, et. al: Williams <strong>Obstetric</strong>s, 21 st ed., 2001
No mother should die<br />
due to pregnancy or childbirth
M<strong>at</strong>ernal mortality in<br />
India: WHO st<strong>at</strong>isitcs-<br />
2005
MMR<br />
No of<br />
de<strong>at</strong>hs<br />
Life time<br />
risk<br />
World 400 536,000 1 in 92<br />
Developed 9 960 1 in 7300<br />
Developing 450 533,000 1 in 75
• 585000 m<strong>at</strong>ernal de<strong>at</strong>hs per year<br />
• 25% secondary to hemorrhage<br />
• 20 million morbidities per year
Saving<br />
Mothers’<br />
Lives<br />
CEMACH<br />
• De<strong>at</strong>hs from hemorrhage<br />
• Declined from 5.3 to 3.3 / million<br />
• Care was substandard in 11 / 14
<strong>Obstetric</strong>al <strong>Hemorrhage</strong><br />
Blood loss associ<strong>at</strong>ed with pregnancy<br />
th<strong>at</strong> meets one or more of<br />
the following criteria<br />
• Causes m<strong>at</strong>ernal or perin<strong>at</strong>al de<strong>at</strong>h<br />
• Requires blood transfusion<br />
• Decreases Hct by 10 points<br />
• Triggers therapeutic response
Why are we Bothered ?<br />
Hypovolumic Shock<br />
Coagulop<strong>at</strong>hy<br />
Anemia<br />
Blood transfusion<br />
Hysterectomy<br />
Lact<strong>at</strong>ion difficulties<br />
MODS, De<strong>at</strong>h
The position of a woman in any civiliz<strong>at</strong>ion<br />
is an index of the advancement of th<strong>at</strong><br />
civiliz<strong>at</strong>ion; is gauged best by the care given<br />
to her <strong>at</strong> the birth of her child.<br />
Haggard, 1929
Major <strong>Obstetric</strong> Haemorrhage<br />
Is it a nightmare only for<br />
the <strong>Obstetric</strong>ian?
Major <strong>Obstetric</strong> Haemorrhage<br />
As an Anaesthesiologist,<br />
wh<strong>at</strong> is our role?
29 year, P 2L 2<br />
• Weight 60 kg<br />
• Spontaneous vaginal delivery<br />
• Severe <strong>at</strong>onic PPH<br />
• Estim<strong>at</strong>ed blood loss : 3 litres<br />
Tre<strong>at</strong>ment given by the primary<br />
physician<br />
IM Carboprost Tromethamine<br />
250 mcg<br />
IM Methy Ergometrine<br />
0.2 mg<br />
PGE1, 400 mg per rectum<br />
IV Syntocinon<br />
40 units infusion<br />
2L of RL, I L of Haemaccel<br />
4 ‘U’ of FFP, 1 ‘U’ of blood
Admission<br />
Conscious, incoherent<br />
De<strong>at</strong>hly pale, feeble peripheral pulses<br />
HR : 136 bpm<br />
BP : 80 / 40 mm of Hg
Admission<br />
H / L : NAD<br />
Abdomen: relaxed uterus<br />
PV : bleeding ++<br />
UO: minimal, blood stained
Simultaneous Team Work<br />
History Taking<br />
Examin<strong>at</strong>ion<br />
Hemodynamic<br />
Assessment<br />
Non invasive<br />
monitoring<br />
Invasive<br />
monitoring<br />
Investig<strong>at</strong>ions<br />
CBC<br />
Coagul<strong>at</strong>ion<br />
profile<br />
Renal Hep<strong>at</strong>ic<br />
function<br />
Lact<strong>at</strong>e/<br />
electrolytes / ABG<br />
Blood products<br />
Ordering<br />
Procure<br />
Resuscit<strong>at</strong>e<br />
PREVENT<br />
C<strong>at</strong>astrophic<br />
exsanguin<strong>at</strong>ion
Estim<strong>at</strong>ion of Blood Loss<br />
• Always, always underestim<strong>at</strong>ed<br />
Alter<strong>at</strong>ions in<br />
BP / PR<br />
only after large<br />
volumes of blood<br />
loss
Emergency Tre<strong>at</strong>ment<br />
IM Carboprost Tromethamine 250mcg<br />
IV Methergin 0.2mg<br />
PGE 1 600 mg/per rectally<br />
IV Syntocinon 40 ‘U’ as infusion<br />
Crystalloids Anesthetist<br />
Called
Ultrasound Done<br />
• No RPOC<br />
• Free fluid ++<br />
ABG<br />
Severe<br />
Metabolic Acidosis pH: 7.1
Lab Results<br />
Haemoglobin Undetectable<br />
Pl<strong>at</strong>elets 65,000 / cumm<br />
PT 14 / 156<br />
aPTT 39 / 805<br />
INR >11.2<br />
Fibrinogen 88 mg / dl<br />
FDP + ve<br />
D dimer + ve
CRISIS<br />
MANAGEMENT!
SURVIVING<br />
BLOOD LOSS
Resuscit<strong>at</strong>ion<br />
Maintain circul<strong>at</strong>ion<br />
Stop hemorrhage
C<strong>at</strong>egoriz<strong>at</strong>ion<br />
of Acute <strong>Hemorrhage</strong><br />
Class 1 Class 2 Class 3 Class 4<br />
Blood loss % 15% 15%-30% 30%-40% >40%<br />
Pulse r<strong>at</strong>e 100 >120 >140<br />
Pulse pressure Normal Decreased Decreased Decreased<br />
Blood pressure Normal /<br />
increased<br />
Decreased Decreased Decreased
C<strong>at</strong>egoriz<strong>at</strong>ion<br />
of Acute <strong>Hemorrhage</strong><br />
Class 1 Class 2 Class 3 Class 4<br />
Resp. r<strong>at</strong>e 15 - 20 20 - 30 30 - 35 > 35<br />
Urine output > 30 ml 20 - 30 5 – 15 ml negligible<br />
Mental st<strong>at</strong>us Slightly<br />
anxious<br />
Mildly<br />
anxious<br />
Anxious /<br />
confused<br />
Confused /<br />
lethargic
Remember…<br />
Blood Loss % Loss Response<br />
< 1000ml 15% Asymptom<strong>at</strong>ic<br />
1000 - 1800 20-25%<br />
1800 - 2200 30-35%<br />
Tachycardia orthost<strong>at</strong>ic<br />
Hypotension<br />
Worsening tachycardia<br />
Tachypnoea, Hypotension<br />
> 2200 40% Shock / Oliguria
Points to Emphasize<br />
Prompt Initi<strong>at</strong>ion<br />
of Resuscit<strong>at</strong>ive Measures<br />
Aggressive Replacement<br />
of Intravenous Volume<br />
RBC Replacement<br />
Not a Top Priority
Resuscit<strong>at</strong>ion<br />
• 2 large bore IV cannulae<br />
• Crystalloids<br />
• Summon extra staff<br />
• Alert Haem<strong>at</strong>ologist / Blood Bank<br />
• Minimum of 6 -8 „U‟ of pckd cells<br />
• Restore normovolemia
Crystalloids<br />
Colloids<br />
Blood Products
Targets of Resuscit<strong>at</strong>ion<br />
Mental st<strong>at</strong>us Responsive to commands<br />
Systolic BP 80 – 90 mm Hg<br />
Heart r<strong>at</strong>e < 120 per min<br />
Pulse oximeter S<strong>at</strong>ur<strong>at</strong>ion > 95%<br />
Urine output Present
Targets of Resuscit<strong>at</strong>ion<br />
Hemoglobin 8 gm / dl<br />
Hem<strong>at</strong>ocrit > 25 %<br />
Prothromin time Test < 6 sec of C<br />
Pl<strong>at</strong>elet count > 50,000 / cc<br />
Fibrinogen > 100 mg / dl<br />
pH > 7.3 / SBE < -5<br />
S Lact<strong>at</strong>e Improving
Pl<strong>at</strong>elet depletion<br />
Factor depletion<br />
Fibrinolytic system<br />
Haemorrhage<br />
Hypotension<br />
Hypoxia<br />
Tissue Damage<br />
DIC<br />
SHOCK<br />
Micro vascular obstruction<br />
Hypoxic organ damage<br />
MODS
Bleeding<br />
Ut.<br />
Blood<br />
flow <strong>at</strong><br />
Term:<br />
@<br />
800ml<br />
/min
<strong>Obstetric</strong> <strong>Hemorrhage</strong><br />
P<strong>at</strong>hophysiology
Fluid Replacement<br />
Volume ( 3:1)<br />
Class I Crystalloids<br />
Class II<br />
Crystalloids + Plasma Volume<br />
Expander<br />
Class III Plasma Volume Expander + PRBC<br />
Class IV Plasma Volume Expander + PRBC
Fluid Choices<br />
Fluid Type Comments<br />
Normal saline Crystalloid<br />
Lact<strong>at</strong>ed Ringer Crystalloid<br />
Inexpensive,<br />
Readily available<br />
Inexpensive,<br />
Readily available<br />
AVOID DEXTROSE CONTAINING FLUIDS
Fluid Choices<br />
Fluid Type Comments<br />
? Albumin Colloid More expensive<br />
Hydroxy-ethyl<br />
starch<br />
Hypertonic saline<br />
with dextran<br />
Colloid More expensive<br />
Colloid<br />
Red blood cells Blood<br />
Expensive,<br />
not licensed in US<br />
Expensive,<br />
limited supply
Very important to maintain<br />
adequ<strong>at</strong>e pressure on<br />
glomerular head<br />
Urine output
Very important to maintain<br />
adequ<strong>at</strong>e pressure on<br />
glomerular head<br />
Urine output<br />
There is no role of inotropes in<br />
Haemorrhagic shock!
Severe Ongoing<br />
<strong>Hemorrhage</strong><br />
Worsening clinical st<strong>at</strong>us - Shifted to ICU<br />
Volume resuscit<strong>at</strong>ion<br />
Inotropic / Vasopressor supports<br />
Em. Intub<strong>at</strong>ion / controlled ventil<strong>at</strong>ion<br />
8 „U‟ Pkd cells, 12 „U” of FFP<br />
20 „U‟ of cryo ppt arranged<br />
Total Abdominal Hysterectomy
Intra – Op Period<br />
Continued Hypotension<br />
Rapid infusion of crystalloids/ colloids<br />
Adrenaline / Ephedrine / Dobutamine<br />
8 „U‟ of Pckd cells<br />
12 „U‟ of FFP<br />
20 „U‟ of cryo ppt<br />
Persisting anuria / oliguria<br />
120 mg Furosemide
Aim to Maintain<br />
• Adequ<strong>at</strong>e intravascular volume<br />
• Oxygen carrying capacity<br />
• Clotting function<br />
• Electrolyte balance<br />
• Prevention of Hypocalcemia<br />
• Normothermia
• GETA – FiO 2: 1<br />
Anaesthetic Goals<br />
• If started under CNB – Rapid sequence GETA<br />
• Wide bore Venous Access: 14g x 2, ABP, CVP<br />
• Avoid Vol<strong>at</strong>ile Inhal<strong>at</strong>ional agents / N 2O<br />
• Low dose ketamine / Fentanyl / Midazolam for<br />
knocking down awareness<br />
• Active warming devices – V. Imp<br />
• ABG, K + , Ca ++ , Coag. Profile – Serially<br />
• Rapid Infusion Devices
The Trigger…<br />
Blood & Blood Components<br />
• Hb < 6 gms / dl<br />
• Hct < 16-18%<br />
• PT / aPTT >1.5 times<br />
• Pl<strong>at</strong>elets < 50000 / cc<br />
• Fibrinogen < 100 mgs/dl<br />
Vitals, Ongoing blood loss, Co-morbid conditions, Coag. St<strong>at</strong>us,<br />
EBL
Dissemin<strong>at</strong>ed Coagulop<strong>at</strong>hy<br />
<strong>Obstetric</strong> <strong>Hemorrhage</strong><br />
• Develops rapidly<br />
• Frequent coagul<strong>at</strong>ion screens<br />
Labor<strong>at</strong>ory and Blood Bank Support
Diagnosis of Coagulop<strong>at</strong>hy<br />
Activ<strong>at</strong>ion of<br />
Coagul<strong>at</strong>ion system<br />
Consumption of procoagulants<br />
Pl<strong>at</strong>elets, Fibrinogen<br />
Clinical scenario<br />
Supportive lab parameters<br />
Activ<strong>at</strong>ion<br />
of fibrinolytic system<br />
Deranged PT / aPTT<br />
D-dimer, FDP +ve
Whole blood (500ml)<br />
Packed cells (250 ml)<br />
Pl<strong>at</strong>elet rich plasma (PRP – 250ml)<br />
Pl<strong>at</strong>elet poor plasma (200ml)<br />
Fresh frozen plasma (200ml)<br />
Cryoprecipit<strong>at</strong>e<br />
Blood<br />
Products
Packed Cell Transfusion<br />
• PRB‟c vs Whole blood<br />
• Class III / IV Haemorrhage<br />
• Target Hb / Hct: 8g / 24-26%<br />
• Gr & Type specific<br />
• O –ve: Emergent situ<strong>at</strong>ions<br />
Karp<strong>at</strong>i PCJ et al. High Incidence of Myocardial Inchaemia during<br />
PPH. Anaesthesiology 2004; 100 (1):30-6
Blood Components<br />
• FFP‟s – ABO comp<strong>at</strong>ible<br />
• Pl<strong>at</strong>elets<br />
– PRP – Gr and type sp.<br />
– RDP – Pooled pl<strong>at</strong>elets<br />
– Apheresis plt. Concentr<strong>at</strong>e – Gr & Type sp.<br />
• Cryoprecipit<strong>at</strong>e – No ABO comp<strong>at</strong>ibility
Intra – Op Findings<br />
• Uterus enlarged, pale & relaxed<br />
• Abdominal Hysterectomy done<br />
• Surgical Haemostasis obtained<br />
• Bleeding from raw surfaces improved<br />
• Abd closed with 2 drains in-situ
Bleeding still uncontrolled…
Post Oper<strong>at</strong>ive – Findings<br />
• Oozing from the incision<br />
• Drains continuous filling<br />
• Haem<strong>at</strong>ologist called in<br />
• Option of r Factor VIIa
Recombinant Factor VII a<br />
• Counseling<br />
• 4.8 mg IV given - 80mcg /Kg<br />
• Drain output reduced<br />
• Haemodynamic stability regained
Post Op Period - Stormy<br />
Prevent<br />
MODS<br />
Multi-organ<br />
supportive /<br />
protective<br />
therapy and<br />
str<strong>at</strong>egies….<br />
V.imp
Weaning from Mechanical<br />
Ventil<strong>at</strong>ion<br />
Early M<strong>at</strong>ernal Bonding<br />
vs<br />
No M<strong>at</strong>ernal Bonding<br />
Observ<strong>at</strong>ional Study: Prerna – <strong>Fernandez</strong> Hospital, 2003
Post Op Period<br />
Weaned off ventil<strong>at</strong>ory supports<br />
Shifted to ward on 8 th POD<br />
Drains removed on 10 th POD<br />
Discharged on 14 th Post Op Day
Total Blood Products - 113<br />
Packed Cells 25<br />
FFP 39<br />
Cryo Precipit<strong>at</strong>e 36<br />
Random Donor Pl<strong>at</strong>elets 12<br />
Apheresis 1
Incidence<br />
PPH : 4 – 6 % of deliveries<br />
Life thre<strong>at</strong>ening hemorrhage -<br />
1:1000 deliveries
Hospital Protocol<br />
Having systems in place<br />
• <strong>Obstetric</strong>ian + Anesthetist<br />
• Multidisciplinary<br />
• Blood products ordering form<br />
• Resuscit<strong>at</strong>ion form<br />
• Transfer Form<br />
• Interventional Radiology Form
Massage Uterus<br />
Protocol<br />
Soft Atonic Uterus<br />
Check Vitals, UO<br />
Bimanual compression of uterus<br />
? retained placental fragments<br />
Replace lost volume<br />
Oxytocics
Bimanual Compression
When Oxytocics Fail<br />
Medical management<br />
Surgical management
Surgical Management<br />
• Tamponade<br />
• Uterine packing / tourniquet<br />
• Compression Sutures<br />
• Uterine / Ovarian / Internal iliac A lig<strong>at</strong>ion<br />
• Arterial emboliz<strong>at</strong>ion<br />
• Hysterectomy
Choice of Procedure<br />
• Age & Parity<br />
• Gravity of the situ<strong>at</strong>ion<br />
• Underlying cause<br />
• Experience of surgeon<br />
• Degree of radiological support
The Best One is Probably the<br />
One th<strong>at</strong> is Most Familiar to the<br />
<strong>Obstetric</strong>ian or Surgeon<br />
in charge
Uterine Tamponade<br />
• Gauge packing<br />
• Condom<br />
• Sengstaken - Blakemore c<strong>at</strong>heter<br />
• Bakri Balloon
Uterine Tamponade
Sengstaken<br />
Tube<br />
Condom<br />
Tamponade
Compression Sutures<br />
B Lynch<br />
Hayman‟s<br />
Cho‟s
B Lynch<br />
2<br />
1
B- Lynch Suture
Hayman‟s Sutures
Cho‟s Sutures
De-vasculariz<strong>at</strong>ion<br />
Uterine<br />
Ovarian<br />
Internal Iliac
Step by Step De-vasculariz<strong>at</strong>ion
Uterine / Ovarian Lig<strong>at</strong>ion
Internal Iliac Artery Lig<strong>at</strong>ion
32 years, 2 nd Pregnancy<br />
• G 2 P 1 L 1<br />
• I pregnancy, 33 weeks CS<br />
• Referred <strong>at</strong> 15 weeks<br />
• USG : Previous CS scar area<br />
• Placenta up to serosal surface uterus
20 weeks<br />
Ultrasound in <strong>Fernandez</strong><br />
• Anterior placenta previa<br />
• Covering Os<br />
• Percreta<br />
• Bladder normal
24 weeks, 4 am<br />
• Pain abdomen + bleeding per vaginum<br />
• Hysterotomy, aimed conserv<strong>at</strong>ive Mx<br />
• Invasion into bladder, <strong>Massive</strong> bleed<br />
• 17 units crystalloids + Starch, 10 units of blood /<br />
FFP‟s<br />
• CARDIAC ARREST
Peripheral shut down!!
Blood loss ?
Resuscit<strong>at</strong>ed<br />
• Re-opened <strong>at</strong> 7 am, Oncosurgeon called<br />
• Resuscit<strong>at</strong>ion continuing<br />
• CARDIAC ARREST – 2 nd time<br />
• DC shock, adrenaline
Resuscit<strong>at</strong>ion Ongoing<br />
• Internal iliacs lig<strong>at</strong>ed, Hysterectomy<br />
Total blood products<br />
– 15 units packed cells<br />
– 14 FFP<br />
– 16 units cryo precipit<strong>at</strong>e<br />
• Crystalloids – 30, Starch – 4<br />
Options Now…
Abdominal / Vaginal Packing<br />
with Factor VIIa<br />
• Ventil<strong>at</strong>or<br />
• Inotrope support<br />
• Multiorgan failure<br />
• Hem<strong>at</strong>ologist consult<strong>at</strong>ion
II Post Op Day<br />
• Re-laparotomy ( 2 nd time)<br />
• Abdominal pack removed<br />
• Bowel decompressed<br />
• Day 4 : weaned off ventil<strong>at</strong>or
Discharged on 17 th POD<br />
• Packed cells : 27<br />
• FFPs : 36<br />
• Cryo : 15<br />
• Factor VIIa : 2
Recombinant Factor VIIa<br />
• Life saving<br />
• Altern<strong>at</strong>ive to hysterectomy<br />
• Initi<strong>at</strong>es coagul<strong>at</strong>ion cascade
Recombinant Factor VIIa<br />
• Cost : Rs 40,000 for 1.2 mg<br />
• Dose: 80 mcg / kg IV<br />
• 60 kg adult : 4.8 mg dose<br />
• Thrombotic events
FVIIa boosts thrombin gener<strong>at</strong>ion on activ<strong>at</strong>ed pl<strong>at</strong>elets
Recombinant Factor VIIa<br />
Our experience – 12 cases<br />
Case 1 : <strong>Massive</strong> Atonic PPH / Fulminant DIC<br />
Case 2 : Infective Hep<strong>at</strong>itis with Coagulop<strong>at</strong>hy / PPH<br />
Case 3 : Abruptio Placenta / DIC / PPH<br />
Case 4 : IUD / AFE / PPH / MODS
Case 5 : Placenta Percreta with <strong>Massive</strong> PPH<br />
Case 6 : ?Transfusion rel<strong>at</strong>ed sepsis / MODS / PPH<br />
Case 7 : Atonic PPH @ Em LSCS<br />
Case 8 : Hep<strong>at</strong>itis / Coagulop<strong>at</strong>hy / PPH<br />
Case 9 : Placenta Percreta / Secondary PPH
Recombinant factor VIIa: use in f<strong>at</strong>al post partum hemorrhage<br />
Indian experience case series and review of liter<strong>at</strong>ure:<br />
Our experience<br />
• 3 pts – 33.3%: Total turn around<br />
• 4 pts – 44.4%: Equivocal<br />
• 2 pts – 22.2%: No benefit<br />
Shailesh R. Singi · Sunil T Pandya . Evita <strong>Fernandez</strong>· H. R. Badrin<strong>at</strong>h<br />
Indian J Hem<strong>at</strong>ol Blood Transfus 25(1):1–5<br />
© Indian Society of Hem<strong>at</strong>ology and Transfusion Medicine 2009
Radiological Interventions:<br />
Adherant Placenta: Our experience<br />
– 2008 to 2009<br />
• 7 Cases – C. Hysterectomy<br />
• Avg.Bld loss: 800 – 1200ml<br />
• No transfusions<br />
• GETA: 1<br />
• CLE: 6
TECHNIQUE<br />
• BILATERAL FEMORAL ARTERIAL<br />
PUNCTURES (6F SHEATHS)<br />
• 6F RENAL GUIDING PLACED IN THE<br />
LEFT COMMON ILIAC FROM RIGHT<br />
FEMORAL SHEATH<br />
• 6F RENAL GUIDING PLACED IN THE<br />
RIGHT COMMON ILIAC FROM LEFT<br />
FEMORAL SHEATH
INFLATED BALLOON IN LEFT INTERNAL ILIAC
TECHNIQUE<br />
• 7 MM BALLOONS WERE PLACED IN<br />
INTERNAL ILIACS<br />
• PATIENT SHIFTED TO OT<br />
• CAESARIAN HYSTERECTOMY<br />
• AFTER BABY DELIVARY BALLOONS<br />
WERE INFLATED TILL<br />
HYSTERECTOMY WAS COMPLETED<br />
• NO TRANSFUSION<br />
• NO HEPARIN GIVEN
Retaining Placenta: Our experience<br />
Methotrex<strong>at</strong>e Followup<br />
Case 1 Yet to have another pregnancy<br />
Case 2 Yet to have another pregnancy<br />
Case 3<br />
C Hysterectomy for hemorrhage /<br />
Neutropenic Sepsis<br />
Case 4 Rupture <strong>at</strong> 20 weeks in II pregnancy
Reducing Mortality<br />
and Morbidity
Wh<strong>at</strong> Can be Done ?<br />
• Recognition of risk factors<br />
• Anticip<strong>at</strong>ion of blood loss<br />
• Being prepared<br />
• Initi<strong>at</strong>ion of resuscit<strong>at</strong>ion
Altern<strong>at</strong>ives to Transfusion Therapy<br />
Autologous Transfusion<br />
– ANTEPARTUM DONATION<br />
– NORMOVOLEMIC HEMODILUTION<br />
– INTRAOPERATIVE BLOOD SALVAGE<br />
– Use of Acellular Oxygen carrying<br />
Haemoblobin solution<br />
– ??Recomb. erythropoietin
Complic<strong>at</strong>ions of <strong>Massive</strong> Blood<br />
Transfusion<br />
• Hemolytic Reactions<br />
• TTI‟s<br />
• Hyperkalemia<br />
• Hypocalcemia<br />
• Hypothermia<br />
• Metabolic Acidemia<br />
• TRALI / ARDS
Recognition of<br />
Risk Factors<br />
Anticip<strong>at</strong>ion<br />
• Tone - uterine <strong>at</strong>omy<br />
• Trauma - genital tract trauma<br />
• Tissue - retained placenta<br />
• Thrombin - coagulop<strong>at</strong>hy
Recognition of<br />
Coagulop<strong>at</strong>hy<br />
Anticip<strong>at</strong>ion<br />
An EMPTY,<br />
CONTRACTED,<br />
INTACT uterus will not<br />
bleed in the absence of<br />
COAGULOPATHY
Diagnosis in<br />
antepartum<br />
period<br />
• Placenta Previa<br />
Anticip<strong>at</strong>ion<br />
• Abruptio Placenta<br />
• Adherent Placenta<br />
Previous CS and Placenta Previa*
Protocol<br />
Prevention<br />
• Active management of III<br />
stage of Labour was the moist<br />
significant intervention
Multidisciplinary Team<br />
• Consultant obstetrician<br />
• Consultant anesthetist<br />
• Interventional radiologist<br />
• Neon<strong>at</strong>ologist<br />
• Urologist, Vascular surgeon<br />
Lessons Learnt from Two Women with Morbidly Adherent Placentas<br />
and a Review of Liter<strong>at</strong>ure, Ann Acad Med Singapore 2007;36:298-303
• Call for help<br />
Communic<strong>at</strong>ion<br />
Teamwork<br />
• Senior obstetrician / anesthetist<br />
• Alert portering service / blood bank<br />
• Alloc<strong>at</strong>e roles<br />
• Practice fire drills
Goals<br />
• Early institution of massive obstetric drill<br />
• Rapid access to circul<strong>at</strong>ion<br />
• Efficient team working<br />
• Management decision making
Early<br />
Warning<br />
<strong>Obstetric</strong><br />
Chart
The Uterotonic Drugs
5000<br />
4000<br />
3000<br />
2000<br />
1000<br />
0<br />
Number of M<strong>at</strong>ernal De<strong>at</strong>hs<br />
2830<br />
<strong>Fernandez</strong> Hospital<br />
3080<br />
3342<br />
3874<br />
4408<br />
4715<br />
1 5 3 5 1 2<br />
2003 2004 2005 2006 2007 2008<br />
Deliveries
5000<br />
4000<br />
3000<br />
2000<br />
1000<br />
Number of M<strong>at</strong>ernal De<strong>at</strong>hs due<br />
0<br />
to <strong>Massive</strong> Haemorrhage: Nil<br />
2830<br />
<strong>Fernandez</strong> Hospital<br />
3080<br />
3342<br />
3874<br />
4408<br />
4715<br />
1 5 3 5 1 2<br />
2003 2004 2005 2006 2007 2008<br />
Deliveries
The Practice Point<br />
Active communic<strong>at</strong>ion<br />
between the oper<strong>at</strong>ing &<br />
anesthesia teams<br />
during the entire surgery<br />
Clin Perin<strong>at</strong>ol 35 (2008) 519–529
<strong>Massive</strong><br />
<strong>Obstetric</strong><br />
<strong>Hemorrhage</strong><br />
is a<br />
Preventable<br />
Mortality
Life is no brief candle to me.<br />
It is a sort of splendid torch which<br />
I have got hold for the moment,<br />
and I want to make it burn<br />
as brightly as possible before<br />
handing it on to future gener<strong>at</strong>ions.<br />
George Bernard Shaw
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