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Anaesthetic Management of Bleeding Obstetric Patient

Anaesthetic Management of Bleeding Obstetric Patient

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Published by Suresh Kumar

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Published by: Suresh Kumar on Sep 16, 2012
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Anaesthetic Management of Bleeding Obstetric Patient
Pof.M.Kannan MD DAProfessor Emeritus Tamilnadu MGR Medical UniversityFormer Professor and HOD , Departmrnt of Anaethesiology,Tirunelveli Medical College
cording to the latest UN Report “
Globally an estimated 287,000 women died in pregnancy andchildbirth in 2010 and India accounting
for nearly 19% (56,000) “
. The report said every ten minutes awoman dies of pregnancy-related complications like severe bleeding after childbirth(38%),infections(11%), high blood pressure during pregnancy (5%),unsafe abortion(8%)and Other Condition(34%) in our country . And our Maternal Mortality Ratio (MMR) has declined to 212 in 2007-2009 asagainst 254 in 2004-2006, recording a fall of 42 points or 17 per cent, as per latest results of the SampleRegistration Survey (SRS). The latest figure of MMR in South India is Kerala- 81,Tamilnadu-97, AndhraPradesh -134 and Karnataka -178. Anaesthesiologist plays a pivotal role in reducing the mortality rate.
There are many reasons for Bleeding in Obstetrics patient s. They can be broadly classified intobroad four categories1.Bleeding in early pregnancy2.Antipatum Haemorrhage3.Post partum Haemorrhage4.Non obstetric cause of bleeding during Pregnancy( In this lecture notes I have confide to Antipatum Haemorrhage and Post partum Haemorrhage)
Postpartum Haemorrhage(PPH)
Quite often PPH is life threatening and it is the major cause of maternal mortality world wide and itoccurs nearly in 5% of the deliveries. In our country (India)out of estimated 25 million deliveries 18million deliveries take place in peripheral centers where perinatal care is poor or nonexistent. There forewe should move on a war footing to reduce the MMR.
World Health Organization definition of primary PPH encompasses all blood losses over 500ml.
Factors predisposes to PPH
Multiple gestation
Abruption of placenta
Adherent Placenta
Foetal death
High parity
Prolonged labor
Precipitous labor
Augmented labor
Uterine Myoma
High concentration of a volatile halogenated anesthetic agent
Instrumental deliveryThe Causes of PPH may be Primary are Secondary.Primary PPH occurs with in 24 hours.Secondary PPH occurs from 24 hours to 6 weeks.Primary PPH Causes
Uterine atony
Injury in Genitaltract
Retained product
Abnormal placenta
Inversion of the UterusSecondary PPH
Retained product
Management of PPH
The management Depend upon the clinical status. The Patient may fall into any one of thecategory. Rapid clinical assessment and treatment should be started with out delay as perthe protocol laid by the Institute.
HaemorrhageClassAcute Blood loss Bloodloss in %SymptomIIIIIIIV500-1000ml1000-1500ml1500-2000ml>2000ml10-15%15-25%25-35%>35%Asymptomatic or TachycardiaOrthostatic hypotension or SupineHypotensionMarkedTachycardia/Tachypnea/HypotensionShock/Air hunger/Oliguria/Anuria
Many cases of PPH have no identifiable risk factors. So prevention of PPH is wiser.
Active management of the third stage of labour lowers maternal blood loss andreduces the risk of PPH.
Prophylactic oxytocics should be offered routinely in the management of the thirdstage of labour in all women as they reduce the risk of PPH by about 60%.
For women without risk factors for PPH delivering vaginally, oxytocin (5 iu or 10iu by intramuscular)
For women delivering by caesarean section, oxytocin (5 iu by slowintravenousinjection) should be used
Methyl ergometrinemay be used in the absence of hypertensionbut increases vomiting.
Misoprostol is not as effective as oxytocin but it may be used when the latter is notavailable
All women who have had a previous caesarean section must have their placentalsite determined by ultrasound. Where facilities exist, magnetic resonance imaging(MRI)may be a useful tool and assist in determining whether the placenta is accretaor percreta.
Women with placenta accreta/percreta are at very high risk of major PPH. If placenta accreta or percreta is diagnosed antenatally, there should be consultant-ledmultidisciplinary planning for delivery.
Consultant obstetric and anaesthetic staff should be present, prompt availability of blood, fresh frozen plasma and platelets
Access to intensive care.
Available evidence on prophylactic occlusion or embolisation of pelvic arteries inthe management of women with placenta accreta is equivocal. The outcomes of prophylactic
arterial occlusion require further evaluation.

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