ANAESTHETIC MANAGEMENT OF

OBSTETRIC HAEMORRHAGE

By
Dr.Sasidhar
Moderated by
Dr.Ravimohan
Assoc professor
ASRAM MEDICAL COLLEGE , Eluru
OBSTETRIC HAEMORRHAGE
 Worlds leading cause of maternal mortality
 Major obstetric haemorrhage complicates up to
10.5% of all births
 In India obstetric haemorrhage contributes to
22.34% of all maternal deaths
 Obstetric haemorrhage is can be classified as
 Antepartum haemorrhage

defined as bleeding from vagina after 24 wks. of

gestation and before delivery
 Post partum haemorrhage

defined as blood loss within 24hrs of delivery

which is more than 500ml following vaginal delivery
,more than 1000ml following caesarean section
ANTEPARTUM HAEMORRHAGE

 Common causes
placenta previa
placental abruption
uterine rupture
vasa previa
PLACENTA PREVIA
 placenta previa is present when the placenta implants in
advance of the foetal presenting part
 incidence of placenta previa is approximately 1 in 200
pregnancies
 total placenta previa ---completely covers the cervical os
 partial placenta previa--- covers part, but not all of the cervical
os
 marginal placenta previa ---lies close to, but does not cover the
cervical os
ETIOLOGY

 Advancing maternal age

 Multiparity
 Multifetal gestations
 Prior cesarean delivery
 Smoking
 Prior placenta previa
 The most characteristic event in placenta previa is
painless hemorrhage.

 This usually occurs near the end of or after the

second trimester.

 The initial bleeding is rarely so profuse as to prove

fatal.

 It usually ceases spontaneously, only to recur.

 Placenta previa may be associated with placenta

accreta, placenta increta or percreta.

 Coagulopathy is rare with placenta previa.

DIAGNOSIS

 should always be suspected in women with uterine

bleeding during the latter half of pregnancy.

 appropriate evaluation, including sonography

 examination of the cervix is never permissible unless the

woman is in an operating room with all the preparations
for immediate cesarean delivery, because even the
gentlest examination of this sort can cause torrential
hemorrhage.
 safest method is transabdominal sonography.
 MRI
 At 18 weeks, 5-10% of placentas are low lying. Most
‘migrate’ with development of the lower uterine segment
OBSTETRIC MANAGEMENT
 Vaginal examinations are best avoided
 If needed done under double setup

 Expectant management

 Surgical management
ANAESTHETIC MANAGEMENT
For Double Set-Up examination
 Rarely performed
 performed in the operating room

 full preparation for cesarean section which includes

maternal monitors,
insertion of two large-gauge intravenous
cannulae,
administration of a nonparticulate antacid
sterile prep , draping of the abdomen
Two units of packed red blood cells (PRBCs
FOR CAESAREAN SECTION
 choice of anaesthetic technique depends on the
indication and urgency for caesarean section
and the degree of maternal hypovolemia
 High risk of intra operative blood loss due to

obstetrician may cut into the placenta during

uterine incision
lower uterine segment implantation site does
not contract well
increased risk for placenta accreta
 A retrospective study with 350 cases of
placenta previa [ 60 % regional , 40 % GA ]
found
decraesed EBL with RA vs. GA
decrased transfusions needs with RA
no difference in hypotension
N Parekh et al Br J Anaesth 2000;84;725
PREOPERATIVE PREPARATION
 patient evaluation, resuscitation, and
preparation for operative delivery all proceed
simultaneously
 careful assessment of the parturient's airway
and intravascular volume
Two large-gauge intravenous catheters
four units of PRBCs
Blood administration sets
fluid warmers
equipment for invasive monitoring
 Rapid-sequence induction of general anesthesia
is the preferred technique
 avoid sodium thiopental

 propofol should not be used in hypovolemic

patients
 Ketamine (0.5 to 1.0 mg/kg) and etomidate (0.3
mg/kg) are the best induction agents for
bleeding patients
 patients with severe hypovolemic shock,
intubation may require only a muscle relaxant
MAINTENANCE
 nitrous oxide and oxygen with a low concentration
of a volatile halogenated agent
 concentration of nitrous oxide can be reduced (or
omitted) in cases of foetal distress
 Oxytocin (20 U/L) immediately after delivery
 lower uterine segment implantation site does not
contract as well as the fundus
 All uterine relaxants should be eliminated if
bleeding continues
 best to eliminate the volatile halogenated agent after
delivery
 substitute nitrous oxide (70%) and an intravenous
opioid
ABRUPTIO PLACENTA
 Placental abruption is defined as separation of
the placenta from the decidua basalis before
delivery of the foetus
 Incidence 1 in 100 pregnancies
 Risk factors
hypertension
advanced age and parity
tobacco use
cocaine use
trauma
premature rupture of membranes
a history of previous abruption
 Presentation
vaginal bleeding
uterine tenderness
increased uterine activity
 complications

haemorrhagic shock
acute renal failure (ARF)
Coagulopathy, DIC
foetal distress or demise
 OBSTETRIC MANAGEMENT
 definitive treatment is delivery of the fetus and
placenta
degree of abruption is minimal
the fetus shows no signs of distress
Maternal haemodynamics stable

Hospitalisation
Foetal HR monitoring
Serial ultra sonography
Maternal haemodynamic monitoring

Delivered after foetal lung maturation

ANAESTHETIC MANAGEMENT
Preoperative preparation
 airway assessment
 Assessment of volume status

 Maternal Haemodynamic monitoring

 FHR monitoring

 Two large bore IV catheters

 Blood for cross matching , haematocrit ,

coagulation
 Maintain supplemental oxygen

 Left uterine displacement

FOR LABOUR AND NORMAL DELIVERY
 Epidural analgesia can be given only if
coagulation studies are normal
no intravascular volume deficit
 Vincent et al.[36] observed that epidural anesthesia
significantly worsened maternal hypotension, uterine blood
flow, and fetal PaO2 and pH during untreated hemorrhage (20
mL/kg)
CAESAREAN SECTION
 General anaesthesia is preferred for most of the
cases
 Regional anaesthesia can be given for a patient
with stable haemodynamics ,good intravascular
volume ,minor abruption, NO foetal distress
 Ketamine and etomidate are inducing agents of
choice
 Rapid sequence induction is preferred
 Large doses of ketamine may increase uterine
tone during early gestation
 So dose of ketamine should be limited to single
dose of 1mg/kg
 Aggressive volume resuscitation with both
crystalloids and colloids
 Blood transfusion
 Central venous catheter and arterial catheter may be
necessary
 High risk for uterine atony and coagulopathy
 Oxytocin 20U/L infused immediately after the
delivery
 Coagulation abnormalities may require FFP
 Recover quickly and completely after delivery
 prolonged hypotension, coagulopathy, and massive
blood volume/product replacement, are best
monitored in a multidisciplinary intensive care unit.
UTERINE RUPTURE
 Rupture of the gravid uterus can be disastrous to
both the mother and foetus
 It may be of two types
uterine scar dehiscence
complete uterine rupture
 Scar dehiscence
foetal distress less common
no excessive haemorrhage
rarely requires emergency section
 Uterine rupture
foetal distress
massive haemorrhage
requires emergency caesarean section
 Presentation
vaginal bleeding
hypotension
cessation of labour
foetal distress
 Obstetric management

uterine repair
uterine artery ligation
hysterectomy – definitive treatment
ANAESTHETIC MANAGEMENT
 Preoperative evaluation , resuscitation and
preparation of OT simultaneously
 GA is often required

 RA can be given in haemodynamically stable

patients , who already have a epidural catheter
,absence of foetal distress
 Aggressive volume replacement

 maintenance of urine output

 Invasive hemodynamic monitoring

VASAPREVIA
 Occurs rarely 1 in 2000 to 3000 deliveries.
 Vasa previa is associated with a velamentous insertion of the
cord where foetal vessels traverse the foetal membranes ahead
of the foetal presenting part.
 Highest foetal mortality rates 50% to 75%
 No threat to the mother
 Early diagnosis and treatment are essential to reduce the
chance of foetal death
 Requires immediate delivery by caesarean section
 Neonatal resuscitation, neonatal volume replacement
 Choice of anaesthetic technique depends on the urgency of
caesarean section
POST PARTUM HAEMORRHAGE

 Major cause of maternal morbidity and mortality

Types
 Primary postpartum haemorrhage occurs
during the first 24 hours after delivery
 secondary postpartum haemorrhage occurs
between 24 hours and 6 weeks postpartum
Causes
 Uterine atony
 Genital trauma
 Coagulopathy
 Placental abnormalities
UTERINE ATONY
 Risk factors
Multiple gestation
Macrosomia
Polyhydramnios
High parity
Chorioamnionitis
Precipitous labor
Augmented labor
Tocolytic agents
High concentration of a volatile agents
Prolonged labor
OXYTOCIN
 first-line drug for the prophylaxis or treatment of uterine atony
 Endogenous oxytocin is a 9-amino acid polypeptide produced
in the posterior pituitary
 exogenous form is a synthetic preparation
 20 U of oxytocin to a litre of NS or RL started as infusion
 Bolus administration of oxytocin causes peripheral
vasodilation, hypotension
 Weis et al.[53] administered oxytocin 0.1 U/kg intravenously to
pregnant women in the first trimester. They noted that heart rate
increased, MAP decreased by 30%, and total peripheral
resistance decreased by 50%
 Secher et al.[54] noted that bolus intravenous administration of 5
or 10 U of oxytocin increased pulmonary artery pressures in
pregnant women
 cardiovascular changes are short lived (less than 10 minutes).
prostaglandin E2
vaginal or rectal suppository 20mg every 2hrly
causes bronchodilation
decreased SVR and blood pressure
increased heart rate , cardiac output
prostaglandin F2-alpha
increases cardiac output
increases systemic and pulmonary artery pressures
Increased PaCO2 and decreased PaO2
alterations of ventilation/perfusion ratios
bronchospasm
15-Methyl prostaglandin F2-alpha (carboprost)
preferred for the treatment of refractory uterine atony
250 μg administered intramuscularly or intramyometrially
Bronchospasm
disturbed ventilation/perfusion ratios
increased intrapulmonary shunt fraction
hypoxemia.
Misoprostol
800 -1000 mcg rectally
prostaglandin E1 analogue
effective treatment for postpartum haemorrhage
unresponsive to oxytocin and ergometrine
Ergot alkaloids
0.2mg iv every 2-4 hrs
Ergonovine and methylergonovine
restricted to postpartum use
rapidly produce tetanic uterine contraction
act on alpha-adrenergic receptors
Cause vasoconstriction, hypertension, Pulmonary
artery pressure , Pulmonary oedema
GENITAL TRAUMA
 Most common injuries at childbirth are lacerations and
hematomas of the perineum, vagina, and cervix
 Pelvic hematomas are three types:
vaginal, vulvar, and retroperitoneal
signs and symptoms
restlessness,
lower abdominal pain,
a tender mass above the inguinal ligament
vaginal bleeding
abrupt hypotension
Ileus
unilateral leg oedema
urinary retention
haematuria
ANAESTHETIC MANAGEMENT OF GENITAL
TRAUMA
For vulval haematomas and small lacerations
Local infiltration and a small dose of intravenous opioid
For extensive lacerations and vaginal haematomas
pudendal nerve block – technically may not be feasible
neuraxial blockade – may cause hypotension
MAC – most preferred
N2O ,O2 with inhalational agents
low dose ketamine
For retroperitoneal haematoma
laparotomy with general anaesthesia
rapid sequence induction
difficult intubation to be anticipated
RETAINED PLACENTAL PRODUCTS

 Retained placental fragments are a leading cause of both early

and delayed postpartum hemorrhage
 OBSTETRIC MANAGEMENT

manual removal and inspection of the placenta

After removal of the placenta, uterine tone should be
enhanced with oxytocin
ANAESTHETIC MANAGEMENT OF RETAINED
PLACENTAL PRODUCTS

 If epidural catheter is in situ additional local

anaesthetic drug can be given
 Subarachnoid block can be given if patient is
haemodynamically stable
 Nitrous oxide analgesia

 Low dose ketamine

 GA can be given with rapid sequence induction

 Methods to facilitate uterine relaxation

halogenated inhalational agents

nitroglycerine
PLACENTA ACCRETA
 Placenta accreta vera is defined as adherence to the
myometrium without invasion of or passage through
uterine muscle
 Placenta increta represents invasion of the myometrium
 Placenta percreta includes invasion of the uterine serosa
or other pelvic structures
 Risk factors
previous uterine trauma
previous caesarean section
low lying placenta
Diagnosis
antepartum diagnosis is rare
difficulty in removal placenta
ultrasonography
MRI
transvaginal colour dopler
 Obstetric management
 uterine curettage, followed by over-sewing of the bleeding
placental bed.
 Balloon occlusion
 embolization techniques
 postpartum hysterectomy – definitive
 Anaesthetic management
 preoperative diagnosis of placental abnormalities
 identifying patients with high risk for placenta accreta
 preparation for hysterectomy
 availability of blood products
UTERINE INVERSION
 Turning inside out of all or part of the uterus
 Occur in 1 In 5000 to 1 in 10,000 pregnancies
 Risk factors
uterine atony
inappropriate fundal pressure
umbilical cord traction
uterine anomalies.
An abnormally implanted placenta
(i.e., placenta accreta)
 Obstetric management
Early replacement of the uterus is the best treatment
Once the uterus has been replaced.
Oxytocin (20 U/L) should be infused initially,
additional drugs (15-methyl prostaglandin F2-alpha)
may be needed
ANAESTHETIC MANAGEMENT OF UTERINE
INVERSION
 uterine tone precludes immediate replacement,
 uterine relaxation is needed before successful replacement can be
performed
 Ideal technique should have
rapid uterine relaxation
no side effects
short duration
restoration of uterine tone after replacement of the uterus
 GA with inhalational agents most preferred
 Equipotent doses of all volatile halogenated agents produce a
similar degree of uterine relaxation
 Endotracheal intubation is mandatory
 Other modes
terbutaline, magnesium sulfate, organic nitrates
INVASIVE TREATMENT FOR OBSTETRIC
HAEMORRHAGE
 Includes
angiographic arterial embolization
balloon occlusion
surgical arterial ligation
hysterectomy
 Embolization
local anaesthesia
complications are few
preservation of fertility is likely
Can be done in presence of a coagulopathy
Requires rapid access to angiographic facility
Requires skilled radiologist
Logistic problems
 Bilateral surgical ligation
uterine, ovarian, and internal iliac arteries
preservation of fertility
damage to other pelvic structures (ureter)
vascular anatomy is variable
lower extremity ischemia
 postpartum hysterectomy

definitive treatment for postpartum haemorrhage

Tissues are oedematous and congested
Amount of blood loss is more
 multicentre review showed that the average blood
loss for emergent cases was 2526 mL, with an
average transfusion requirement of 6.6 units of blood
ANAESTHETIC MANAGEMENT
 obstetrician requires good skeletal muscle relaxation and a quiet operative
field
 Choice of technique
 Regional anaesthesia
Risk of hypotension
The operative time for caesarean hysterectomy is more
patient may have fatigue and restlessness.
Intraperitoneal manipulation, dissection, and traction result in pain,
nausea, and vomiting.
hyperemic pelvic viscera with engorged, edematous vasculature
require careful dissection facilitated by a quiet operative field
 If RA is given then
Maintenance of a T-4 sensory level
prophylaxis against nausea and vomiting
judicious sedation
 Most of the cases require GA for emergency obstetric hysterectomy
 Regardless of the anaesthetic technique used
 two large-gauge intravenous catheters
 at least two units of packed PRBCs should be
immediately available.
 Additional units should be available without
delay.
 Vasoactive drugs (e.g., phenylephrine,
dopamine, epinephrine).
 establish invasive monitoring.
 A fluid warmer
 equipment for rapid infusion of fluids
RECENT ADVANCES
 Intra operative cell salvage
Chance of amniotic fluid embolism
Haemolytic disease in future pregnancies
Leukocyte depletion filter is useful
Separate suction for amniotic fluid advised
 Thromboelastography
Useful guide in massive haemorrhage
Provides information regarding coagulation factors , platelet
function, fibrinogen levels , fibrinolysis
Rapid results
Can be done near the patient
 Role of tranexaemic acid
Antifibrinolytic
1gm IV stat dose
Followed by a second dose after 30 min if bleeding doesn’t stop
World maternal antifibrinolytic trail
 Recombinant factor VIIa
useful in unresponsive massive haemorrhage
Coagulopathy has to be corrected prior
Prerequisites
platelet count >50,000
fibrinogen > 0.5gms /L
ph. >7.2
Dose – 90 mcgs/kg stat dose
followed by 120 mcg/kg if bleeding persists
Thromboembolic events can occur
High cost , lack of availability
REFERENCES
 Chestnut: Obstetric Anesthesia: Principles and Practice,
3rd ed. By David H. Chestnut, M.D

 Miller’s Anesthesia , 7th edition

THANK YOU