ETIOLOGY OF OBSTETRIC HAEMORRHAGE (2)

Slide 1: 

DEPARTMENT OF ANESTHESIA J.J.M MEDICAL COLLEGE DAVANGERE Seminar On OBSTETRIC EMERGENCIES (Ectopic Pregnancy/APH / PPH) Chair Person Presented By Dr.Gangadhar Gowda Dr.Shoeib Assistant Professor. Date: 22 nd March 2011

Slide 2: 

“ If you can keep your head when all about you are losing theirs, it’s just possible you haven’t grasped the situation .” Jean Kerr

Slide 3: 

“Lots of people confuse destiny with bad management.” -Kin Hubbard To avoid “bad management”, we should know: • Risk factors • Diagnostic criteria • Obstetric management • Anesthetic management

ETIOLOGY OF OBSTETRIC HAEMORRHAGE: 

ETIOLOGY OF OBSTETRIC HAEMORRHAGE (a) Those related to pregnant state Abortion 95% Ectopic pregnancy Hydatiform mole Implantation bleeding (b ) Those associated with pregnant state Cervical lesions like vascular erosion polyps genital malignancy. 1. Early trimester bleed

Slide 5: 

( a)Placental bleeding(70% ) Placenta previa (35%) Abruptio placentae (35%) (b) Unexplained or Indeterminate (25%) Vasa previa , bloody show, maternal coagulaopathy . Circumvallate placenta, uterine rupture. (c) Extraplacental causes Cervical polyp Cervical cancer Varicose veins Local trauma 2. Antepartum haemorrhage

Slide 6: 

3. Post partum haemorrhage Atonic uterus Uterine inversions Retained placenta / Placenta accrete Genital tract trauma

Slide 7: 

An ectopic pregnancy is defined as any pregnancy that occurs outside the uterus generally in the genital tract and less commonly in abdominal cavity. Ectopic Pregnancy

Types of Ectopic pregnancy- based on site of implantation : 

Types of Ectopic pregnancy- based on site of implantation Extrauterine : Tubal(95%) Ovarian(<1%) Abdominal(1%) Uterine Cervical(1%) Angular (2%) Cornual

Slide 9: 

TUBAL PREGNANCY Incidence varies between 1 in 300 to 1 in 150. Risk factors  Congenital anamolies of tube Prior tubal surgery PID IUCD Progesterone contraceptives ART Previous tubal pregnancy.

Slide 10: 

Types of tubal pregnancy- Interstitial – 2% Isthmic – 12% Ampullary - 80% Fimbrial – 5% Mode of termination- Tubal mole. Tubal abortion Tubal rupture Tubal perforation with secondary abdominal pregnancy

Slide 11: 

Ruptured ectopic is responsible for approx 7% of all pregnancy related maternal deaths. It is leading cause of 1 st trimester maternal mortality. Most ectopic pregnancy related deaths result from hemorrhage (92%), infection (3%), embolism (3%) & lastly anesthetic complications(1%).

Slide 12: 

CLINICAL SYMPTOMS PHYSICAL FINDINGS Abdominal/pelvic pain (90-100%) Abdominal tenderness with or without rebound tenderness (80-95%) Menstrual irregularities (75-99%), Tender adnexal mass (30-60%). Vaginal bleeding (50-80%). Acute rupture may present with shock. Diagnosis is often clinical & is confirmed by transvaginal USG. Management is either by laparotomy or laproscopy .

Slide 13: 

Antepartum Haemorrhage is defined as bleeding from or into the genital tract after 28 th week of pregnancy but before the birth of the baby. 28 th week limit is taken as arbitrary. Incidence is 3% amongst hospital deliveries. ANTEPARTUM HAEMORRHAGE:

VASA PREVIA: : 

VASA PREVIA: Incidence of 1 in 2500 deliveries, Risk factors Succenturiate placenta Placenta previa IVF Increased levels of MSAFP. Multiple pregnancy

Slide 15: 

Diagnosis: Vasa previa is diagnosed when vaginal bleeding(minimal) and foetal bardy cardia or foetal death accompany rupture of membranes. Prenatal diagnosis is possible with reasonable accuracy with advances in USG (color doppler ). Anesthetic Management:

Anaesthetic management: 

Anaesthetic management Pre-op diagnosis of Vasa previa  Elective LSCS under regional technique Bleeding Vasa previa + Alive fetus  emergency LSCS under GA Bleeding previa + IUD(Conclusive) Vaginal delivery ± epidural analgesia

PLACENTA PREVIA: : 

PLACENTA PREVIA: Epidemiology: 1 in 200 pregnancies Perinatal mortality rate – 15-20% Risk factor: Advanced maternal age Multiparity Prior CS or other uterine surgery Previous placenta previa Multiple pregnancy Smoking Increased levels of MSAFP

Slide 18: 

PP is classified according to the extent of encroachment of placenta. Type I or lateral or low lying placenta :- encroaches the LUS but does not infringe on internal cervical OS. Type II or marginal placenta :-touches ,but does not cover the internal cervical OS.

Slide 19: 

Type III or incomplete central or partial :- placenta previa , partially covers the internal cervical OS. Type IV or central or complete placental previa :- covers the entire cervical OS.

Complications : 

Complications Maternal APH with Shock Malpresentation Premature Labour Cord Prolapse PPH Retained Placenta Puerperal sepsis Fetal LBW Asphyxia IUD Congenital malformations

Management of Placenta previa: 

Management of Placenta previa EXPECTANT MANAGEMENT ACTIVE INTERFERENCE Pregnancy <38 weeks Pregnancy >38 weeks Maternal stability- good Maternal or fetal compromise No active bleed Active bleed FHS- good Active labour Fetal malformation/ IUD Type I & II anterior- Vaginal delivery allowed Type II posterior, III, IV- Caeserean section

Slide 22: 

Anesthetic Management: Patients with PP remain at risk for increased intraoperative blood loss for atleast three reasons Obstetrician may cut into the placenta during uterine incision After delivery, the LUS implantation site does not contract as well as the normal fundal implantation site A patient with PP is at increased risk of placenta accrete, especially if there is a past history of CS .

ABRUPTIO PLACENTAE: : 

ABRUPTIO PLACENTAE: The term refers to the premature separation of normally implanted placenta from decidua basalis after 20 weeks gestation and before birth of fetus. Epidemiology: Complicates 1% of pregnancies Implicated in 10% preterm births Recurrence rate of abruption is 10%

Risk Factor: : 

Risk Factor: Advanced maternal age Multiparity Hypertension Smoking Trauma PROM. Cocaine abuse. Placenta previa Folic acid deficiency. Supine hypotension syndrome.

Slide 26: 

Grade 0 - Clinical feature of placental separation are absent. Diagnosis is made after inspection of placenta following delivery. Grade 1 – Asymptomatic, associated with virginal bleeding with mild uterine tenderness, no maternal or fetal distress. Grade 2 – Uterine tenderness is always present. Symptomatic mother and fetal compromise. Grade 3 – Uterine tenderness is marked. Severe bleeding leading to maternal shock and fetal death is rule. Associated with coagulation defect or anuria . Classification :

Slide 27: 

Varieties: Revealed  Concealed  Mixed 

Complications: 

Complications Maternal APH with shock DIC ARF Sheehans syndrome PPH Fetal Asphyxia IUD

Anesthetic Mananagement: : 

Anesthetic Mananagement : Anesthetic management depends on degree of abruption and maternal and fetal stability. Mild abruption with maternal and fetal stability - vaginal delivery to be allowed after ARM with judicious use of oxytocin . Epidural analgesia can be given provided coagulation studies are normal. In severe placental abruption, maternal hemorrhage or deteriorating fetal status emergent CS required. GA is technique of choice

UTERINE RUPTURE: : 

UTERINE RUPTURE: This refers to separation of a uterine scar that is clinically apparent and results in non reassuring status, maternal haemorrhage requiring emergent CS or postpartum laparotomy .

Slide 31: 

Causes: Separation of prior uterine scar. Rapid, tumultuous labor. Prolonged labor associated with oxytocin infusion. Traumatic rupture Weakned uterine musculature ( grandmultipara , polyhydramnios ) Obstructed labour Breech version & extraction.

Slide 32: 

True Rupture Contractions stop Continuous pain Tender abdomen Fundus ill-defined PV Bleeding Fetal heart dips or absent fetal heart Scar Dehiscence Dehiscence may be silent – no bleeding Fetal distress Haematuria Vague uterine outline Failed induction

Slide 33: 

Diagnosis: High index of suspicion Fetal bradycardia is most consistent entity of uterine rupture occurring in 70% of patients. Other signs include acute abdominal pain, vaginal bleeding, shoulder pain, hypotension and collapse. Anesthetic management: When diagnosed emergent CS is indicated under GA with simultaneous attempts of volume resuscitation. Anesthetist should be prepared for caesarean hysterectomy if necessity demands.

POST PARTUM HAEMORRHAGE: : 

POST PARTUM HAEMORRHAGE: Any amount of bleeding from or into genital tract following birth of baby upto the end of the puerperium which adversely affects the general health of the patient evidenced by rise in pulse rate and falling blood pressure is called PPH

Slide 35: 

Types: Primary haemorrhage occurs with in first 24 hours Loss >1500ml >40gm/l or greater drop in Hb . Transfusion of 4 or more units of RBC`s Secondary – haemorrhage occurs beyond 24hours & within 6 wks after delivery. Reference-Blood banking & Transfusion med.- Hillyer , 2 nd ed.

RETAINED PLACENTA: : 

RETAINED PLACENTA: Definition:- Placenta is said to be retained when it is not expelled out even 30 mins after birth of baby. Risk Factors: H/O retained placenta Previous injury to uterus Preterm delivery Induced labor; prolonged labor Multiparity .

Slide 38: 

Anesthetic management: Depends on Amount of placenta retained Associated shock/ haemorrhage Previous regional block given or not. Types of anesthesia: IV analgesia with ketamine 0.1mg/kg, BZD and judicious use of opiods ( fentanyl ) care must be taken to prevent loss of maternal reflexes. GA is anesthesia of choice when retained placenta is complicated with haemorrhage . Uterine relaxation may be provided either with volatile anesthetic (1.5 -2%MAC Halothane) incremental doses of IV nitroglycerine 25-250µg IV. inhalation route can also be tried (800µg/2puffs).

PLACENTA ACCRETA: 

PLACENTA ACCRETA Risk factors: Previous CS/ Uterine curettage. Previous placenta previa . Anterior Placenta Multigravida >6. Maternal age >35yrs.

PLACENTA ACCRETA:   : 

PLACENTA ACCRETA: Diagnosis: USG is primary modality in diagnosing accreta . Anesthetic management: Pre-partum diagnosis Placement of intenal iliac balloon catheter Epidural anesthesia/ combined epidural & GA Intra- partum diagnosis May require conversion to GA

UTERINE INVERSION: : 

UTERINE INVERSION: Varieties: 1 degree – dimpling of fundus which remains above internal OS. 2 degree - fundus passes through the cervix but lies inside vagina 3 degree or complete – endometrium with or without the attached placentae is visible outside the vulva . Risk factor: Overzealous fundus pressure excessive umbilical cord traction Uterine anomalies Uterine atony Placenta accreta

Slide 42: 

Diagnosis: Cases of uterine inversion are often obvious because of haemorrhage and mass in vagina. Obstetric management: Aims at quick replacement of the uterus. Atony usually resolves after placement of uterus; followed by medical treatment.

Anesthetic management: 

Anesthetic management It has two important components Management of shock. Replacement of uterus. GA is anesthetic of choice; uterine relaxation being produced by volatile anesthesics , or nitroglycerine 50-100mcg. Recent reports have suggested the use of terbutaline and MgSO4 tocolytic therapies as well.

UTERINE ATONY: : 

UTERINE ATONY: Risk factor:- Rapid or protracted delivery. tocolysis . Over distension of uterus. Prolonged oxytocin infusion. Retained placenta. Operative assisted vaginal delivery. Previous or current GTD.

Anesthetic Management: 

Anesthetic Management

Slide 46: 

Invasive Therapy Uterine artery ligation B- Lynch suture, hypogastric artery ligation hysterectomy.

Complications secondary to PPH: 

Complications secondary to PPH Sheehans syndrome Myocardial Ischemia- seen when BP <88/50 mmhg & HR >115bpm. ARF Acute lung injury/TRALI Consumptive coagulopathy

ASSESMENT AND MANAGENMENT OF HAEMORRHAGE:: 

ASSESMENT AND MANAGENMENT OF HAEMORRHAGE: Clinical evaluation Brief history to elicit cause of haemorrhage . Vital signs: Resting tachycardia Bradycardia Hypotension Orthostatic Vital Sign: Significant postural change defined as Increase in pulse rate by 30 beats/min Decrease in SBP >20mm Hg or dizziness on standing

Investigations: : 

Investigations: Haemoglobin Haematocrit In early hours of acute haemorrhage , hct reflects resuscitation effort and not the severity of blood loss. Use of hct to estimate acute blood loss is unreliable and inappropriate. (Reference: Committee on trauma, Advanced trauma life support student manual chicago , ACOS-1989:47-59)

Arterial Base deficit: 

Arterial Base deficit Base deficit is defined as the amount( mmoles ) of base needed to titrate one L of whole blood to pH 7.4 (at Temp 37 o C) Elevated deficit marker of tissue acidosis. Normal range: +2 to -2 mmol /L Correction of base deficit within hours  Favorable outcome Persistant elevation are often prelude to MODS. Mild -2 to -5 mmol /L Moderate -6 to -14 mmol /L Severe < -15 mmol /L (Reference: ICU book – Paul Marino, 3 rd edition)

Arterial Lactate: 

Arterial Lactate Lactate concentration is a marker of impaired tissue oxygenation >2meq/L are abnormal. Persistant serum lactate despite volume resuscitation carry a poor prognosis. Lactate show a closer corelation with magnitude of blood loss and risk of death from haemorrhage . (Reference: ICU book – Paul Marino, 3 rd edition)

Slide 52: 

Class Acute blood loss(ml) %Lost Clinical Findings I < 1000 15% None, HR<100, mild hypotension II 1200-1500 15-30% Orthostatic blood pressure changes, positive tilt test, pulse pressure<30mmHg, Hypotension (80-100mm Hg). prolonged capillary refill time tachycardia (100-120bpm) III 1500-2000 30-40 Oliguria cold clammy skin, tachypnoea , hypotension tachycardia (>120bpm) altered consciousness. IV >=2000 >40 Profound shock , anuria , non palpable pulse pressure.

Estimating the resuscitation volumes: : 

Estimating the resuscitation volumes: “Evaluation of intravascular volume is so flawed, that it has been called a comedy of errors” Estimate normal blood volume(BV) 60ml/kg in females. Estimate % loss of blood volume – class I to Class IV Calculate volume deficit VD=BV x % loss BV Determine resuscitation volume RV= VD x 1 (colloids) VD x 3(crystalloids)

End Point Of Resuscitation: : 

End Point Of Resuscitation: Cardiac Index =3 L/min/m2. Systemic O2 delivery(DO2) >500ml/min/m2 Systemic O2 uptake (VO2)> 100ml /min/m2. Arterial lactate <2mmol/L or base deficit >-2mmol/L.

Fluid Facts- Colloid-Crystalloid War: 

Fluid Facts - Colloid-Crystalloid War Initial resuscitation with crystalloids No documented survival benefits seen with colloid resuscitation. Colloids are more effective in increasing cardia output when compared to whole blood & crystalloids. Packed cells are never used alone for volume resuscitation. Tailoring of resuscitation fluids to specific clinical condition seems to be most logical approach at present.

Bleeding Parturient Management: : 

Bleeding Parturient Management: Initial management: Insert 2 large bore IV cannulas Take 20ml blood for baseline lab studies Call for experienced help Prepare the operation theater Transfer in left lateral tilt (if antepartum ) Anesthetic considerations Preanesthetic evaluation Heamodynamic assesment & volume resuscitation

Slide 57: 

3. Aspiration prophylaxis 4. Monitor mother and fetus 5. Provide anesthesia 6. Blood transfusion & correction of coagulopathy 7. Avoid hypothermia & acidosis 8. Treat complications 9. Post anesthesia care in high dependency care unit

Anesthesia for CS/ Caeserean hysterectomy: 

Anesthesia for CS/ Caeserean hysterectomy Regional technique General anesthesia Pt. hemodynamically stable Pt hemodynamically unstable Adequately resuscitated Maternal or fetal compromise No ongoing blood loss Ongoing blood loss Coagulopathy absent Coagulopathy present Fetus stable Anticipated long & difficult surgery

General anesthesia: 

General anesthesia Premedication & acid prophylaxis Rapid sequence induction Induction agents: ketamine 0.5 – 1mg/kg, etomidate 0.3-0.5mg/kg Relaxants; Scoline , atracurium , vecuronium Intubation: difficult airway because of soft tissue edema Maintainance : 50% oxygen + 50% N2O± halogenated compounds & opoids Reversal & extubation

Transfusion in obstetric haemorrhage: ASA Guidelines and ACOG recommendations: : 

Transfusion in obstetric haemorrhage : ASA Guidelines and ACOG recommendations: A routine blood cross match is not necessary for normal vaginal or operative delivery. Although the physiological changes of pregnancy help mitigate the parturient response to haemorrhage and vital signs may not change until >1500ml of blood loss has occurred, patients should be transfused when there are signs of significant hypoperfusion . PRBC administration is rarely indicated when haemoglobin concentration is >10g /dl but is almost always indicated when the hemoglobin level is <=6g/dl.

Slide 61: 

If base deficit is >15, in presence of significant and ongoing blood loss, then blood is administered. O2 extraction of 50% can be used as an indication of transfusion of erythrocytes. Hb should be maintained between 6-10g/dl. Platelet count maintained over 50,000/dl. INR to be maintained <1.5 by using FFP @ 10-15ml/kg body wt. Cryoprecipitate should be used when fibrinogen levels fall below 100mg/dl @ 1U/5-10kg body wt.

Misconceptions Busted: 

Misconceptions Busted Trendelenburg position: It does nor promote venous return to the heart in hypovolemia. This manuvere should be abandoned for the management of hypovolemia Central Vs. Peripheral venous canulation: The rate of volume infusion is determined by dimensions of vascular catheter, not the size of vein. For rapid volume resuscitation, canulation of peripheral veins is preferred over canulation of large central veins with long catheters. (Reference: ICU book – Paul Marino, 3 rd edition)

What`s new in transfusion medicine?: 

What`s new in transfusion medicine? Recombinant factor VIIa . ( rFVIIa ) binds to exposed tissue factor & directly activates factor IX & X. Dose is 50-100mcg/kg every 2hrs I.V until evidence of hemostasis . Not effective when fibrinogen level is less than 50mg/dl. Hypothermia & acidosis reduces its activity. Complications  thrombosis, M.I, P.E & clotting of vascular access. Used as last resort when other strategies fail.

Slide 64: 

Vasopressin Used in hemorrhagic shock unresponsive to conventional vasopressors . Infusion rate- 1-4mu/kg/min. Mech of action  unclear. Has a potential to cause Myocardial Ischemia. Intraoperative cell salvage & acute normovolemic hemodilution

Types of Replacement Products under research: 

Types of Replacement Products under research Oxygen Carrying Solutions Hemoglobin Based Oxygen Carrying Solutions (HBOCS) Perflourocarbons Other Antigen Camouflage Recombinant Plasma Proteins Transgenic Therapeutic Proteins Platelet Substitutes

REFERENCES : 

REFERENCES Obstetric Anesthesia- Brenda. A. Bucklin 1 st edition Obstetric Anesthesia- Freeman 1 st edition Obstetric Anesthesia- Sunanda Gupta, 3 rd edition Miller’s Textbook of Anesthesia, 7 th edition ICU Book, Paul marino , 3 rd edition. Clinical cases in anaesthesia, Allen. P. Reid, 3 rd edition. Anaesthesia for obstetrics and gynecology, Robin Russel . Emergency medicine clinic of North America, Feb 2010, Vol 28. Textbook of Obstetric, Dutta , 6 th edition.