Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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19 Critical Care
Management of life-threatening illness
Haemorrhage
Examples of the poor management of haemorrhage in obstetric patients have been raised in this, and
previous Reports. Obstetric haemorrhage continues as one of the major reasons for admission to Critical
Care and so overall its management must be good if the low mortality amongst obstetric admissions is to
be easily explained:
A woman suffered a postpartum haemorrhage after a normal vaginal delivery and, following an
examination under anaesthesia, went on to have a hysterectomy during which her estimated blood
loss was 3,000 mls. She received 1,000 mls of Hartmann’s solution, 1,000 mls of normal saline,
1,000 mls of a gelatine based plasma expander, six units of re-suspended red cells and 2 units
of FFP. There was no Critical Care bed immediately available so anaesthesia was reversed and
she was admitted to the high dependency unit (HDU). She remained tachycardic for the next four
hours but maintained her blood pressure at 110/60 mm/Hg. Over the next few hours she became
increasingly tachycardic up to 160bpm and hypotensive down to 90/28 mm/Hg. During this period
she received a further seven units of re-suspended red cells, 1,000 mls of Normal Saline, two
units of FFP, one pack of platelets and fi ve units of cryoprecipitate. She was eventually admitted
to Critical Care some hours after the end of her surgery where she was intubated and ventilated
because of poor blood gases and appeared to develop a disseminated intravascular coagulopathy
(DIC). She had a cardiac arrest some hours later and subsequently died.
There are lessons to be learnt from several aspects of this case. 3,000 mls is a major loss of blood during a
hysterectomy and the junior staff involved should have asked for senior help earlier. Although her circulating
volume was reasonably well replaced during surgery this was almost entirely with a mixture of red cells and
saline with little or no appreciation that this would inevitable lead to a serious dilutional coagulopathy.
Recently the whole question of transfusion regimens for signifi cant bleeding has been questioned. The
American military have moved to using a ratio of one FFP to every unit of packed red cells and have
apparently demonstrated an improvement in battlefi eld mortality. Using a pharmacokinetic model of clotting
factor levels Ho et al 7 concluded that in major haemorrhage the equivalent of whole-blood transfusion is
required to prevent the development of a coagulopathy and whole blood transfusion remains a widely
used practice in combat situations. The exact requirement for FFP replacement will never be known but
the availability of increasingly reliable point-of-care testing devices for haemoglobin estimation and clotting
tests will help in the management of bleeding patients.
Many units have massive transfusion protocols and these should be regularly reviewed as new evidence
becomes available. Effective management requires experience, the ability to predict likely requirements,
good communication with, and cooperation from, haematology and blood bank services and appropriate
fl uid delivery and warming equipment.
The management of massive obstetric haemorrhage is included in commercially available advanced life
support courses 8 although at present these are primarily directed at medical staff only. There is perhaps
a need to develop a nationally approved, scenario based team training in the management of major
obstetric haemorrhage that is available and affordable to all members of theatre, recovery and high
dependency unit teams.
The delay in obtaining a critical care bed has been discussed before and overall the provision of critical
care beds has improved since the last Report. Despite this, delays will on occasion be inevitable but are no
excuse for poor quality care.